Chapter C: H. Thomas of Philadelphia has given me the particulars of a case of (3)

Massage should often be combined with the Swedish movement cure. In the movement cure one object is to call out the suppressed will of the patient. This is very applicable to cases of hysteria. The cure of cases of this kind is often delayed by using massage alone, which is absolutely passive. These movements are sometimes spoken of as active and passive, or as single and duplicated. Active movements are those more or less under the control of the individual making or taking part in them, and they are performed under the advice or direction, and sometimes with the assistance, of another. They proceed from within; they are willed. Passive movements come from without; they are performed on the patient and independently of her will. She is subjected to pushings and pullings, to flexions and extensions, to swingings and rotations, which she can neither help nor hinder. The same movement may be active or passive according to circumstances. A person's biceps may be exercised through the will, against the will, or with reference to the will.

A single movement is one in which only a single individual is engaged; speaking medically, single movements are those executed by the patient under the direction of the physician or attendant; they are, of course, active. Duplicated active movements require more than one for their performance. In these the element of resistance plays an important part. The operator with carefully-considered exertion performs a movement which the patient is enjoined to resist, or the latter undertakes a certain motion or series of motions which the former, with measured force, resists. Still, tact and experience are here of great value, in order that both direct effort and resistance should be carefully regulated and properly modified to suit all the requirements of the case. By changing the position of the patient or the manner of operating on her from time to time any muscles or groups of muscles may be brought into play. It is wonderful with what ease even some of the smallest muscles can be exercised by an expert manipulator.

The duplicated active movements are those which should be most frequently performed or attempted in connection with massage in hysterical patients. The very substance of this treatment is to call out that which is wanting in hysteria—will-power. It is a coaxing, insinuating treatment, and one which will enable the operator to gain control of the patient in spite of herself. As the patient exerts her power the operator should yield and allow the part to be moved.

Much of the value of massage and Swedish movements, in hysteria as in other disorders, is self-evident. Acceleration of circulation, increase of temperature, direct and reflex stimulation of nervous and muscular action, the promotion of absorption by pressure,—these and other results are readily understood. “The mode in which these gymnastic proceedings exert an influence,” says Erb,[123] “consists, no doubt, in occasioning frequently-repeated voluntary excitations of the nerves and muscles, so that the act of conduction to the muscles is gradually rendered {281} more facile, and ultimately the nutrition of the nerves and muscles is augmented.”

[Footnote 123: _Ziemssen's Cyclopædia_.]

The objects to be attained by the use of electricity are nearly the same as from massage and duplicated active movements: in the first place, to improve the circulation and the condition of the muscles; and in the second place, to make the patient use the muscles. The faradic battery should be employed in these cases, and the patient should be in a relaxed condition, preferably in bed. A method of electrical treatment introduced some years ago by Beard and Rockwell is known as general faradization. This is sometimes used in the office of the physician. In this method the patient is placed in a chair with his feet on a large plate covered with chamois-skin; the operator then takes hold of the patient's hand and the other electrode is passed over the muscles of the neck, back, trunk, and extremities.

When the patient is in bed, as in the regular rest treatment, this method has to be modified, and then the best treatment is by direct muscular faradization. Two sponge electrodes are employed. The sponges are moistened, so that the current may pass through the skin and reach the muscles. Both electrodes are taken in one hand, the handle of one, pointing backward, being between the first and second fingers, while the handle of the other is between the third and fourth fingers. In this way the distance between the points of application can be readily altered. The current is then applied to the muscles everywhere, beginning with those of the feet. Muscles should be relaxed before passing the current through them. The whole body can be gone over in this way in the course of half an hour.

The hydropathic treatment of hysteria is one that has much in it to be commended. Jolly approves the systematic external application of cold water; Chambers advocates the daily morning use of shower-baths, holding that the bracing up of the mind to the shock of a cold shower-bath is a capital exercise for the weak will-power of the hysterical individual, and some admirable results have been reported by Charcot in inveterate neurasthenics and hysterics. Hydrotherapeutic treatment, continued perseveringly for a long time, says Rosenthal, “diminishes the extreme impressionability of hysterical patients, strengthens them, and increases their power of resistance to irritating influences, stimulates the organic functions, combats the anæmia, calms the abnormal irritability of the peripheral nervous system, and by diminishing the morbid increase of reflex power relieves the violence of the spasmodic symptoms. Even chronic forms which are combined with severe paroxysms of convulsions are susceptible of recovery under this plan of treatment.”

The hydrotherapeutic treatment may be contrasted with the treatment by seclusion, rest, massage, and electricity. Undoubtedly, one class of hysterical patients is greatly benefited by the latter method systematically carried out; these have already been described. In other cases, however, this method of treatment is useless; in some of them it has a tendency to prolong or aggravate the hysterical disorder, while in the same cases a well-managed hydrotherapeutic treatment will answer admirably. This is applicable in hysterical patients who eat and drink well, who, as a rule, preserve a good appearance, but whose mind and muscles are equally flabby and out of tone, and need to be stirred up both physically and mentally.

