FIG. 25.
The figure is a representation of the opisthotonos of tetanus.11 It is the sketch of a soldier, struck with opisthotonos after having been wounded in the head; and in connection with it I will briefly call attention to the points of differential diagnosis as given by Richer, and which have been confirmed by my own observations. In the opisthotonos of tetanus the contraction of the face and the peculiar grin are distinguishing points, and are well represented in Bell's sketch. In the hysterical arched position, while the jaws may be strongly forced together, the features are most often without expression. The contracture of the face and the distortion of the features will be met with more often in the other varieties of contortion. The curvature of the trunk differs but little in the two cases, but the abdominal depression observed in the sketch of Bell is far removed from the tympanitic appearance present in the majority of hystero-epileptics. In the tetanic cases the patient rests only on the heels, while in the hysterical cases the knees are slightly flexed, and the patients are usually supported on the bed by the soles of the feet.
11 From Sir Charles Bell's Anatomy and Physiology of Expression as connected with the Fine Arts.
Hystero-epileptics are often suspected of simulation. Richer refers to many facts which seem to throw out conclusively the idea of simulation. Among these are the results obtained by æsthesiogenic agents, the experiments in hypnotism, where many of the results produced could not be simulated. Some English authors—and among them notably the physiologist Carpenter—have endeavored to find the explanation of the results obtained by the æsthesiogenic agents in a special action of the moral on the physical nature which they designate expectant attention. While the reality of the action of expectant attention in certain cases will not be denied, it cannot be invoked to explain satisfactorily all the phenomena. The patients are not aware of the results sought; which, indeed, in some cases, are contrary to the expectations of the observer himself.
PROGNOSIS.—A few cases of hystero-epilepsy get well, either with or without treatment, in a short time. Some cases, which in addition to the grave attack have had in the intervals the other striking symptoms of major hysteria, such as hemianæsthesia and contractures, get well only after many months or years; some never recover, although, as a rule, they do not die from anything directly connected with the disease, but from some accident or more commonly from some intercurrent disorder. Cases supposed to be cured often relapse. The patient may be apparently well for months, or even years, when under some exciting cause the old disorder is again aroused. On the whole, the prognosis is more serious the longer the case has endured. Family history and environment have much to do with determining the prognosis.
TREATMENT.—In considering the treatment of hystero-epilepsy I will, in the main, confine my attention to a discussion of the methods of managing and treating the convulsive seizures. With reference to the numerous special phenomena of this disease, the directions given and the suggestions made in the general article on Hysteria will be equally applicable in this connection.
Ruault12 has recently recommended compression of a superficial nerve-trunk in order to terminate an attack of hysteria or hystero-epilepsy. The face being always accessible, he prefers making pressure on the infraorbital nerves as they emerge from their foramina, but he has also compressed the ulnar nerve behind the inner condyle of the humerus. In a brief note to the Philadelphia Neurological Society, made Feb. 23, 1884, I called attention to the value of strong nerve-pressure for the relief of hysterical contracture, and can confirm from several successes Ruault's recommendation for the employment of the same measure to avert convulsive attacks.
12 La France médicale, vol. lxxxvi., p. 885.