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^y J. i..con4rd Corning, M.A.,
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COLLEGE OF PHYSICIANS AND SURGEONS
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A TREATISE ON
HYSTERIA AND EPILEPSY,
WITH
SOME CONCLUDING OBSERVATIONS ON EPILEPTIC INSOMNIA,
J. LEONARD CORNING, M. A., M. D.,
ConsuHant in Nervous Diseases to St. Francis Hospital ; formerly one of the Resident Physicians to the Hudson River State Hospital for the Insane ; Fellow of the New York Academy of Medicine : Member of the New York Neurological Society, of the Amer- ican Neurological Association, of the Medical Society of the County of New York of the Physicians'' Mutiial Aid Association, of the Medical Society of the State of New York Author of "^ Treatise on Headache and Neuralgia,'' '^ Brain Rest, being a DLsquisition on the Curative Properties of Prolonged Sleep," ' Local Anaesthesia," "'Brain Exhaustion, with Some Preliminary Considerations on Cerebral Dynamics," ''Carotid Compression" etc.
GEORGE S. DAVIS,
DETKOIT, UICH.
Copyrighted by
GEORGE S. DAVIS.
i88S.
TO THE MEMORY OF MY MATERNAL GRANDFATHER,
FREDERICK DEMING,
THESE PAGES ARE INSCRIBED AS A SLIGHT TOKEN OF
AFFECTION AND ADMIRATION FOR HIS
NOBLE QUALITIES OF HEART
AND MIND.
NOTE.
One year ago I published a series of papers on " Epi- lepsy" and " Hysteria," which articles appeared in the "New- York Medical Journal " and " Gaillard's Medical Journal."
The present publication is an amplification of those studies, which, as they now appear, possess, to all intents and pur- poses, the qualities of a systematic treatise.
26 West 47th Street, ) New York, July 30th, 1888. )"
TABLE OF CONTENTS.
PART
HYSTERIA. CHAPTER. PAGE.
I. Introductory Note — Definition i
II. Symptomatology — Psychical Manifestations 4
III. Sensory Disorders — Hyperaesthesia 25
IV. Sensory Disorders Continued — Anaesthesia 37
V. Motor Disorders — Spasms — Paralysis 41
VI. Vaso motor Disorders — The Hysterical Cough. ... 49
VII. The Hysterical Paroxysm 57
VIII. Hysteria in Children — Hysteria in Men 62
IX. Causation — Pathology — Diagnosis 68
X. Prognosis — Treatment 74
PART II.
EPILEPSY. CHAPTER. PAGE.
I. Classification — Symptomatology-Symptoms which Immediately Precede the Attack — Aurae Epi-
lepticse 83
II. The Manifestations of the Epileptic Paroxysm —
Grand Mai go
III. The Manifestations of the Epileptic Paroxysm
Continued — Petit Mai — Seizurers Character- ized by Loss of Consciousnes and Local Spasms 05
IV. Masked Epilepsy gg
VIII.
PART II— EPILEPSY— Continued.
CHAPTER, Page.
V. "Thalamic" Epilepsy — Jacksonian Epilepsy —
Sensory Epilepsy 103
^ VI. Causation 109
— -VII. Experimental Researches 117
VIII. Experimental Researches Continued 123
IX. Patho-anatomical Findings 139
X. The Mechanism of the Epileptic Seizure 142
XI. Concerning the Nature of the Irritation — Theories
of Nothnagel, Todd and Hughlings Jackson. . 152
XII. Prognosis — Treatment 157
XIII. Treatment Concluded — Epileptic Insomnia 163
Index , 171
HYSTERIA.
CHAPTER I.
INTRODUCTORY NOTE— DEFINITION.
So heterogeneous and multitudinous are the symp- toms of the disease known as hysteria that an exact description of the affection is exceedingly difficult, and an adequate definition little short of impossible.
We can be certain, however, that a large propor- tion of the manifestations of the affection are directly attributable to a functional derangement of the brain and spinal cord, while not a few of the phenomena are probably traceable to a morbid condition of the sympathetic and peripheral nervous system.
It is impossible, moreover, to regard hysterical phenomena as the result of other than purely func- tional disturbances of the nervous system, since patho- logical anatomy has failed to afford other than ' nega- tive data. Nor is it probable that much enlighten- ment as to the ultimate morphology of the disease is to be anticipated from purely patho-anatomical sources On the contrary, if we are ever to be informed as to the nature of the occult pathology involved, it is un- doubtedly to a future pathological chemistry that we
are to look for such knowledge. When, too, the pres- ent incompleteness of physiological chemistry is borne in mind, there is evidently no immediate prospect of enlightenment from that source, were our metaphysi- cal endeavors ever so great. It cannot, therefore, be said that the probabilities of early enlightenment upon the subtle pathological changes which lie at the root of hysterical phenomena are considerable.
Whatever the ultimate nature of these changes may be, we may nevertheless, rest assured that they must be wide-spread in character, since only on the basis of such an assumption is it possible to account for the heterogeneous array of symptoms.
For the present, then, hysteria may be regarded as a general neurosis of the nervous system, character- ized by psychical, motor, sensory, secretory, vaso- motor and reflex derangements. The justification for including symptoms of so heterogeneous a nature un- der one common designation has been questioned. But, on the other hand, it has been urged that all these symptoms, though not always, are frequently associated in one and the same individual, so that the assumption that they are all attributable to one gener- al cause seems in a measure justifiable.
Be the merits in the case what they may, we shall, at all events, adhere to current usage, if for no other reason than to avoid uncertain and profitless dis- cussion.
Dismissing this portion of the subject, we will
— 3 — content ourselves with but one more observation, be- fore proceeding to give a comprehensive description of the affection. Owing to the circumstance that hysteria is found to prevail to a greater extent among women than men, and also to the fact that changes in the condition of the female genital organs exert an undoubted influence upon the development of hysteri- calphenomena, it has been assumed that hysteria is an affection exclusively confined to females. Moreover, the same line of reasoning has led to the assumption that hysteria is invariably the result of a diseased con- dition of the genital organs.
The integrity of the first portion of this proposi- tion simply depends upon the breadth of significance which we give to the term hysteria. Most certainly a lachrymose condition, accompanied by laughter and choking, is found in men, as I have already had oc- casion to show in former communications.* But whether the more serious manifestations of the affec- tion are found in the male sex has been questioned.
On the other hand, the second portion of the proposition — that which assumes that hysteria is in- variably the result of uterine or ovarian disease — may be dismissed without further comment as manifestly opposed to a vast sum of clinical evidence.
* Brain Exhaustion. By J. Leonard Corning, M. D., New York, D. Appleton & Co., 1884. p. 116, et seq.
CHAPTER II.
SYMPTOMATOLOGY— PSYCHICAL MANIFESTA- TIONS.
Symptoms. — The disease usually develops gradu- ally, though in certain cases there is apparently a sudden exacerbation of symptoms, doubtless attrib- utable to the fact that the prodromata had been overlooked. In another category of cases, however, the onset of the disease is evidently sudden, the attack coming on in the course of a few days in persons pre- viously healthy. Thus it sometimes develops after sudden fright and grief, or after acute diseases or se- vere hemorrhage. Cases of this kind must, however, be regarded as constituting rather the exception than the rule; but they are not the less worthy of attention, since a knowledge of the possibility of their occur- rence will serve to prevent many an error in diagnosis. This form of onset is frequntly characterized by the occurrence of one of those paroxysmal seizures so peculiar to hysteria. We shall take occasion to refer at length to those convulsive phenomena, in connec- tion with the discussion of the motor manifestations of the disease. For the present we will content our- selves with observing that, although we shall adhere as much as possible to a systematic discussion in the following description, no corresponding chronological order is really found in the disease itself. Indeed,
— 5 — there is no affection in the whole range of medicine the symptoms of which are subject to greater varia- tions than those of hysteria. As a consequence, the order of discussion adopted in any description is pure- ly a matter of convenience, and is utterly devoid of objective significance, as far as the disease itself is concerned. Since mental disturbances are usually among the earliest and most characteristic manifesta- tions of the disease, it will be well to take up their consideration first, though this is not the method usually adopted in the books.
Psychical manifestations. — A certain mental exalt- ation, accompanied by extreme irritability, is the most obvious psychical symptom. The inhibitory power of the intellect over the emotions seems suppressed; the subject yields herself with apparent indifference to sentiments of the most opposite character; joy suc- ceeds sorrow, as evinced by alternate attacks of laugh- ter and crying; there is an apparent complete paralysis of volition.
As a direct result of these chaotic and ebullient emotions, the patient becomes exhausted and peevish. She is excited and moved to immoderate annoyance by the veriest trifles; or perchance an exactly opposite condition of things is engendered, and she signifies approval in terms so extravagant as to cause amuse- ment and astonishment to those about her. By de- grees, however, the susceptibility to pleasant emotions diminishes, as the exhaustion consequent upon the in-
— 6 —
ordinate psychical output becomes greater and greater. And, as a final result, disagreeable emotions become preponderant. At the same time a chronic tendency to introspection becomes established, a condition which culminates in one of the most disagreeable and at the same time characteristic manifestations of hys- teria, a morbid craving for sympathy. The subject be- comes completely absorbed in what she considers her deplorable condition, and thinks and talks of her ail- ments without ceasing. As, by degrees, her friends become accustomed to these lamentations, and by as- cribing them to imaginary causes, fail to render the customary sympathy, she becomes desperate. Her in- ordinate egotism is offended; to her distorted vision there is but one commanding personage in the uni- verse— herself — in comparison with whom the rest of mankind are as nothing. But, like many a royal egotist, while heartily despising the ways of the ple- bian portion of humanity, she is eminently anxious to obtain its plaudits and servility. How to obtain an endless sympathy from obdurate mankind, without the slightest return, is the great question to the hysterical, the cord from which all their present and future hopes hang suspended. In order to obtain the coveted boon, the whole moral nature is trampled under foot; prevarication, false witness, theft, and even murders, are the means to which resort is had, when the milder expedients of constant lamentations and weeping have failed to keep the sympathy of
— 7 — family and friends up to the desired standard. These crimes of the hysterical, committed apparently, in many cases, without the slightest tangible reason, form one of the most extraordinary chapters in the whole range of criminal jurisprudence.
