Case XXXIII. Cataleptic Fits—Six Years’ Duration—Operation—Cure.
Miss ——, æt. 38, single; admitted into the London Surgical Home August 10, 1865.
History.—Was tolerably well until two years and a half ago, but since that time has suffered more or less from menorrhagia, with severe pain in back. Has also severe smarting pain in the bowels, and has frequently lost a considerable quantity of blood per anum. Has always been subject to hysterical attacks, but for the last six years has had fits of a much more serious character. They have increased in severity, duration, and frequency, and it is on account of them that she seeks relief. Almost immediately after admission, this patient had a fit, and she was kept a fortnight under observation, that the nature of the attacks might be thoroughly investigated.
She would have a fit sometimes twice a day; but on an average about every other day—either early in the morning or late in the evening. She was most generally attacked when walking about the room—sometimes when sitting—but she was never observed to have one when asleep. She would at the commencement of an attack cease walking, or doing whatever she was employed in; her face would become very pale and set; the eyelids, at first quivering, would be fixed; the eyes wide open and looking upwards, the pupils very dilated. Her mouth would be rigidly shut, and during the attack it was impossible by any means to open it. Her arms would fall straight by her side, and be immovable; the hands unclenched, and fingers extended. If standing, she would be quite upright, and require no support. If sitting, she would always stand up when a fit was coming on. If lying, she would be extended straight on her back. The fit would last for two or three hours, and on a few occasions for as many as six hours. The experiment was frequently made of moving her arms when in the cataleptic state, and on such occasions the limb would remain in the position in which it was placed, till the end of the attack. She was always perfectly unconscious, and no kind of stimulant was of the slightest use in restoring her during the paroxysm—time alone was of avail. The attack was sudden, but the recovery to consciousness was but gradual; she would appear as if awoke from a deep sleep, and would be very exhausted, but express no desire for food, wine, or other stimulants. As soon as she recovered, she would sleep for many hours, and awake quite well, but still weak.
Aug. 24. The clitoris was excised, and a painful fissure of the rectum divided. She never had a fit after the operation. Menstruation came on on the 28th, in moderate flow.
Oct. 5. This patient has improved wonderfully since operation, and now looks extremely well. The wound is quite healed. She takes walks daily, and has had no fits, and is to be discharged as cured.
In November she called at the Home, to say that she was quite well, and had never had the slightest return of her former illness; she menstruates regularly and normally.
Feb., 1866. She remains well.
CHAPTER VII.
EPILEPSY, WITH CASES.
Referring my readers for full information on the pathology and history of epilepsy to Dr. Russell Reynolds’s exhaustive treatise on the subject already referred to, I would mention, as shortly as possible, a few facts which are necessary to be borne in mind, with especial reference to the class of cases which I am now considering.
Dr. J. C. Prichard, in writing of diseases of the nervous system, has well said that “few diseases are better characterized by them symptoms than epilepsy; yet in this instance there is such a variety in the phenomena as renders it difficult to contrive a definition in a few words which may comprehend every form of the complaint.”
I have said that when convulsions become chronic they are considered to take on an epileptiform character. Now, although we know that in a few cases involuntary spasm may take place in sleep, i.e. with loss of consciousness, I think we may, for all general purposes, take as a definition of epilepsy a chronic convulsive disease, each convulsive attack being accompanied with “sudden and complete loss of consciousness,” this latter symptom being considered by the late Dr. Todd[[5]] as “the pathognomonic symptom of the disease,” but only, as Dr. Reynolds[[6]] has shown, “when it occurs as a paroxysmal or occasional event.”
[5]. Medical Times and Gazette, August 5, 1854, p. 129.
[6]. Op. cit., p. 31.
The causes of epilepsy are various—“partly physical, partly immaterial.” Of the former are injuries and tumours of the brain or meninges, intestinal worms, renal and biliary calculi, &c. &c. These are termed by Dr. Handfield Jones[[7]] “eccentric causes.” As “centric causes,” he names “poisoning of the blood from retention of excrementitious matter; this, by deranging the nutrition of the nervous tissue, generates the abnormal excitability, which then manifests itself without any special irritant. Various causes of exhaustion, such as hæmorrhage and excessive discharges, venereal excesses, prolonged want of sleep, unremitting pain,” &c., are all “centric” causes of epilepsy.
[7]. Op. cit., p. 209.
Dr. Reynolds is right in considering epilepsy an idiopathic disease, inasmuch as it occurs, without discoverable organic lesion with which it can be associated, and because there is no structural lesion of the brain, or spinal cord, to be found constantly associated with it; but when he says that it is idiopathic because, “in many cases, eccentric irritation cannot be shown to be the cause of the attacks,” I cannot go with him. Epilepsy is a name signifying a disease, which may be idiopathic, or may arise from a variety of causes; but that eccentric irritation is a powerful and very frequent cause, there is not the slightest doubt. Dr. Reynolds classes it as second of six in a table given in his book, physical conditions being mentioned as first; and finding, in a hundred cases, that 24·63 have no assignable cause, and 18·84 are doubtful, he gives 13·04 as due to eccentric irritation.
In considering peripheral irritation of the pudic nerve as a cause of this disease, we must, I think, consider mental emotion, which occupies the highest rank in causes of epilepsy, in conjunction with that second in the list,—eccentric irritation. I would, therefore, classify the cause of epilepsy depending on such irritation as both eccentric and centric. The former, inasmuch as it produces exhaustion, and, by deranging the nutrition of the nervous tissue, generates abnormal excitability; the latter, for that it is a physical excitant which is not only “a mere provocative of the paroxysms, the convulsions being supposed to ensue as the reflex results of irritation, but that it actually sets up in the nervous centres that state of excitability which is the essence of the disorder.” Further still, looking on epilepsy as a direct sequel of hysteria, when it is produced by excitation of the pudic nerve, the patients are, in an eminent degree, predisposed to the disease.
Women are also more naturally prone to epilepsy from mental emotion than men; “Emotional disturbance being assigned,” says Dr. Reynolds, “as the cause of their attacks in so many as 36 per cent., whereas in the male sex there were only 13 per cent. who referred their diseases to that cause.”
It would be out of place in a work of this nature to detail at length the symptoms of these attacks. Whether they are truly epileptic will be seen as the cases are related. I have been very careful to separate those which seemed to be of an hysterical or epileptoid nature; and have had the advantage of being able to show the greater number of them to many eminent members of the medical profession, who have witnessed my practice in the London Surgical Home.