{282} Dujardin-Beaumetz recommends prolonged warm baths of from one to two hours' duration, and believes that the therapeutic virtues of these baths are augmented by infusions of valerian.

In order to obtain satisfactory results from hydrotherapy, as well as from massage, electricity, etc., it is best to remove patients from their family surroundings. Good sanitariums near our large American cities where hydrotherapy and other special methods of treatment can be carried out are sadly needed. Hydrotherapeutic treatment is much more efficacious when conducted at a well-regulated institution, for several reasons. Measures troublesome in themselves are here carried out as a matter of daily routine. Numerous patients permit of the employment of competent attendants. The change is often of great benefit. The close personal supervision which hysterical patients are likely to have in a hydrotherapeutic establishment is also to be taken into consideration. Better modes of living, proper forms of exercise, regulated diet, etc. also enter; but still, a fair share of the good which results can be attributed to the water treatment.

While, however, it is better to remove hysterical patients, for hydrotherapeutic as well as for other treatment, from their family surroundings, and to place them in some well-regulated establishment, it is not by any means impossible to carry out such treatment in private practice, particularly in a house supplied with a bath-room. Many of our hydrotherapeutic institutions are in the hands of charlatans or of individuals who are not practically well fitted for their work. Not infrequently, however, good results are obtained even under these circumstances. Much more can be done in this direction with modest buildings and appliances than is generally supposed. It is not necessary to have numerous apartments: three or four rooms in a well-appointed house, if the arrangements for carrying out the hydrotherapeutic treatment are of a proper kind, will suffice for a large amount of good work. In almost any house provided with bath-rooms with hot and cold water some useful hydrotherapy may be attempted. The spinal douche or pour can be used by placing the patient in a sitz- or ordinary hip-bath and pouring the water from a spout or hose held at a certain height, the distance being regulated according to the patient's condition. Again, the patient sitting in a tub, water can be poured upon her, beginning at first with a high temperature and gradually lowering it. The shower-bath may also be used. An extemporaneous shower-bath can be provided by an ordinary watering-pot. Whole, three-quarters, or half baths at different temperatures can be given. One method of carrying out the wet pack is very simple. A comforter is spread upon the bed; next to this is placed a woollen blanket, and over the blanket a wet linen sheet, upon which the patient rests, with the head on a low pillow. The wet sheet, blanket, and comforter are then wrapped closely about the patient, bottles of hot water being placed at the feet. The cold drip-sheet method is another easily used. It consists in placing about the patient, while sitting up or standing, a sheet wet with cold water, and then vigorously rubbing her through the sheet.

Baths to the head may be used in some cases; cool head-baths are most frequently applied. One method of using these baths is to have the patient lie in such a position that the head projects a little beyond the {283} edge of the bed and over a basin or receptacle of some kind. Water of a suitable temperature is then poured gently or squeezed out of a sponge over the head. For some forms of insomnia or some of the disorders of sleep in hysteria this treatment is a valuable auxiliary to other measures.

For the hysterical spine cold compresses may be used along the spine. On the other hand, hot fomentations may be found of benefit in some cases. Where hydrotherapeutic measures are employed attention should be paid to the condition of the circulation, particularly in the extremities. If the feet or hands are cold, hot applications or frictions should be used.

For certain of the vaso-motor disorders of hysteria, such as cold or hot feet, flushings, etc., local hydrotherapeusis will be of service. In hysterical contractures local stimulation by the douche method or by the steam bath may be tried. For the excitable rectum cold enemata in small quantities, so as not to be expelled, will be found to be very efficacious. For spasmodic attacks, whether purposive or involuntary, the use of the wet pack or the plunge-bath will sometimes be found of good service. In neuralgias and other painful local disorders of hysteria, frictions, fomentations, Turkish or Russian baths, and the wet pack are often very beneficial.

When hysteria is complicated, as it very often is, with disorders of the liver and stomach, hydrotherapeutic measures will be of added efficacy. When it is associated with genito-urinary disorders, even though the latter are not regarded as the cause of the former, special beneficial effects, both local and general, can be obtained from hydrotherapeutic measures. Locally, sitz-baths, hip-baths, douche-baths, hot and cold injections, and foot-baths may act as revulsives, astringents, or local tonics, while at the same time they are measures which tend to strengthen the system as a whole.