The following history, furnished by Cullingworth,* is an illustration of a case of this kind:
" In December, 1876, a girl of eighteen was found one evening standing, with her clothing wet and muddy, and in an apparently stupefied condition, in the closed doorway of a restaurant in the centre of Manchester, a few yards from where she was lodging. She was taken home and put to bed, and a medical man was sent for. He found her to all appearance unconscious of what was going on around her, and uttering some disjointed and incoherent complaints of having been drugged and threatened. He thought she was recovering from the effects of some narcotic, and did not at first pay much attention to her story. The following day, however, she appeared worse, and in the evening her condition was considered so critical that the police were communicated with, with a view to her statement being taken down. She was visited by two experienced detectives, who, seeing how mat- ters stood, and having the doctor's assurance that she was in a dying state, sent at once for a magistrate, before whom she made a solemn declaration to the
* Cited by Ross, op. cit., p. 855.
following effect: she believed herself to be dying. On the previous evening a solicitor, at whose office she had called on business, told her that she must go into a convent, and gave her some sort of dark, sweet drink, which rendered her senseless. On going down stairs from the office, she met a Jesuit Father, whom she had met once before. This gentleman pulled her along the street to a little house in a court, where there was an upper room with a bed in it, and a cross on the wall. Having got her into this room, he said improper things to her, and gave her a little cake, which affected her directly. The woman of the house came into the room and found her on the floor, after which she somehow got outside; the priest following her, again dragging her along in the dirt to the street corner, when he ran away."
" The solicitor and the priest, both of them well known and highly respected, were thereupon placed under arrest in the middle of the night, on the charge of having administered certain poisonous drugs with intent to murder. The story was proved to be purely imaginary, and the magistrate dismissed the case."
Self-mutilation is sometimes practiced by hysteri- cal patients in order to obtain sympathy. The follow- ing is a case in point, which was reported some years since by Dr. Channing:*
" Mrs. Miller was first seen by us in 1875, a month
* American Journal of Insanity, January, 1878, p. 368.
— 9 —
after admittance to the asylum. She was an intelli- gent German Jewess, rather below the medium size, thirty years of age, hair and 'complexion light. She was then thin in flesh, pulse weak, hands red and cold, lips bluish, tongue pale and tremulous when ex- tended; but few of her teeth remained, and her face had a pinched look; her smile was very pleasant, but her expression at other times was suspicious and irri- table."
" She was in bed suffering from what seemed to be a severe attack of hsematemesis; various remedies were applied, but the hemorrhage continued several days unabated. Her bodily condition continuing, however, perfectly good, "notwithstanding the blood lost, simulation was suspected; treatment was sus- pended, and the bleeding ceased. The coffee-ground appearance of ejected matter she had imitated by vomiting food into her chamber-vessel and covering it with blood (pricked and sucked from her gums) and urine. This attack was followed by others of hysteri- cal dysmenorrhoea and dysentery. Toward the end of the month she became much depressed. * * * On the 25th of the month, in a paroxysm of despair, she broke twenty-three panes of glass; with a small piece of glass she cut her left wrist, and, inserted it into the wound, endeavored to reach the arteries. * * * She was much agitated, trembling from head to foot, and crying, but however said nothing. The next day she was very repentant for what she had done, and said that she
would never try to do it again; but in about three weeks she again became 'discouraged,' to use her own words, or depressed, irritable, and suspicious, and, be- ing enraged because she had been refused opium, cut her arms to avenge her wrongs. The wounds were immediately below the elbow, on the inner surface of the forearm, where the flexors are thickest. One cut was six inches in length, the other four. * * * She was crying, and endeavored to conceal the cuts when seen, and would say nothing as to the situation or number of pieces of glass she was said to have thrust into the wounds." On examination under ether, several pieces of g'ass were found in the wound and removed. Subsequently, she v^^ounded herself in like manner several times, with the result of finally setting up an erysipelatous inflammation, which, in its turn, was followed by oedema glottidis; suffocation appear- ing imminent, tracheotomy was performed; on the eleventh day the tube was removed, and the wound healed in three weeks after the operation.
For some time subsequently she appeared to im- prove; but after a time the mutilations were begun afresh and continued more or less frequently until June, 1877, when she cut herself for the last time, and soon afterwards "broke her chamber-vessel to pieces on the wall over her head."
" The following is a list of articles which have been removed from her arms and saved: ninety-four pieces of glass, thirty-four splinters, two tacks, four
shoe nails, one pin, one needle. Several pieces of glass, and the pins and needles first removed, were un- fortunately mislaid and lost. Including these, the whole number of objects removed amounted to one hundred and fifty. * * * The longest splinter was nearly six inches long." * * *
" Strange as it seems, she apparently experienced acute erotic pleasure from the probings which she was subjected to." * * * u gj^g ^^g ]^qq^ ^ery hys- terical, having frequent attacks of choking, globus hystericus, and imagined at one time that she had a spool in her throat, and could only swallow through the hole in the middle."
This case is certainly unique, as regards the character and extent of self -mutilation practised.
Dr. Channing also cites the case reported by Dr. Robie,* of the Dundee Asylum, in which an hysteri- cal woman swallowed a circular tea-cady, one and one-fourth inches in diameter, with suicidal intent.
Dr. J. B. Andrews, of the Utica Asylum, has re- ported a most interesting case, in which he removed three hundred needles from the body of a female pa- tient. The needles had all been inserted before she became a patient in the asylum. The patient was hysterical, and bore a strong resemblance, in some re- spects, to the case of Mrs. Miller, f • Soon after the introduction of anaesthetics, an
*Journal of Mental Science for July, 1875.
f Journal of Insanity for July, 1872; quoted bv Channing.
unusual form of accusation made its appearance in court. These accusations were based upon the allega- tions of certain women, to the effect that they had been outraged while under the influence of an anaes- thetic, in the office of a physician or dentist. Medico- legal literature abounds in cases of this character.* When these peculiar charges were first made in court there can be little doubt that gross injustice was fre- quently done, as both judge and jury were but too liable to lend undue credence to the women declaring them- selves aggrieved. In a short time, however, it became evident to court and jurors alike that the women who made these accusations had either labored under some unusual mental aberration, incident to the inhalation of the anaesthetic, or were the victims of some form of neurosis. It was natural, under these circumstances, that the thoughts of medical witnesses should revert to hysteria; and accordingly, at the present day, the connection of this insiduous affection with many cases of this kind has been clearly made out.
The following are evidently cases in point: " In 1854 a clergyman's sister came to my office for the purpose of taking ether and having a tooth extracted.
*Vide " Medical Jurisprudence " of Wharton and Stille.
"Artificial Anaesthesia and Anaesthetics," by Henry M. Lyman, A.M., M.D., etc. New York: William Wood & Co., 1881. Also
"A Manual of Medical Jurisprudence, by Allan McLane Hamilton, M.D., Birmingham & Co., New York, 1883.
— 13 — and brought her brother's wife with her. I began to administer the ether to the patient, and whilst renew- ing it she got away from me, and seemed alarmed and offended. I did not attempt to compel her to breathe any more ether, but urged her to take it, and so also did her brother's wife; but she would take no more; she had the impression, so her brother told me, that I attempted to violate her, and that his wife assisted me. It was a long time afterward before she would fully give up that she was mistaken in the matter."*
The following case is quoted by Lyman :f "A case of the utmost importance to the whole profession, not in Great Britain only, but everywhere, was tried before Mr. Justice Hawkins, at the assizes at North- ampton, on the 9th of November. It was a charge against a surgeon's assistant of criminal assault — of rape upon a patient when under the influence of chloroform. If there is a dastardly crime, it is to take advantage of a woman's helpless unconsciousness to violate her person. And so the magistrate thought, who sent the accused to jail on the 14th of September, declining to hear anything in his favor, and resolutely refusing to accept bail. The charge was that a mar- ried woman, named Child, went to the surgery of her family medical attendant to have her teeth operated
*Dr. N. L. Folsom, in the Med. and Surg. Reporter for January 12, 1877. Quoted by Dr. Lyman, op. cit., p. 95;
fContained in the Philadelphia Medical Times for De- cember 22, 1877.
— 14 —
upon. She had been there a day or two before, but the attempt to put her under chloroform had failed. A second attempt was rather more successful. She evidently had some peculiar idiosyncrasies in relation to chloroform, for he gave it for an hour, and yet she was never sufficiently under its influence to admit of the operation being performed. She was accompanied by a friend — a Miss Fellows. At the end of an hour Miss Fellows went out of the room and saw Mr. Child. In a quarter of an hour Miss Fellows returned. The prosecutrix maintained that on Miss Fellows' return she was quite conscious, but unable to speak. Find- ing it impossible to perform the operation, the accused accompanied the prosecutrix and her friend home. So far Mrs. Child had been unable to speak, but shortly after the accused left the house she complained to her husband that he had taken advantage of the absence of Miss Fellows to assault her criminally. Next day, when the accused called, he was told about what she had said, and he replied that she was labor- ing under a.delusion. Under cross-examination, Mrs. Child said that she told the accused that if he would admit the offense and quit the town (Birmingham) she would forgive him. This the accused declined to do, denying that he had committed any offense. He was then given into custody. The prosecutrix stated that the offense was perpetrated immediately after Miss Fellows left the room, that the prisoner went upon his knees and then assaulted her. Miss Fellows
— In- stated that on her return she found Mrs. Child in pre- cisely the same position in the chair which she occu- pied when she went out of the room. Such were the facts of the case. * * * j^ ^^g meantime the un- fortunate surgeon's assistant was sent to prison.
" When the case came to be tried, a large number of medical men of repute came forward voluntarily to aid the accused's defence, and did this quite gratui- tously."*
A number of cases were related by medical wit- nesses, in which females, undergoing operations at the hands of dentists and surgeons, had alleged that they had been criminally assaulted, persisting in this belief in some cases for years afterwards.
Finally, the judge demanded of the jury whether it was necessary to sum up, and they replied it was unnecessary; they were already agreed upon a verdict of acquittal. " Mr. Justice Hawkins pointed out that such a verdict would not be the slightest imputation upon the absolute sincerity of the prosecutrix, who, no doubt, firmly believed every word of what she had said. He then congratulated the accused upon hav- ing had an opportunity of fully vindicating himself upon the charge preferred, and said that the verdict of acquittal did not mean that there was insufficient
*Among these witnesses, was the celebrated Dr. B. W. Richardson, to whose testimony the subsequent acquittal of the accused was in great measure attributable.
