A beautiful illustration of one of the positions assumed by a hystero-epileptic is shown in Fig. 24 from Allan McLane Hamilton's treatise on Nervous Diseases. The patient, æt. eighteen, represented in the figure had suffered from hystero-epileptic attacks since the beginning of the menstrual period. Usually, she had severe but distinct epileptic seizures, and afterward an hystero-epileptic paroxysm. The muscles of her back were rigidly contracted in opisthotonos. Her arms were drawn over her chest, and her forearms slightly flexed and crossing each other. Her thumbs were bent in and covered by her other fingers, which were rigidly flexed. Her toes were also flexed, and her right foot presented the appearance called by Charcot le pied bot hystérique, or hysterical club-foot.
As has already been stated, hystero-epilepsy of irregular, imperfect, or abortive type is most commonly observed in this country, or at least in the Middle States, of which my own knowledge and experience are greatest. As has been demonstrated by Richer and Charcot, the irregular type may be of any form, from a paroxysm with a scarcely detectible convulsive seizure and scarcely recognizable loss of consciousness up to frightful attacks which from their terrible nature have been termed demoniacal, and in which occur the wildest phenomena of movement, frightful contortions and contractions, with grimaces and cries of fury and rage. Sometimes the movements show a violence beyond description. These frightful seizures are of extreme rarity in America. Sometimes attacks of ecstasy or attacks of delirium are the predominating or almost the only feature. The epileptoid attack, so far as my experience has gone, is the most prevalent variety of hystero-epilepsy. Epileptoid attacks are simply the result of the predominance and modification of the first or epileptoid period of the typical grave attack. Richer has described several varieties.
I have seen a number of cases of the epileptoid variety or other irregular forms. These cases have presented a few or many of the symptoms of grave hysteria, such as anæsthesia, analgesia, hyperæsthesia, blindness, aphonia, paralysis, contracture, etc., and have also had attacks of tonic and clonic spasm, with complete or partial loss of consciousness. The phenomena of the periods of contortions and great movements, of emotional attitudes, and of delirium have been, however, altogether or almost entirely absent. These epileptoid attacks have varied somewhat in different cases.
The following are the notes of three cases observed by me:8
8 Published in Journal of Nervous and Mental Disease, vol. ix., No. 4, October, 1882.
M——, æt. twenty-seven, a widow, admitted to the Philadelphia Hospital February 4, 1882, was married thirteen years before, when only fourteen years of age, and remained in comparatively good health for four years after her marriage, during which time she had three children, all of whom died in early infancy. Four years after her marriage, while carriage-riding, she for the first time had a spasm. According to her story, the seizure was very severe; she lost consciousness, and passed from one spell into another for an hour or more. She had a second attack within two weeks, and since has had others at intervals of from one week to three or four months. Four years ago she passed into a condition of unconsciousness or lethargy in which she remained for three days. On coming out of this state she found that the left half of her body was paralyzed and that she was speechless. In two weeks she recovered her speech and the paralysis disappeared. On June 15, 1881, she gave birth to a male child. On the night of the 16th she became delirious, and on the 17th she again lost her speech and had a paralytic seizure, the paralysis now affecting both legs. She recovered her speech in a few days, but the paralysis remained. Her babe lived, and with her was admitted to the hospital. He had had seven attacks of spasm at intervals of about a month. The patient's mother was for a time insane, and had been an inmate of an insane asylum for some months since her first epileptiform attack.
She was carefully examined on the day of her admission. She was bright, shrewd, and observant. She gave an account of her case in detail, and said she was a puzzle to the doctors. Both legs were entirely helpless; the feet were contractured in abduction and extension, assuming the position of talipes equino-varus; the legs and thighs were strongly extended, the latter being drawn together firmly. The left upper extremity was distinctly weaker than the right, but all movements were retained. She had no grasping power in the left hand. She was completely anæsthetic and analgesic below the knees, and incompletely so over the entire left half of the body. Pain was elicited on pressure over the left ovary and over the lower dorsal and lumbo-sacral region of the spine. Both knee-jerks were exaggerated.
I lectured on this patient at my clinic at the hospital, stating that I believed the case to be one of hystero-epilepsy, and only needed to see an attack of spasm to confirm the diagnosis. Up to this time she had not had a seizure since admission. She had, however, been complaining for several days of peculiar sensations in the head and of severe headache. She had also been more irritable than usual, and said that she felt as if something was going to happen to her. The same afternoon, Dr. Rohrer, the resident physician in charge of the patient, was sent for, and found her in a semi-conscious state. She did not seem to know what was going on around her, but was not in a stupor. Her pulse was 114 to 120; respirations were 20 to 22, regular. The corneæ responded on being touched. Some twitching movements of the eyeballs and eyelids were noticed; the thumb and forefinger of the left hand also moved, as if rubbing something between them.
In a few moments an epileptoid paroxysm ensued. She became unconscious 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.