Sea-bathing is often of the greatest value, although it is sometimes difficult to induce hysterical patients, who are willing enough to go to the seashore, to resort to surf-bathing. Few measures are better calculated to bring up the tone of the nervous system of an hysterical or neurasthenic patient than well-directed sea-bathing. Where sea-bathing cannot be employed sea-water may be used indoors. Sea-water establishments, where baths at various temperatures may be had, are now to be found at all the best seaside resorts. In a few cases the internal use of large quantities of either hot or cold water, or of the ferruginous mineral waters, may be associated with the external treatment.

The climatic treatment of hysteria has received little or no attention; undoubtedly, much could be said in this connection. In a great country like ours a climate suited to the requirements of almost every form of disease can be had. The climate of those regions, either of the seaboard or inland, particularly well suited to cases of lung trouble, will often be useless, and sometimes harmful, to neurotic patients. For a certain class of hysterical patients a sojourn at the seashore, if not too protracted, will prove of great value. On the whole, for most hysterical patients of the neurasthenic type the best plan is to go first to the seashore for a few weeks, and then resort to an inland hilly or mountainous country, but not at too great an elevation. I have known the climate of some of the high altitudes of Colorado to be of positive injury by depressing the nervous system. Resorts like Capon Springs in West Virginia, out of {284} the reach of steam and worry, with prevailing south-west winds, are desirable places.

The treatment of hysteria by the method of metallotherapy is worthy of some consideration. It is a method by no means new. It was known and practised by the ancients with rings and amulets. Popularized at the beginning of the present century by certain travelling charlatans, it was later, for a time, wholly ignored. In recent years it has been received with considerable attention. One Burq for many years practised metallotherapy in Paris disregarded or scouted by the profession, but claiming many remarkable cures. Finally, Charcot was induced to give him an opportunity of demonstrating the truth or falsity of his claims at Salpêtrière.[124] Cases of grave hysteria were submitted to the treatment, and in certain instances with striking results.

[Footnote 124: _Lancet_, Jan. 19, 1878.]

After having determined by a series of experiments the particular metal to which the patient is sensitive, bits of metal may be applied to the surface of the body in various places; this constitutes external metallotherapy. Or the metal, in the form of powder (as reduced iron) or an oxide or some other salt, may be administered; this is internal metallotherapy. That certain definite effects may be produced by the application of metals to the surface of the body is unquestionable. Some of the results which have followed their employment are the removal of anæsthesia and analgesia, relief of hysterical paralysis, improvement in the circulation, removal of achromatopsia, relief of contracture.

Many investigations in Germany, England, France, and this country have demonstrated that the same or similar effects can be produced by the application of other non-metallic substances, such as discs of wood, minerals, mustard plasters, etc. Hammond, among others, has shown this. How the results are obtained is still a matter of dispute. On the one hand, it is claimed, principally by the French observers, that the cures are due to the metals themselves, either by virtue of some intrinsic power or through some electrical currents generated by their application. On the other hand, it is asserted, particularly by the English observers, that the phenomena are best explained on the doctrine of the influence of the mind on the body; in other words, by the principle of expectant attention. Some at least of the effects are to be explained on the latter hypothesis, but it is likely that the monotonous impressions made upon the peripheral sense-organs by different substances applied locally may act reflexly on the brain.

Seguin[125] reports a case of convulsion and hemianæsthesia in an adult male cured by metallotherapy; the metal used was gold. Two ordinary twenty-dollar gold pieces were placed in the patient's hands, and afterward on his forearm, cheek, and tongue. Nothing else was suggested or done to him; sensibility returned, and the staggering and other symptoms disappeared. The patient left the hospital claiming to be perfectly well. The same author reports several other successful cases of metallotherapy, all of them reactions to gold. One was a girl sixteen years old with analgesia.

[Footnote 125: _Arch. of Medicine_, New York, 1882.]

Not a few cases are now on record of the cure of hysterical contracture and other forms of local hysterical disorders by the application of a magnet. Charcot and Vigouroux cured one case of hysterical contracture {285} of the left arm by repeated applications of the magnet to the right or healthy arm. Debove by prolonged application of magnets relieved hemianæsthesia and hemiplegias—not only the hysterical varieties, but also, it is said, when dependent upon such conditions as alcoholism, plumbism, and even cerebral lesions. Maggiorani of Rome studied the physiological action of the magnet and laid down the first rules for its therapeutic use. In the case of powerful magnets we have more room for believing that an actual, tangible force is at work in producing the results than in the case of simple metals.

The question has been sometimes asked whether hypnotism can be used with success in the treatment of hysteria. Richer reports a few cures of hysteria through this agency. Braid has put on record between sixty and seventy cases which he claims to have cured by the same means. This list undoubtedly includes some hysterical cases—of paralysis, anæsthesia, aphonia, blindness and deafness, spinal irritation, etc. Both on theoretical grounds and from experience, however, I believe that the practice of hypnotization may be productive of harm in some cases of hysteria, and should be resorted to only in rare cases of mental or motor excitement.