— i6 —
evidence, but that the accused was entirely cleared of any imputation in respect to the charge preferred against him. * * * The accused was then dis- charged from custody, having been in prison two months for no offence."
It is a common belief among certain persons that the mental phenomena recorded above are due to some extraordinary effect of the anaesthetic. But it is a noteworthy circumstance that such cases are usually observed among neurotic, hysterical females, or among those in whom there is a strong erotic tendency. A certain constitutional predisposition seems, therefore, a pre-requisite in all'such cases. There can be little doubt that such an hysterical predisposition was pres- ent in the foregoing case, though the clinical history is somewhat incomplete on this point.
When such instances occur, diligent inquiry should always be made regarding the family history. The discovery of the existence of consanguineous insanity, or the affirmation of witnesses that the prosecutrix is of a " nervous," hysterical disposition, should be ac- cepted, in the absence of other more positive testi- mony, as proof positive of the innocence of the ac- cused. In our estimation the verdict rendered in the case above cited was most just and in entire harmony with the most enlightened scientific opinion.
Fictitious attempts at suicide are a favorite means of attaining sympathy among hysterical women. An instance of this kind came under my immediate notice
— 17 —
but a few weeks since. The history in brief was as follows:
Mrs. C, a young woman of apparently robust constitution, had been married but two years, when she became feverish and restless, complaining that, ever since the birth of her child, she " had not been the same woman." She also developed the idea that her husband was faithless in his marital relations, al- though the latter gave constant and convincing proof of his affection. Her constant complaining, and al- ternate weeping and laughter, caused such pain and annoyance to those about her that the family physician was consulted on several occasions with regard to her condition. On hearing that her medical adviser had expressed the opinion that she was a sufferer from hysteria, and that her sufferings were purely the pro- duct of the imagination, she became very angry, and declared that she was the victim of a "plot." Soon afterwards, while the family were sitting at table, she suddenly appeared m the room, and declared that she had taken poison, exhibiting, in corroboration of her assertion, a vessel containing a quantity of finely- powdered glass. During the scene of consternation which succeeded this tragic announcement, she pre- served an imperturbable exterior, and seemed rather gratified than otherwise at the sorrow depicted upon the countenances of those about her. When, however, the hastily summoned medical attendant proposed the administration of an emetic, and at the same time
— i8 —
made preparations to introduce the tube of a stomach pump, she protested vigorously, by word and action, biting and scratching those who attempted to restrain her. Finding, however, that her strength was failing, and that she was about to be overpowered, she confess- ed that she had not yet swallowed the broken glass, but was about to do so in the presence of the family, in order that her loss might be more "appreciated."
Such cases are common enough in practice, and when the previous history of the patient is accessible, they need cause but slight embarrassment.
It would be possible to multiply histories of like character, growing out of a morbid desire for notoriety and sympathy, almost ad infinititm. Medical and legal literature abound in cases of this kind. Without pursuing the subject further, however, we will content ourselves with stating that such instances are by no means confined to the female sex, but are found to prevail among men, though to a less extent than among women.
Besides the more pronounced mental phenomena exhibited by hysterical persons, which the foregoing description and cases have served to display, individ- uals of this class are subject to various other forms of psychical disturbance.
One of the most distressing mental symptoms found in the hysterical consists in a persistent morbid impulse to commit some act of violence. The objects of such morbid impulses are usually found among the
— 19 — immediate friends or family connections of the patient. Thus I was consulted recently by a German as to the mental condition of his wife, who had caused great uneasiness by announcing that she was afraid to re- main alone with her children, as she had an uncon- trollable impulse to "throw them out of the window.'' She also begged her husband to remove a revolver, which he was in the habit of placing under his pillow at night, as she declared that she felt an almost resist- less impulse to take the weapon and " shoot him in his sleep." Her general mental condition was described as "nervous," by which was meant that she was fretful, feverish, and lachrymose. In appearance she is stout and healthy, and the only derangement in bodily func- tion is an occasional attack of dysmenorrhoea.
This morbid explosiveness, this tendency to com- mit acts of violence, frequently finds expression in the destruction of inanimate objects. This form of men- tal disturbance is prevalent among young girls of hys- terical tendencies. Instead of the irritable and ex- plosive tendencies finding vent in violent conduct toward individuals, the destructive impulses are di- rected towards the inanimate environment. The bed clothes are torn into shreds ; tapestries are pulled down ; the clothing is thrown about, and the furniture broken in pieces. Sometimes the house is set on fire, and the most incredible intrigues concocted against friends and acquaintances. In many instances, as we have seen, the subject seeks to gain sympathy and notoriety
by her extraordinary conduct ; and to attain this end she does not hesitate to lie, defame at, or even commit murder. On the other hand, in not a few cases, it is utterly impossible to ascertain the slightest motive for the commission of the various heinous crimes of which the hysterical are guilty. Sometimes the duplicity of hysterical women is so profound as to baffle the efforts of the most expert medical witnesses. As a conse- quence, the ends of justice are frequently perverted, and on more than one occasion perfectly innocent per- sons have suffered at the hands of the law for crimes which have subsequently been shown to be the acts of hysterical females. From what has been said, it is evident that the medico-legal relations of hysteria are of the utmost interest and importance. Were this the proper occasion an entire chapter could well be de- voted to this branch of the subject ; but as such a digression would evidently transcend the scope of the present work we must content ourselves with referring to the excellent book of Legrand du Saulle,* and the more recent little work of Dr. Allan McLane Hamilton, which certainly constitutes a valu- able contribution to legal medicine.
Hysteria is frequently complicated with mental disturbances of such profundity as to constitute a ver- itable "insanity." By this we mean that the psychi- cal disturbances attain the gravity of mania or melan-
■^Les Hysteriques etat physique et etat mental, etc., par le Dr. Legrand du Saulle, Paris, 1883.
cholia, with sexual or uterine symptoms, feigned bod- ily affections and other deceptions, practiced with a view to obtain sympathy; and a morbid irascibility and erotomany. The erotic tendencies may be con- ^ cealed at first ; but careful interrogation and observa- tion almost invariably end in their discovery.
The threats and abortive attempts at suicide re- sorted to by the patient have usually little significance, and rarely result in grave consequences. Hysterical convulsions and retention of urine, of which we shall take occasion to speak later, are sometimes present.
Sometimes the diagnosis of this form of mental derangement presents peculiar difficulties, and there is great liability of confounding it with masturbational and "adolescent" insanity. The most we can do when doubts of this character arise is to postpone a definite verdict until all the facts in the case are thor- oughly known. We should, moreover, guard against pronouncing a case one of hysterical insanity until we have become thoroughly convinced that the hysterical symptoms constitute its most prominent feature.
Of hysterical insanity Clauston observes : " The fasting girls, the girls with stigmata, those who see visions of the Saviour, and the saints, and receive special messages in that way, the girls who give birth to mice and frogs, and those who live on lime and hair, are all cases of this disease."*
*0p. cit., p. 331 -
The following case, quoted from Clauston, is a fair illustration of hysterical insanity : " J. U., age 21, of nervous and excitable temperament; habits correct. An epileptic. Had on one occasion at home a mild attack of what must have been sub-acute maniacal excitement. The cause of the present attack, which had lasted for four days, was a fright which first produced ordinary hysterical symptoms, and then maniacal symptoms engrafted on them. She shouted and screamed, and spoke of hearing God speaking to her, and would rush to the window to jump out. She imagined she was a most important person, attitudin- ized, and did everything to attract attention to her- self. Attention and sympathy were craved by her, and if she could not get them in one way she tried another. She refused her food, saying it was pois- oned, but took it rather than be fed with the stomach pump. She had raenorrhagia, and was most mi- nute and circumstantial in the details as to her health. She was tried with hyoscyamine, valerian, and monobromide of camphor, with apparent benefit ; but I consider the greatest improvement was produced in her case by discipline, work, open air exercise, ton- ics, and good plain food in abundance. She improved at first, and once or twice relapsed, but in two months she recovered and was discharged. I do not like to keep hysterical cases too long in the asylum after con- valescence, as a general rule, for they sometimes get too fond of the place, preferring the dances, amuse-
— 23 — ments, and general liveliness of asylum life, even with its restrictions, to the humdrum and hard work of poor houses."*
The following is an exceedingly characteristic let- ter of a maniacal hysterical girl, and seems to illus- trate in a striking manner the morbid psychology of the subject : f
" My Dear Mamma — It is time that I leave to re- turn home. I have been tremendously changed for the better. I think papa will be able to get me a com- mission under Garibaldi before long. There are three to whom I am especially indebted — one Mr. C, the modeller, the other, the doctor, a eunuch who mod- elled me at the fire and attended me and bathed me. He is, I am sure, a gentleman, a splendid doctor. Could not papa get him into a regiment abroad? And there is the nurse. Could not papa get him a situation away from Morningside Asylum, where I am at present ? I should like papa to come for me as soon as possible. Do you remember the verse, " There are," etc. (12th verse, ix. chapter of Matthew) about eunuchs ? Then I beg to inform you that, according to Scripture and my conscience, Jessy, your cook, is
*" Clinical Lectures on Mental Diseases," by T. S. Claus- ton, M. D.. etc., Philadelphia, 1884.
f Taken from the " Morosonian Lectures," by Drs. Skaal and Clauston, for 1873, Journal of Mental Science" vol. xix, p. 500; vide also "Clinical Lectures on Mental Diseases," by T. S. Clauston, Philadelphia, 1884-1885, p. 341.
— 24 —
a man ; and Janet, the mad devil, is a man ; and D. and H., boys, who can have children. Aunt I. is a man, and yourself also, both made of men, and I am a boy, made of Dr. C. and Dr. Z. Mrs. T. is a man made of men. They are very ignorant on this sub- ject here ; but as for me, it is certain that at least the spirits have shown me, which Christ sent me when I was under drugs ; they showed me this. I have at times since I come here passed the shadows of death, and therefore am authorized to speak in opposition to all men and women, gentlemen and ladies, who oppose me. I am, I can swear, as you want to know what sex I belong to, a mixture of a nymph and a half man, half woman and a boy, and a dwarf, and a fairy. I know more than my fellow mortals, have expired eleven times before the time. — I am, etc."
