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.
W. Page McIntosh6 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.
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 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.