By some, special measures during the hysterical fit are regarded as unnecessary. Jolly, for instance, says that we must merely take care that the patients do not sustain injury in consequence of their convulsive movements, and that respiration is not impeded by their clothing. Rothrock[126] reports several cases of hysterical paroxysms relieved by the application of either snow or ice to the neck. The applications were made by stroking up and down either side of the neck along the line of the sterno-cleido-mastoid muscles. He believed that the most probable explanation of the results obtained was the shock received from the cold substance, but that supplemental to this there may have been supplied through the pneumogastric nerve a besoin de respirer. This measure and the use of the cold spinal douche are both to be recommended.

[Footnote 126: _Philada. Med. Times_, 1872-73, iii. 67.]

Emetics are sometimes valuable. Miles[127] reports several cases of severe hysterical seizure in which tobacco was promptly efficient in controlling the affection. He used the vinum tabaci in doses of one drachm every half hour or hour until the system was relaxed and nausea induced, the effects usually being produced after taking three or four doses. Fifteen grains of sulphate of zinc may be used in adult cases. James Allen for a case of hysterical coma successfully used a hypodermic injection of one-tenth of a grain of apomorphia. Recently, at the Philadelphia Hospital this remedy has been successfully employed in two cases, one of hysterical coma and the other of hysterical mania. Inhalations of nitrite of amyl are often of surprising efficiency. This and other measures referred to under HYSTERO-EPILEPSY are also applicable in the treatment of any form of hysterical spasm.

[Footnote 127: _Clinical Med. Reporter_, 1871, iv. 25-27.]

For hysterical convulsions occurring during pregnancy an enema of asafœtida, camphor, the yolk of an egg, and water, such as has been recommended by Braun of Vienna, will often be found promptly efficacious.

Fagge[128] mentions a procedure which he had often seen adopted by Stocker—namely, pressure upon the arteries and other structures on each side of the neck.

[Footnote 128: _British Medical Journal_, March 27, 1880.]

{286} For hysterical paralysis faradism and galvanism hold the chief place. Metallic-brush electricity should be used in the treatment of anæsthesia.

Whenever, in local hysteria, particularly of the paralytic, ataxic, or spasmodic form, it is possible to coax or compel an organ or part to perform its usual function long unperformed or improperly performed, treatment should be largely directed to this end. Thus, as Mitchell has shown, in some cases of aphonia, especially in those in which loss of voice is due to the disassociation of the various organs needed in phonation, by teaching the patient to speak with a very full chest an involuntary success in driving air through the larynx may sometimes be secured. Once compel a patient by firm but gentle means to swallow, and œsophageal paralysis begins to vanish.

Mitchell makes some interesting remarks upon the treatment of the peculiar disorders of sleep, which he describes and to which I have referred. When the symptoms are directly traceable to tobacco, he believes that strychnia and alcohol are the most available remedies, but gives a warning against the too liberal use of the latter. A treatment which was suggested to him by a clever woman who suffered from these peculiar attacks consists in keeping in mind the need of breaking the attack by motion and by an effort of the will. As soon as the attack threatens the patient should resolutely turn over, sit up, or jump out of bed, and move about, or in some such way overcome the impending disorder. Drugs are of little direct use. Small doses of chloral or morphia used until the habit is broken may answer, but general improvement in health, proper exercise, good food, and natural sleep are much more efficient.

Fagge says that he has seen more benefit in hysterical contracture from straightening the affected joints under chloroform, and placing the limb upon a splint, than from any other plan of treatment. Hammond[129] (at a meeting of the New York Neurological Society, Nov. 6, 1876) reports a case of supposed hysterical contracture in the form of wry neck, in which he divided one sterno-cleido-mastoid muscle; immediately the corresponding muscle of the other side became affected; he cut this; then contraction of other muscles took place, which he kept on cutting. The case was given up, and got well spontaneously about two years later. Huchard[130] entirely relieved an hysterical contracture of the forearm by the application of an elastic bandage.

[Footnote 129: _Philadelphia Medical Times_, vol. vii., Nov. 25, 1876.]

[Footnote 130: _Revue de Thérapeutique_, quoted in _Med. Times_, vol. xiii., June 16, 1883.]

A lady with violent hysterical cough was chloroformed by Risel of Messeberg[131] for fourteen days at every access of the cough, and another for eight days. In both the symptoms were conquered. Nitrite of amyl is useful in similar cases.

[Footnote 131: _Allg. Med. Centralzeitung_, Oct. 9, 1878.]

Graily Hewitt[132] reports a case of hysterical vomiting of ten 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.

On several occasions I had the opportunity of watching every phase of 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.

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.

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.

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.

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.