CHAPTER 111.
SENSORY DISORDERS— HYPER/ESTHESIA.
Hyperaesthesia is an almost invariable accompani- ment of hysteria, and may involve a portion or all of the special senses. Sometimes there is an abnormal increase in the acuteness of the perceptive faculties; so that it is a subject of common remark, even among the laity, that hysterical persons see, hear, smell, and taste with greater keenness than those in health. Again there may be a certain degree of sensory per- version, manifested by a dislike for certain stimuli which by the healthy are looked upon with indiffer- ence or even regarded as pleasurable. Or there may exist a positive liking for sensations which, to the majority of mankind, are regarded with feelings of repugnance.
Coupled with these anomalies of sensation, there exists, in the majority of cases, a corresponding per- version of the higher mental faculties — a veritable '■''psychical hypercBsthesia," as Jolly calls it. We have already discussed the various mental disorders of the affection, which may properly be comprised under this heading, in the previous paragraph, and therefore ab- stain from further particularization on the present occasion. Coeval with these sensory disturbances, certain anomalies of perception appear, which, in the absence of all primary excitement of the peripheral
— 26 —
apparatus, cannot be regarded otherwise than as purely subjective. It is thus that the true hallucina- tions of hysteria originate — phenomena which un- questionably lie at the root of the illusions and delu- sions of the more serious mental complications of the affection.
Perversion and exaltation of the senses of smell and taste are especially frequent. The subject de- clares that she detects odors of an agreeable or repugnant nature, which remain imperceptible to those about her; and careful investigation shows that she really is able to discover the presence of astonishingly minute quantities of semi-inert substances. With this unusual power of perception there is often marked sensory perversion, manifested in a strong dislike for certain substances which by healthy persons are con- sidered to possess an agreeable taste or odor. Or the process is reversed, the subject expressing herself as delighted with the odor and taste of the most disgust- ing substances. Thus a lady afflicted with hysteria confessed to me that the odor of excrement was agreeable to her; while another patient, a young girl, tells me that the odor of eau de cologne excites in her feelings of the liveliest repugnance.
Cases exhibiting a decided increase in the acute- ness of the sense of smell are found in the literature of the subject, and are by no means as rare, according to my experience, as some writers appear to imagine. For example, the lady above referred to declared that
— 27 —
she was able to detect the presence of her four-year- old child by the aid of the sense of smell, when the latter entered unexpectedly a neighboring apartment; and a hysterical boy whom I have recently seen is able, according to his father, to appreciate the pres- ence of a dog or cat, even when the latter are at some distance and totally invisible. Doubtless similar in- stances will occur to most physicians of extended ex- perience.
When hallucinations of smell and taste exist in complicated cases, they are said to particularly facili- tate the establishment of more or less permanent delusions.*
I cannot say that my own experience agrees en- tirely with the foregoing, since I have found that hallucinations of other senses, particularly those of hearing, are quite as prolific of erroneous ideas as those of smell and taste.
Hyperaesthetic conditions of the organ of sight are frequently met with. Sometimes the subject com- plains that bright light is disagreeable to her, and resort is had to colored spectacles, which may afford apparent relief. In other cases the photophobia is so great that the afflicted women seclude themselves in darkened rooms for days together, refusing food ex- cept when brought to them. Sometimes the hyper- sensitiveness is only apparent in connection with
* Vide Jolly on Hysteria, op. cit., p. 497.
— 28 —
certain colors, especially red. Subjective sensations of light, assuming the form of spots, flashes, and sparks are also observed. In some cases, the subjec- tive appearances attain to the dignity of veritable hallu- cinations, which may be agreeable or repulsive in character. The physiological substratum of the con- dition known as ecstacy is unquestionably to be sought after among these visual hallucinations.
Sometimes the subject recognizes the subjective nature of many of these impressions; but in other cases it is impossible to convince her of the unreality of the phenomena. Under the latter circumstances delusive opinions may arise.
In some cases there is a manifest increase in the acuteness of vision, which is not to be accounted for merely on the score of a prolonged sojourn in a dark- ened room. The extraordinary narratives of the vis- ual powers of hysterical persons, in which the latter are said to read with their back turned or with closed eyes, are evidently unconscious perversions of the truth or gross deceptions.
The sense of hearing is often exaggerated in hysr terical persons to such a degree that they readily ap- preciate sounds which are imperceptible to healthy mdividuals. So sensitive do they become to sound that such an ordinary occurrence as the squeaking of a door, the rumbling of a cart, or the cry of a child is sufficient to cause the most intense annoyance. Subjective sensations, such as ringing.
_ 29 —
blowing, roaring, humming, and singing are frequently encountered; and true auditory hallucinations are also met with. As we have already had occas.on to observe, the latter frequently result in establishment of more or less pronounced mental aberration.
In almost all cases of hysteria there is present a morbid sensibility to pain. This exalted susceptibility to painful impressions may be confined to the skin or may involve the more deeply seated tissues. It is sub- ject, moreover, to irregular topographical distributions. This is particularly true of cutaneous hypersesthesia, which, though sometimes general — being distributed over the entire surface of the body — is often confined to certain isolated regions of the integument. Some- times the skin of one half of the body, or one or more extremities, or of certain portions of the trunk, is alone affected. In yet other cases hyperaesthesia and anaes- thesia are encountered side by side, or at all events isolated anaesthetic islands are found in the midst of more or less extended hyperaesthetic areas. These curious phenomena certainly constitute a most enig- matical chapter in pathology; but it would be a practi- cal waste of time to examine the various more or less ingenious hypotheses which have been advanced with a view to their explanation.
When the cutaneous hyperaesthesia is general, the patient suffers great torture on attempting to execute such simple movements as turning about in a chair or dressing. In the more exquisite cases, the mere im-
— 3° — pact of the bed-clothes is sufficient to cause acute pain, and in some instances convulsions.
Besides the hypereesthetic phenomena above re- ferred to, almost all hysterical individuals complain of pain, which may be diffuse in character or confined to the most diverse localities. Sometimes the pain is felt over the entire extent of the abdomen, and may be associated with tympanitis. x\t others neuralgic pains are present in the mammary glands, the latter being often of such intensity as to render the contact of the clothing or bed-linen absolutely unendurable. The hyperaesthesia is particularly marked during the menstrual period. Cardialgia is another frequent symptom of hysteria, and one which is often associated with more or less persistent vomiting — a combination of symptoms which may give rise to the erroneous preconception that we have to do with perforating ulcer of the stomach. This impression is furthermore enhanced by the fact that hysterical females are often great gourmands, devouring everything set before them with an appetite apparently insatiable. It is evi- dent that such persistent gluttony can only result in. an aggravation and perpetuation of these digestive disturbances; indeed, I am not sure but that this over- loading of the stomach constitutes the starting point of many of the gastric disorders to which the hysteri- cal are liable.
Hysterical persons are often afflicted with an hyperaesthetic condition of the ovaries, associated, in
— 31 —
many instances, with anaesthesia of the same side. At the same time they complain of irritation about the external genital organs, associated with a morbid in- crease of sexual excitement. This latter condition, which is particularly pronounced at the time of men- struation, may give rise to reflex spasm of the sphincter muscle (" vaginismus ")* a state of things peculiarly unfavorable to coitus. Owing to the irritated condi- tion of the urethra and bladder, which is an almost constant concomitant, the desire to urinate is frequent, and the act is rarely accomplished without consider- able pain.
Dorsal pain is a more or less frequent accompani- ment of hysteria. Sometimes it is situated in isolated spots between or above the scapulae, at others it is dis- tributed in a more or less continuous band along the course of the vertebral column {spinal irritation). In the more exquisite cases the slightest pressure above the vertebrae is sufficient to cause severe pain, while the passage of the wire-brush, with a moderate cur- rent, along the spine is sufficient to reveal the presence of hyperaesthetic spots, in the less severe cases. Sensi- tiveness of the uterus, though not a constant symptom as formerly supposed, is frequently met with; and while doubtless dependent, in some instances, upon
*Vide the writings of Drs. J. Marion Sims and T. Gail- lard Thomas; also, Axenfeld et Heuchard. " Traite des nevroses," Paris, 1883.
— 32 —
uterine disease, must in man}- other cases be regarded as of purely neurotic origin.
Thus cases of uterine pain are often met with in those who have been treated for protracted periods for some form of supposed disease affecting the uterus without the slightest beneficial result. But when placed upon the back and treated according to the system of spinal rest so ably advocated by Mitchell, they often display astonishing improvement in a short space of time.
Of great theoretic and practical interest are the pains occurring about the joints of hysterical persons pains which are frequently mistaken for symptoms of true articular disease.
To Sir Benjamin Brodie* has been ascribed the credit of having directed the attention of the profes- sion to the frequency of these enigmatical symptoms.
When pressure is exercised upon the joints of those affected by this form of articular neurosis, severe pain is produced. It is evident, however, that this pain is located in the soft tissues about the joint rather than in the latter, since the forcible apposition
*Brodie, Sir Benjamin, " Lectures Illustrative of Certain Local Nervous Affections," London, 1837. Also Esmarch, Ueber " Gelenkneurosen," 1872. Stromeyer, " Erf ah run gen ueber " Localneurosen," Hanover, 1873. Werner, "Ueber Nervose Coxalgie," Deutsche Zeitschrift fuer Chirurgie, Band L Berger, " Zur Lehre von den Gelenkneuralgien," Berliner Klinische Wochenschrift, 1883.
— 33 —
of the articular surfaces fails to produce the disagree- able symptoms and shock peculiar to true joint-dis- ease. Atrophy of certain muscles has been noted by some observers,* after the affection had continued for a series of years. It is probable, however, that the attenuation of the muscles is never so great as in organic disease of the joints.
The articulations most frequently involved are the knee and hip joints, but even the smaller joints of the wrists, ankles and, fingers are sometimes af- fected.
It is evident that an accurate diagnosis in cases of this kind is of the utmost importance, since, if the affection be mistaken for true joint trouble, the patient is liable to all the inconvenience arising from pro- longed antiphlogistic and orthopaedic treatment. Be- fore delivering a final opinion, therefore, the patient should be subjected to a rigorous physical examina- tion. At the same time the most searching inquiry should be instituted regarding her general physical and mental health, with a view to discovering any in- dications of hysteria or other neurotic trouble. Not until we have exhausted the last resources of investi- gation are we justified in forming a definite conclusion as to the nature of the affection.
