DURATION AND COURSE.—The duration and course of hystero-epilepsy are very uncertain; most cases last many years. In a few instances the hystero-epileptic attacks are all from which the patient suffers; even in the cases of long duration the general health does not appear to become greatly impaired.
DIAGNOSIS.—To arrive at a correct diagnosis between hystero-epilepsy and epilepsy is sometimes very difficult. The fact that the patient is a male does not decide for epilepsy. In making this diagnosis close attention should be given to—1, The history and the causes of the disease; 2, the physical and mental condition of the patient; 3, above all, the phenomena of the spasmodic attacks.
In hystero-epilepsy a careful study of the history of the case will often elicit a moral cause. The patients rarely injure themselves seriously by falling, whereas in true epilepsy they often suffer from severe injuries. The mental and physical health of a person suffering from hystero-epilepsy differs widely from that of the true epileptic. In hystero-epilepsy the number of attacks has little or no apparent influence on the patient's mental or physical condition. Little or no deterioration of the mind occurs. The memory is not much impaired. Hystero-epileptics are usually well nourished and frequently of good physique. This is not the case in true epilepsy; the number of attacks has a decided effect on the patient's mental condition. The demented appearance of the old epileptic is well known, whereas in the hystero-epileptic nothing in physiognomy or carriage indicates that the patient has been suffering from any disease. It cannot be said that all epileptics have no mental power, but some deterioration of the mind usually occurs, and becomes well marked as the case progresses.
The paroxysms in epilepsy are very well marked, especially if it is epilepsy of the grave form. They are often ushered in with a scream. The patient suddenly falls, and at times is severely injured. The convulsion is generally violent, rapidly alternating from clonic to tonic spasm, without special phases or periods. Complete and profound loss of consciousness, with great distortion of face and eyes, is present. The tongue is frequently bitten. After the attack the patient passes into a deep stupor. In hystero-epilepsy usually the seizure does not begin with a scream or sudden fall, the convulsion has periods and phases, and the tongue is not bitten.
It is said that in hystero-epilepsy there is no loss of consciousness, but this is not strictly true. This point is the most difficult one for physicians to clear up in arriving at a diagnosis, as in many textbooks complete loss of consciousness is laid down as the strongest evidence of epilepsy. Loss of consciousness does occur in hystero-epilepsy, particularly in certain varieties. Richer says that the loss of consciousness is complete during the entire epileptoid period in a case of the regular type. To decide as to consciousness or unconsciousness is not as easy as might be supposed. Varying degrees of consciousness may be present. At times in hystero-epileptic attacks the patient may respond to some external influences and not to others. Consciousness is perverted or obtunded often, and it is hard to decide whether the patient is positively and entirely unconscious of her surroundings. In epilepsy the loss of consciousness is profound and easily determined. In regard to the distortion of the face and eyes, this sign is usually absent in hystero-epilepsy, as in the German Hospital case, in which the patient had a series of violent seizures lasting two hours, with marked opisthotonos, yet the facial expression remained calm and serene throughout.
In hystero-epilepsy the attacks are rarely single; usually they are repeated, constituting the hystero-epileptic status. They are more frequently repeated than in epilepsy, although it is of course well known that there is an epileptic status terrible in character. In a series of hystero-epileptic attacks usually the seizures come on in rapid succession, the interval being brief. These series are apt to last for hours or days. The attacks that compose a series in hystero-epilepsy vary in duration and in violence. At first they are of violent character; toward the end the seizures may gain in extent, but they are likely to lose in intensity.
Charcot and Bourneville make a strong diagnostic point between hystero-epilepsy and true epilepsy of the fact that in epilepsy there is a peculiar rise of temperature during the convulsion, even to 104° F., whereas in hystero-epilepsy the temperature is nearly or quite normal.
Arrest of attacks by ovarian compression in females, and by nerve compression, nitrite of amyl, and the application of electric currents, can be brought about in hystero-epilepsy, and not in epilepsy. A study of the effect of bromides may assist in arriving at a diagnosis. The action of bromides, drugs which are often used in both affections, favors the opinion that the two diseases are distinct. Bromides, according to Charcot and Richer, so effective in epilepsy, are without effect in hystero-epilepsy. Dujardin-Beaumetz, however, on the other hand, declares that “who says hysteria says bromides,” and also that at the present time there is not an hysterical patient but has taken bromides, the bromide of potassium being most frequently used. The truth is, that bromides may be useful for temporary purposes, for certain phases and symptoms of the disease, but produce no radical permanent improvement in the disease hystero-epilepsy.
D. Webster Prentiss,10 in reporting a case, gives some good points of distinction between real and hysterical tetanus, which is practically hystero-epilepsy. In his case, which was hysterical, the attack was ushered in by noise in the ears, deafness, and blindness, whereas in true tetanus and strychnia-poisoning the senses are preternaturally acute. There was unconsciousness during the paroxysm, which does not occur except just before death in the other affections. The eyes were closed during the spasms; they stare wildly open in the other diseases. The patient had long, uninterrupted sleep at night; in true tetanus no such relief comes until convalescence.
10 American Journal of the Medical Sciences, 1879.