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 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 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.
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. 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.