*Vide "Nervous Mimicry of Organic Disease, by Dr. J. Paget. The Lancet, Vol. II. 1873.
— 34 —
The following cases reported by Skey* are fair illustrations of these joint affections:
"Annie W , aged twenty-two, was admitted
into Treasurer's Ward in the spring of last year. She had been confined to her bed for twelve months, and was sent up from her parish, near Bedford. During twelve months she had been totally deprived of motor power in the left leg, and during ten months in the left arm. The two extremities lay on the bed perfect- ly motionless and paralytic. Indeed, her case was re- ported to me as one of hopeless and incurable palsy. There was something strange in the girl's aspect, and in the total absence of motor power extending to the toes. A truly paralytic limb is rarely so dead as these limbs were; we can often obtain some sligh manifesta- tion of volition, even though in the slightest motion of one or more of the toes. In this case there was ab- solutely none detectable to the eye. I suspected it to be a case of hysteria, and ordered her valerian and ammonia in full doses after the first three days; meat diet and porter. In four days movement on voli- tion was perceptible in all the toes and in the hand. In a fortnight she could move her arm and leg slowly in all directions. In one month she walked on crutches about the ward, and in six weeks she left the hospital convalescent."
* " On Hysterical Affections of the Joints," by Frederic C. Skey. F. R. S. The Lancet, March 12, 1859.
— 35 —
The history of the above case is not as complete as might be desired; but the following instance, quoted from the same author, is more to the point:
" Eliza J , aged twenty-two, was admitted in- to Treasurer's Ward in April last with an affection of the knee, which incapacitated her for movement of any kind on the affected limb. The joint was scarcely perceptibly swollen, yet she could not bear the most superficial examination by the hand without an ex- pression of pain quite disproportionate to the apparent amount of disease. The temperature of the joint was slightly, but not much, increased. The only explana- tion obtainable from the girl's statement referred the injury to a fall six weeks prior to her admission, and three weeks before the first appearance and even the suspicion of disease. During the interval of the first three weeks, she " thought the joint felt occasionally more stiff than usual." This girl had a somewhat florid complexion; she had a weak pulse, and, as almost a matter of course, had cold feet and severe headaches. Both sides of the joints bore marks of previous treat- ment in the form of pretty active scarifications. It appeared that blood had been taken from the joint by cupping on two occasions, to the extent, as nearly as I could learn, of about twelve ounces; and a blister of some magnitude had been applied on its front surface. From these remedies I could not ascertain that any benefit had been derived to the affected knee, and she thought, on the whole, her attacks of. headache had
- 36 -
been more frequent and severe. Her bowels were habitually constipated. I ordered her the local appli- cation, for three or four consecutive nights, of a lini- ment composed of two drachms of the fluid extract of opium to an ounce of compound soap liniment, and the joint to be rolled with flannel; twice a day a draught of ammonia and valerian; full diet with a pint of porter daily. The local application was continued with intervals, for eight or nine days, with much re- lief and without return of pain. At the expiration of a fortnight the medicine was changed to eight-grain doses of ferro-citrate of quinine, and she left the hos- pital in five days convalescent."*
* Other contributions to the literature of the subject are: " Nervous Mimicry of Organic Diseases," by Sir. James Paget, The Lancet, Nov. i, 1873. " Paralysie hysterique, attitude vicieuse, pied bot consecutif," by N. Damaschino, Gazette des Hopitaux, 1879, P- 5^- "Diseases of the Nervous System," Lecture on, by Francis E. Anstie, M. D., The Lancet, 1873, Nol. I., pp. 437-
CHAPTER IV.
SENSORY DISORDERS CONTINUED. — ANAES- THESIA.
AncBsthesia. — Sensibility is frequently diminished or even entirely lost in hysteria. Sometimes the an- aesthesia is circumscribed in character, as we have already had occasion to observe, whereas in a certain per cent, of cases it may involve the greater portion of the integument, and even extend to the muscles and other deep-seated tissues. Nor do the nerves of special sense escape; but, on the contrary, as we shall presently see, their implication often gives rise to pro- nounced functional impairment. Cutaneous anaes- thesia usually appears after an hysterical attack, and is liable to aggravation from subsequent seizures. The anaesthesia thus induced exhibits certain ambli- tory characteristics of a most interesting nature from a clinical standpoint. Thus, after a fresh attack, the anaesthesia may apparently disappear; but, on careful examination, other parts are found to be affected. Or, the previously anesthetic portions of the integument may become hyperaesthetic.
Sometimes tactile and thermic sensibility as well as sensibility to pain are impaired or lost; but as a rule the capacity to appreciate pain is alone affected. The distribution of the anaesthesia is subject to great
variation. In a considerable number of cases it is situated on the dorsal aspect of the hands and feet; in another category of patients one or more limbs are in- volved, whereas in a small per cent, of cases it is limited to one-half of the body. Anaesthesia of the entire integument is least frequently met with.
Anesthesia of the various mucous membranes is frequently encountered, and gives rise to a variety of secondary phenomena. Thus, if the nasal mucous membrane be anaesthetic, irritating substances and tickling fail to cause sneezing. If the conjunctiva be affected it may be touched and irritated by foreign substances without giving rise to a flow of tears or reflex spasm. In anaesthesia of the pharynx and adjacent parts, the membrane in question may be titillated and otherwise irritated without giving rise to vomiting; and if the loss of sensibility be very exten- sive, taste and smell may be abolished. That the bladder and rectum may sometimes be involved seems probable from the fact that they are sometimes greatly distended by the accumulation of feces and urine, a condition which causes the patient no appre- ciable discomfort.
The mucous membrane of the vulva and vagina is frequently profoundly anaesthetic. It is this condition which causes that complete loss of sexual appetite sometimes observed in married women, a state of affairs prolific of conjugal unhappiness.
As we have already had occasion to remark, the
— 39 — special senses frequently become anaesthetic after severe hysterical attacks. Sometimes the sense of smell and taste may be entirely lost; at others the sensory impairment is unilateral. Unilateral and even bilateral deafness are sometimes observed in the ab- sence of all disturbances affecting the peripheral ap- paratus of hearing.
More or less profound visual disturbances are also encountered among the hysterical; the most fre- quent of these is probably unilateral amblyopia. Com- plete amaurosis is, however, also observed. Of ninety-three cases of ansesthesia of different sensory districts examined by Briquet,* amblyopia was present in six instances.
Without entering upon a further consideration gf these anomalies of vision, which have been exhaust- ively discussed by Charcot and others, I will simply observe that examination with the ophthalmoscop usually fails to reveal any noteworthy changes in the disks. The case described by Galezowsky exhibited infiltration and capillary reddening of the disk; but the amblyopia had existed for a long time without opthalmoscopic changes, and it is consequently reason- able to infer that the latter were induced by some unknown intercurrent causes. In accordance with what we already know of the amblitory nature of
* Quoted by Jolly, op. cit.
— 40 —
hysterical symptoms, we are not surprised that both hysterical blindness and deafness sometimes suddenly disappear and give place to other phenomena.
CHAPTER V.
MOTOR DISORDERS.— SPASMS.— PARALYSIS.
Motor Disorders. — The phenomena of motility, like those of sensibility, may be exaggerated or diminished.
Spasms. — These may be of a tonic or clonic na- ture, and are manifested either as circumscribed twitchings of individual muscles or groups of muscles, or as convulsions involving the motor apparatus, more or less extensively.
When the spasm is located in the pharynx and oesophagus, it gives rise to the sensation of choking known as globus hystericus, a term which has been ap- plied to this condition from the fact that the subject complains of feeling a ball in her throat. So con- vinced are most females of the objective reality of these sensations, that they make the most strenuous efforts to swallow the foreign body, apparently lodged in the throat; and, failing in this, they attempt to dis- lodge it with the finger, or by the aid of a hair-pin. In certain cases the spasm of the oesophagus may be so severe and persistent in character as to induce the belief that organic stricture is really present. When the spasm extends to the tongue, which occasionally happens, the organ is distorted' to such a degree as to greatly interfere with articulation and swallowing.
Sometimes, too, the stomach becomes involved in
— 4^ — the spasm, and, consequently, the retention of food becomes almost impossible, the subject vomiting her food immediately after it had been swallowed. Peris- taltic movements of various portions of the intestines, accompanied by borborygm, eructations and colicky pains are sometimes present. When this spasm of the intestine become localized and persistent, stricture may be produced. As a result of this condition the progress of the foeces is impeded, while at the same time, owing to the incarceration of gas above the point of constriction, the bowel becomes so distended as to give rise to the phenomenon known as a " phantom tumor." Sometimes, however the results of the per- sistent spasm are even more serious, and a veritable intestinal obstruction may occur.
The genito-urinary apparatus may also become the seat of spasm, and in a considerable percentage of cases the latter gives rise to spasmodic retention of urine, which is, curiously enough, associated with a persistent desire to urinate. This desire to micturate is explicable in most cases by an unusually hyperses- thetic condition of the bladder, which may or may not be associated with irritability of the vagina and vulva.
When the hyperaesthesia of the genital organs is great, reflex activity is sometimes increased to such a degree as to render coitus impossible. Under these circumstances the mere contact of the male genital organs with the vaginal orifice is sufficient to provoke severe and painful vaginismus. Concerning the causa-
— 43 — tion of vaginismus, Scanzoni published some interest- ing statistics in 1868. These observations have been summarized by Dr. T. Gaillard Thomas* as follows: "During the preceding three years he (Scanzoni) had seen thirty-four marked cases, due chiefly, he thought, to violent efforts at sexual intercourse, practiced upon women having small vaginas and well-developed hymens. Scanzoni found that twenty-five of his thirty- four patients had various functional and organic diffi- culties, which in twenty cases had come on after marriage; in eleven there was congestive dysmenor- rhoea; in one, amenorrhoea had existed for three years; in thirteen, there was chronic metritis; four had either ante or retroversion; in one there was perimetritis; in seventeen, chronic uterme catarrh; in fourteen, vagi- nal catarrh; in one, anteflexion; in two, retroflexion; nine had urinal difficulties; one had inflammation of the right Bartholin's gland; in fourteen there were symptoms of anaemia; and in seventeen of hysteria.'" \
And continuing. Dr. Thomas \ proceeds to state that: "Although the sexual act could not be fully completed, conception was not entirely impossible, as out of the thirty-four cases two had conceived; in the other thirty-two, sterile marriages had existed from one
* A Practical Treatise on the Diseases of Women, by T. Gaillard Thomas, M. D., Philadelphia, 1878, p. 143. f The italics are ours. X Op. et loc. cit.
— 44 — to eleven years. This sterility was not due to want of sexual desire, but arose entirely from spasm involving all the muscles of the pelvis, which also rendered ex- amination, either by the touch or speculum, impossible without the use of an anaesthetic."
The hysterical attack, which we shall presently take occasion to describe more in detail, is frequently characterized by screaming, crying and laughing of a more or less spasmodic nature. In this connection it is well to bear in mind that the spasmodic closure of the glottis, which sometimes takes place during these seizures, may give rise to dangerous dyspnoea. Con- sequently, the medical attendant should be prepared to act with energy and precision.
Of diagnostic importance only secondary to globus are the more or less incessant facial contortions, the "facies hysteria" of the older writers — an appearance characterized at once by a certain fulness of the cheeks and a drooping of the eyelids.
Paralysis. — Complete or partial loss of muscular power is frequently present in hysteria. Sometimes the paresis is exceedingly limited in character, involv- ing but one or two small muscles. Thus it is probable that the drooping of the eyelids, so characteristic of hysterical women, is due to weakness of the lavator palpebrae superiosis muscles. In some cases, however, the paralysis is much more extensive, involving one or more limbs, or assuming the form of hemiplegia or paraplegia.
— 45 —
The evolution of these motor disturbances is, in some cases, extremely gradual, the first symptom worthy of note being a sensation of weakness or heaviness in the affected extremities. Sometimes, however, the advent of the paralysis is sudden, and takes place without the slightest warning, usually after an hysterical seizure.
In cases of hysterical paraplegia, in which the muscles of the lower extremities are only partially or slightly affected, the patient is able to walk about by the aid of a cane or crutch; when, however, the motor disturbances are more profound in character, she may be confined to her bed.
With the more or less extensive paralysis of hys- teria, anaesthesia is frequently associated. Sometimes cutaneous sensibility is alone affected; but, on the other hand, in not a few cases the anaesthesia extends to the subjacent muscles.
Like so many of the other symptoms of hysteria, these paralytic phenomena are often amblitory and evanescent in character. Sometimes they disappear from one side of the body only to reappear on the other. Sometimes, again, the paralysis may persist for a few days, weeks, or months, and then suddenly disappear altogether. But it would be a mistake to infer from such disappearance that the subject is henceforth exempt from accidents of the kind, since it not infrequently happens that, even after the lapse of several years, the paralytic symptoms again return subsequent to an exceptionally severe seizure.
- 46 —
With regard to the differentiation of the paralytic phenomena of hysteria from true paralysis, resulting from organic lesions, this much may be briefly stated: That hysterical paralysis is, almost without exception, accompanied by the psychical disturbances, hyperaes- thesia, spasms, and numerous other manifestations of the disease; so that the evidence afforded is so preg- nant that mistakes are usually easily avoided.
After all has been said, however, which the sub- ject admits of, it must be admitted that where the typical hysterical phenomena are slightly pronounced errors are extremely liable to occur. But to admit this fact affords no extenuation for those errors in diagnosis and treatment which are so constantly perpetrated, even where the evidence is most con- clusive.
Before concluding the consideration of the motor anomalies of the affection, a word respecting those contractures which have been so repeatedly and ably described by recent French authors.*
When tonic spasms in the muscles of the limbs are both severe and persistent, certain distortions of the latter are produced, which may be evanescent or recurrent in character, or may persist for a series of years. If the contracture be situated in the upper ex- tremity, the forearm, hand, and fingers are rigidly
* Vide Charcot, " Lecons sur les Maladies du System Nerveux," Paris, 1872-1873. Also, Bourneville et Voulet, " De la Contracture HyKterique," Paris, 1872.
— 47 —
flexed, so that extension is often impossible. But if the spasmodic condition be present in the lower limb the latter is extended upon the pelvis and the leg up- on the thigh. At the same time the foot usually as- sumes the attitude of talipes equino-varus, while, owing to spasm of the adductors, the thighs are rigidly approximated.
Sometimes these contractures may persist for a series of years and then disappear without other warn- ing than some form of violent mental disturbance. The final result is not, however, always so fortunate; since, after the contracture has continued for a long time, atrophy of the affected muscles may occur. If, under these circumstances, a careful electrical exam- imation be instituted, it is often possible to demon- strate a well-marked degenerative reaction.
Tremor is sometimes observed to accompany these contractures, and may be evoked by any sudden tension of the muscular system. In exquisite cases the knee-tendon reflexes may be exaggerated. In a case of this kind, in which the contractures had per- sisted for many years, Charcot* was able to demon- strate, by post mortem examination, sclerosis of both lateral columns of 'he cord. To infer, however, from this fact that the presence of tremor in these cases is an infallible indication of an organic lesion of the lateral columns is manifestly impossible, since recovery
* Cited by Bourneville, op. cit.
sometimes takes place after the tremulous condition has persisted for a long time. On the other hand it is possible, and perhaps even propable, that in old contractures with atrophy a lesion more or less per- manent in character is actually present; and, further- more, it is even conceivable that such a lesion might extend to the anterior horns of gray matter. Assum- ing this to be the actual state of things, both the per- manent contracture and subsequent atrophy are easily accounted for. Speculations on this point are, how- ever, of little avail in the present state of knowledge; and, in spite of the mterest attaching to Charcot's case, a single instance of this kind cannot set at rest a question of such magnitude. Evidence in corrobora- tion or rebuttal is, therefore, in order.
It should be borne in mind, in this connection, that tremor is not, however, necessarily always accom- panied by contracture, but may exist quite independ- ently of the latter. I have at present a case of this kind under treatment. The patient, a young man of thirty, exhibits a variety of hysterical mental and physical symptoms, and not the least interesting feature in the case is persistent tremor of the facial muscles, which is also present to some extent in the hands. There is, however, no tremor in the tongue. The tremulous condition, which I have already succeeded in ameliorating to a considerable extent, is excited by insignificent emotional disturbances, and resembles closely the tremor of paralysis agitans.
CHAPTER VI.
VASO-MOTOR DISORDERS— THE HYSTERICAL COUGH.
Vaso-motor Disorders. — These are frequently ob- served in hysteria, and may consist in a local diminu- tion in temperature — a condtion peculiarly prone to occur in hysterical joint trouble, as Brodie and others have observed; or the vaso-motor insufficiency is ex- hibited in frequent and unaccountable blushing. Car- diac derangements of a functional nature are also frequent accompaniments of hysteria, and are usually associated with general anaemia.
The various miraculous accounts of hysterical persons, whose wounds "emitted little or no blood," are probably founded upon the observation that bleed- ing is much less profuse in the anaesthetic regions of such individuals than in other portions of the body. Charcot, I believe, was the first to draw attention to this fact.
Remarkable and sudden elevations of tempera- ture are sometimes observed in hysteria. These ther- mic variations have been recorded in medical literature by a number of reliable witnesses; so that, although intentional deception has undoubtedly been resorted to in some instances, it must be regarded rather as the exception than the rule. Some of these cases possess great interest from a theoretic point of view.
— 5° —
The Hyste7-ical Cough. — Among the local manifes- tations of hysteria, to which more or less extended reference has already been made, there remains to be enumerated the phenomenon known as the hysterical cough. It consists in a succession of explosions of air through the glottis, of such rapidity as to cause the impression that the cough is continuous. These paroxysms of coughing are rhythmical in character, and at the same time wholly unaccompanied by ex- pectoration. There is no dyspnoea during the interval; respiration is somewhat less profound than usual, and physical examination of the chest yields only negative results.
As a rule the character of the cough is hard and dry; but in its more complex manifestations it is some- times accompanied by aphony and vomiting.
The hysterical cough is a chronic affection, re- markable for its tenacity, persisting for months and even for years. It is, moreov.er, more or less exempt according to Lasegue, from the influences arising from menstruation and other intercurrent events of physio- logical consequence. The results of treatment are, as a rule, by no means flattering, and recovery usu- ally takes place suddenly and without warning, or by slow and almost imperceptible degrees. In whatever manner recovery takes place there can be no cer- tainty that the restoration to health is permanent, since relapses are of frequent occurrence.
The affection is confined to women, and has al-
— 51 —
most always been observed before the age of five and twenty.*
According to Lasegue it is peculiar to no par- ticular form of hysteria, though Sydenham is of a con- trary opinion, f
When the origin of the attack is traceable to a simple cold, the subjects usually exhibit no particular predisposition to catarrhal or pulmonary affections. Upon close inquirj^, however, most cases of the kind disclose the histories of previous hysterical attacks, or at all events there is evidence of strong neurotic tendencies.
During the persistence of the cough the appetite is diminished and the digestive functions may suffer more or less. There may also be a considerable loss of flesh. But whatever the general symptoms ob- served, the latter are rarely of sufficient gravity to justify the anticipation of a fatal termination. With- out entering upon the details of the subject further, I will cite a case or two from my own practice and that of others. The following extraordinary case of hysterical cough is reported by Dr. Hartley:| " In
* " De la Toux Hysterique," by Dr. Ch. Lasegue, Archives Generales de Medicine, 1854, vol. I, p. 513.
f Op. cit., p. 517.
X Extraordinary case of spasmodic cough in a girl aged fourteen years. Recovery under the influence of valerianate of zinc and the cold douche. The Medical Times and Gazette, vol. II., p. 116.
— 52 —
the end of January last Rebecca D., a tolerably well- developed, dark-complexioned girl of fourteen years of age, came under the care of Dr. Hartle)'-, at Uni- versity College Hospital, complaining of weakness, loss of appetite, and suppression of the menses. She had menstruated regularly two or three times, and then ceased to do so during the three months prior to her appearance at the hospital. Tonics, both mineral and vegetable, were administered, and the girl went on improving until March 31, when the mother brought her back to the hospital, saying that four- teen days previously she had been seized with a cough, which gradually got worse, until it became al- most incessant. In fact, according to the mother's account, the girl never ceased coughing from the time she rose in the morning till the time she went to bed at night. While standing in the waiting room the patient coughed incessantly, and as she was a highly hysterical girl she was kept there for nearly an hour, in order to try and tire her out. But at the end of the hour she was just as bad as when she entered the room. It was one continual round of short barks (she did not give herself time to fill the lungs com- pletely in order to be able to give a proper cough), with no perceptible interval even for respiratory pur- poses. The mother declared that she could not take food. On being scolded and ordered to cease cough- ing, she burst into tears; but the cough went on. The patient answered questions hurriedly, and while
doing 50 she did not cough, but with the last words the cough recommenced. After a time it was found that she could control the cough by an effort of the will, but only for a few seconds. There was no chest affection, and no apparent disease of the throat or fauces. The cough seemed to be entirely spas- modic-Iaryngeal and the result of hysteria. One of the students counted at inter^-als the frequency of the cough, and without the patient's knowledge, and it was found that she coughed at the regular rate of seventy per minute, or four thousand two hund- red times per hour. And reckoning that the girl coughed during twelve hours out of the twenty-four, if the mother, an intelligent and not at all enthu- siastic female, was to be believed, the girl coughed more than that— she must have coughed the enor- mous number of fifty thousand four hundred times daily (5 0,400). A mixture containing the valerianate of zinc, the tincture of asafoetida, and camphor was ordered to be taken three times a day, and a cold douche with frictions to the spine to be applied night and morning. On April 7 the patient was again brought to Dr. Hartley, and the mother with evident satisfaction stated that the cough had gradually ceased three days after the commencement of the treatment, and now the patient only coughed once or twice a dav. On questioning the mother closely she stated positively that the girl had coughed incessantly, except when she was in bed (it ceased immediately on
— 54 —
lying down), during eight days, and that the cough was just as frequent at home as it was while the patient was in the hospital. So that if we even reckon seventy per minute, and for only nine hours a day, during the eight days she would still have cough- ed the almost fabulous number of 302,400 times. As the treatment related had proved so successful, it was continued for a fortnight, and then changed to quassia and iron.
The catamenia reappeared on May 19, and from that time the girl went on improving until June 2, when she was dismissed as cured.
The following case came under my observation some years since, while serving a portion of my medical apprenticeship as resident physician to the Hudson River State Hospital for the Insane:
A. C, a girl aged nineteen years, of nervous tem- perament, was committed to the hospital on account of several mild attacks of what was evidently subacute maniacal excitement. The cause of the last attack was a severe fright caused by threats, on the part of her mother, of sending her to jail if she did not "stop her everlasting coughing."
Upon entrance into the hospital, and while I was endeavoring to record the principal points in her case, she coughed so incessantly and loudly that I was obliged to have her conducted to a remote female ward. On the following day, I learned, upon inquiry, from the attendant that she was menstruating co-
— 55 — piously, and that she was suffering acutely from dys- menorrhoea. Her conduct was mischievous in the ex- treme; she called out the window to the patients en- gaged in work upon the farm, and addressed them as angels; she tore the aprons and other articles of ap- parel from the persons of the female patients about her, and then ran away laughing and crying in a most hysterical manner. After every explosion of this kind she was seized with violent and continuous coughing, which lasted for two or three hours.
After she had remained in the hospital for some months, it was found that these attacks of coughing invariably began a short time before menstruation and continued until a day or two after the subsidence of the same.*
Examination of the chest and larynx yielded ab- solutely negative results.
What eventually became of this patient I am un- able to state. She was removed from the hospital up- on the subsidence of the mental symptoms; but the at- tacks of coughing remained unaffected up to the time of her departure.
The attacks ceased completely during sleep in this case, a point upon which great stress is placed by some diagnosticians.
*The connection between the menses and the cough is apparently contrary to the experiences of Lasegue and others; though I am convinced from this case of its existence, at least in some cases.
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Dr. Synclair* presents the following case as an instance of the " acute " forms of hysterical cough:
A young girl of eighteen years, having had sev- eral attacks of hysteria, complained of rheumatic pains and headache without febrile disturbances. Fifty drops of laudanum mixed with a little water were prescribed for her. On the 2 2d of October, immedi- ately after the administration of the medicine, the pa- tient was seized with a continuous cough. There was no dyspnoea, no febrile movement and no pain about the throat. At night, while asleep, the cough ceased altogether, but only to return the following morning upon awaking. Thus matters continued in spite of treatment until the fourth day, when the cough sud- denly disappeared to return no more.
This case does not appear sufficient to establish the existence of an acute variety of the affection, and I therefore cite it merely on account of the intrmsic interest which attaches to the case, and entirely irre- spective of any theoretic significance which it may possibly possess.
* Edinburg Medical and Surgical Journal, 1825.
CHAPTER VII.
THE HYSTERICAL PAROXYSM.
The Hysterical Paroxsym. — By hysterical attacks are commonly understood certain general tonic and clonic convulsions associated with peculiar psychical manifestations.
It is impossible to give a description of these at- tacks of sufficient breadth to cover the manifold varia- tions of which they are capable, and we shall therefore confine ourselves to a delineation of the more salient features, trusting to the resources of individual ex- perience to fill in the details of the picture.
In the milder forms of the attack there are rhythmical clonic spasms of the extremities, while at the same time respiration is accelerated, irregular, or interrupted. Consciousness, however, is not abolished, since the subject gives evidence of understanding what is said in her immediate neighborhood, and is also able to exercise a certain amount of control over her movements. The duration of an attack of this kind is usually brief, rarely lasting more than a few minutes. Sometimes, however, the primary attack is followed by a rapidly occurring series of others, and we have a somewhat analogous condition to that which is present in certain forms of epilepsy. The course of the attack is, however, by no means always
— 5» —
so benignant in character as the foregoing description would indicate. In the more severe forms of the seizure, consciousness is completely lost; the convul- sions become tetanic, the trunk and extremities be- come fixed and variously distorted; there is frothing at the mouth and the respiration becomes slow and stertorous. The convulsions, which were alternately tonic and clonic in character, resemble so closely those of true epilepsy that the seizure cannot be dis- tinguished from the latter. This close resemblance has gained for these paroxysms the designation of ^'' Hystero- Epilepsy,'' a title which has found favor among recent medical writers of France where a vast literature upon the subject has made its appearance.
Previous to the attack, and indeed throughout the interparoxysmal period, the hystero-epileptic sub- jects complain of the most varied hysterical symptoms. Hemiangesthesia and hyperaesthesia of the ovaries are among the most constant symptoms observed.
The paroxysm itself is usually preceded by an aura emanating from the affected ovary and proceed- ing in an upward direction. When the aura has at- tained the upper portion of the trunk, the subject utters the loud and piercing cry peculiar to epileptics, and falls to the ground in an insensible condition. Tetani- form spasms of the muscles now makes their appear- ance. The muscles of the neck, trunk, upper and lower extremities, are rigid; respiration is labored and infrequent; the mouth is bedecked with foam, and the
— 59 — tongue is protruded between the teeth, lending a re- pulsive appearance to the countenance.
Upon the stage of tetanic muscular contraction, there succeeds a period of complete muscular relaxa- tion, during the continuance of which the breathing is stertorous and the mental condition one of coma. Soon, however, the exaggerated muscular phenomena again make their appearance, this time in the form of violent interrupted contractions, which give rise to the most varied distortions. The body is bent violently backwards and maintained in an opisthotonotic position; or it may be rigidly extended, while the limbs are flexed or extended, or it may be bent for- wards or laterally (pleurosthotonos). Sometimes the subject executes gesticulations of an evident purposive nature, which, though in some cases characterized by violence, are quite as often devoid of all injurious in- tent, and recall forcibly the antics of a harlequin. At such times the patient endeavors to stand upon her head, turns somersaults, or bows with mock gravity to those about her.
By degrees the purposive character of these ges- tures become more pronounced, and at the same time the emotional element enters more and more into their composition. In the beginning of this stage of the attack,^ the patient, as a rule, assumes attitudes of a threatening character. The brows are contracted; the lips are compressed and the whole facial expres- sion is one of rage and resentment. Sometimes the
— 6o —
subject suddenly starts from a recumbent posture, and clenches her fists, at the same time fixing a look of defiance upon some unseen enemy. After the lapse of a few moments, however, the attitude of anger is succeeded by one of profound apprehension, which is of short duration and is in turn followed by an ex- pression of countenance indicative of the most beatific hallucinations. The expression of beatitude gradually passess into one indicative of extreme voluptuousness, and is accompanied or succeeded by movements of a correspondingly lascivious nature. This stage is fol- lowed by a mental condition resembling somewhat that of delirium tremens. She sees frogs, mice, ser- pents, rats, and other offensive creatures which causes her to cry out with apprehension, while at the same time her countenance presents a frightful picture of mingled fear and disgust.
By degrees the terrible hallucinations which lie at the root of these phenomena subside; the face of the subject wears an expression of contrition, and with clasped hands she begs for clemency. From this period recovery is rapid. The subject has alternate fits of weeping and hysterical loquacity, during which she upbraids those about her for being the cause of all her distress.
It is very easy to provoke an attack resembling that above described, in a person afflicted with hystero- epilepsy. Thus, the sudden pinching of the skin in the neighborhood of the inguinal region and about the breasts is sufficient to cause a seizure.
— 6i —
Attacks of hystero-epilepsy are much less frequent in this country than abroad, and when they do occur, the phenomena presented are usually greatly modified. Of the causation and pathology of hystero-epilepsy little of a specific nature can be added; the most that we can do so far as active interference is concerned, is to utilize what is known concerning the mechanism of the epileptic seizure, and to make due allowance for the hysterical elements of the picture.
CHAPTER VIII.
HYSTERIA IN CHILDREN— HYSTERIA IN MEN.
Hysteria in Children. — As we have already had occasion to observe, when considering the etiology of the affection, hysteria may occur in girls and boys under ten years of age; but the disease is far more frequent about the time of puberty. In very young girls the appearance of the disease is characterized by alternate laughter and weeping, as well as extreme mental irritability and intellectual inertia. The symp- toms manifested by many boys at the time of puberty are analogous in their general characteristics. Besides the mental phenomena, however, the young boys thus affected execute the most extraordinary gestures and gymnastics. They stand upon their heads, creep about the floor, uttering cries in imitation of various animals, and otherwise misdemean themselves. Mas- turbation is also common in both sexes at this time. The following cases reported by Dr. William Roberts* are good illustrations of hysteria in boys:
*" Cases of Hysteria in Boys," by William Roberts, M. D. A paper read before the Manchester Medical Society, "The Practitioner," 1879, vol. xxiii, p. 339, et seq. Vide: also "Cases of Malingering," communicated by Mr. H. T. Batlin, Registrar of the Hospital for Sick Children, London, 1871. "On Hysteria in Children," by Dr. H. Paris, Journal de Therapeutique, May lo, 1880; also London Medical Record, viii, p. 232.
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Case I. — "The first example of hysteria in boys that arrested my attention was the son of a merchant in this town, whom I saw in 1870, This boy at the age of thirteen, and as a sequence to some trifling ail- ment, began to show hypochondriacal symptoms. He became depressed in spirits, and dyspeptic, and suf- fered from various undefinable ailments. Eight months later a dry cough set in, which soon assumed the character of the true hysterical bark. I was con- sulted some four months after this began. The bark had now degenerated into a hoarse sound, resembling the bleating of a goat. The boy persisted for many months in uttering this horrible noise oil day long, almost without cessation, except during the hours of sleep. At one time, for about four months, the symp- . toms exhibited a curious diurnal periodicity. As soon as the boy awoke in the morning he began to bleat every two or three minutes, and continue to do so for about three hours, and then cease; but precisely at eight o'clock in the evening, with the regularity of clock work, he began to bleat again, and continued to do so until he went to bed and fell asleep. These symptoms went on altogether for about fifteen months, and then gradually subsided. Since then this boy has grown into a fine, strong young man. There could be no doubt as to the hysterical nature of the symp- toms in this case. The patient was seen by Gendrin, of Paris, and by Sir William Gull, both of whom pro- nounced the case to be one of pure hysteria. An
— 64 —
interesting episode occurred during the progress of the case. The boy was separated a good deal from his brothers and sisters during the continuance of his ailment, but on one occasion he passed some days in the society of his elder brother. Some four months afterwards this brother had an attack of hysterical barking, which lasted a fortnight and then passed off. A sister also was subsequently seized with similar symptoms. She was nine years of age when her second brother — the subject of this history — was suf- fering from the above-described bleating. When she reached the age of fifteen, four years after her broth- er's recovery, she began to "bark" and show other signs of hysteria. In her case the bark became a sort of hoarse growl, which continued almost without inter- ruption for nearly three years, and then slowly passed away. In this family the hysterical bias was distinctly inherited from the mother, who, in her youth, dis- played severe hysterical symptoms of the classical type." The subjoined case quoted from the same authority is an illustration of the fact that hysteria is sometimes developed during ths period of feebleness which is associated with convalescence from an acute disorder.
Case II. — '' The subject was a boy between eight and nine years of age, whom I visited last year with Dr. Mules, of Bowdoin. He was the second child of a family of six. Dr. Mules informed me that three weeks previous the boy was commencing to be conva-
- 65 -
lescent from a febrile attack of doubtful character, when he was suddenly seized with paroxysms of loud, passionate, tearless crying, with incoherent ravings of a most alarming and distressing character. The par- oxysms continued for a week almost without interrup- tion. At the end of this week they suddenly ceased, and the boy appeared almost quite well again. In a few days, however, they recommenced, but not so continuously. The paroxysms now lasted two or three hours, and recurred three or four times a day. In the intervals between them the boy appeared quite well, eating and sleeping and amusing himself like a boy in health. When I saw the patient he was in his bed- room, looking calm and collected, with a soft, smiling demeanor. Soon after we had descended into the sit- tingroom to hold our consultation one of the parox- ysms broke forth, and we heard the boy screaming. We went up-stairs into his bed-room and found the boy passionately crying and clinging to his mother, as if in the extremity of terror. Nothing could pacify him, and when we left the house the paroxysm was still proceeding. To my mind the attack had an un- equivocally hysterical complexion. What else could it be ? The symptoms evidently concerned, and con- cerned alone, the nervous system; and they resembled those of no disease in the nosological category except those of the chameleon of patholog}^, hysteria. As these paroxysms had now persisted without ameliora- tion for a period of three weeks, in spite of the resto-
6 z
— ae- ration of the general health, we decided to send the child away from home, in order to eliminate that most fruitful of all promotors of hysterical manifestations, home surroundings and sympathy. The interrupted galvanic current was also directed to be applied daily. Under this treatment the attacks became less and less frequent, and finally, in about six weeks, ceased alto- gether; and the boy has since remained in perfect health. I must allow that the diagnosis in this case was not so plain and undoubted as in the preceding, but if any one doubts its correctness, I would ask him this question: Suppose he saw these symptoms in a young girl on the threshold of puberty, what would he call the disorder?"
In the subsequent course of his paper. Dr. Roberts reports cases which he considers to be in- stances of hysterical contracture and " a clumsy imita- tion of epilepsy." The ages of the subjects were eight and eleven years respectively.
While I am not prepared to question the diag- nosis in these last cases, I cannot help believing that such instances must be comparatively rare, much less frequent in fact than the variety of the affection ex- emplified in the first two cases. Of that form of the affection, which is characterized by uncouth noises, alternate lachrymation, and spasmodic laughter, I have seen several instances, as well as of that variety of the disease in which the boys run about upon their hands and knees, uttering barks and discordant
- 67 -
howls, or upsetting chairs and other articles of furni- ture.
Hysteria inMenJ^' — It was formerly supposed that hysteria was entirely confined to the female sex; but, as we have already had occasion to remark, in the course of this discussion, recent writers admit that the affection is encountered in the male sex, though far less frequently than among women. In many of the so-called cases of hysteria, however, symptoms of cerebral exhaustion are a far more prominent feature than the purely hysterical manifestations; so that to classify such cases as bona fide instances of hysteria would be a manifest error. In all instances where there is doubt as to whether we have to do with a case of hypochondriasis, cerebral exhaustion, or cerebral irritability, the best we can do is to classify the affec- tion according to the characteristics of its most pre- dominant symptoms. This is an axiom which, though it fails perhaps to fulfill the most ideal theoretic exi- gencies of the problem, will be found eminently useful in practice. I have laid particular stress upon this point in the classification of obscure functional affec- tions of the nervous system in former publications.!
* See " A Case of Aggravated Hysteria occurring in a Man," under the care of Dr. Todd. Recovery. The Medical Times and Gazette, New Series, vol. vii., p. 242.
f " On the Nature of Nervousness," by J. Leonard Corn- ing. The Medical Gazette, New York, Nov. 24, 1883. Also " A Treatise on Brain Exhaustion," by J. Leonard Corning, D. Appleton & Co., 1884, p. 116, et seq.
CHAPTER IX.
CAUSATION.— PATHOLOGY.— DIAGNOSIS.
Causation. — Hereditary influence constitutes an important factor in the etiology of hysteria. The affection is, moreover, far more common among females than among males. This preponderance of the disease among women is owing, in great measure, to the increased development of the em^otional system in the latter — a state of things which is greatly fostered by the sensational nature of many features of modern social life. But while sensational literature, exaggerated drama, and the innumerable other ex- travagancies of society undoubtedly play a prominent part it the causation of the disease, it is equally cer- certain that morbid states of the sexual apparatus are not without etiological influence. Proof of the truth of this proposition is seen in the extraordinary ex- acerbation of symptoms, which takes place in hysterical women at the period of menstruation, and in the fact that the first indications of the disease are observed in a large percentage of cases at the age of puberty.
General anaemia, hemorrhage, digestive derange- ments, and in fact all causes which lower the nutri- tion of the central nervous system may give rise to hysteria.
All depressing emotions, such as conjugal jeal-
- 69 -
ousy, dread of pecuniary embarrassment, sudden fear and protracted anxiety may induce the affection.
Contusions, even when of apparently trivial im- port, may cause the disease in those of neurotic con- stitution; and the concussion incident to railway and other accidents may cause an outbreak of hysterical symptoms in men and women alike.*
I have recently had under my care a gentleman who met with a severe accident on the Long Branch Railway, and in whom, in addition to other symptoms of concussion, these hysterical symptoms were a prominent feature. While sitting in my office he would suddenly shed tears without the slightest ap- parent provocation; but in an * equally short space of time his weeping would be transformed into laughter. When interrogated as to the cause of these manifesta- tions, he could assign no reason, affirming in the most emphatic manner that the weeping and laughter were alike entirely involuntary.
Imitation is a powerful exciting cause of the dis- ease in those of impressionable constitution; it is thus that the " epidemics " of hysteria in recent and ancient times are to be accounted for.
* Vide " On the Concussion on the Spine, Nervous Shock and other Obscure Diseases of the Nervous System," by John Eric Erichsen, F. R. S., etc.. New York, 1S82. Also, "In- juries of Nerves and their Consequences," London, 1872. And "Lectures on Diseases of the Nervous System," by F. E. Anstie, The Lancet, vol. ii, 1872.
— -JO —
In a large percentage of cases hysteria makes its appearance between the ages of fifteen and twenty- one; though idle and vicious modes of living may cause it to appear in children under ten years of age.
A factor of great importance in the causation of the disease is masturbation, which is far more preval- ent among girls than is commonly imagined. The practice appears to be far more prolific of the disease when indulged in by females than by males. I have, however, seen two cases of the affection, both occur- ring in men over thirty-five years of age, w^hich were directly attributable to this vice.
Pathology. — Post-mortem examinations of the nervous systems of hysterical persons have revealed absolutely no lesion which may be considered as characteristic of the affection. About all that we can do is to submit the various symptoms of the affection to analytical inspection, and thereupon construct as consistent a theor}^ as we are able respecting their origin. In this attempt the physiology of the nervous system will certainly prove our most valuable guide. Following this line of thought, it is evident in the first place, that the greater part of the mental manifesta- tions of the affection are to be regarded as the natural outgrowth of the volitional paralysis and intellectual torpor, which are such characteristic features of the disease. For we find that, as soon as the will and the purely intellectual faculties in hysterical persons are developed by proper methods, the abnormally active
— 71 —
emotions are brought under subjection and there is immediate mental improvement. The essential psy- chological picture in hysteria is indeed but a complex of riotous emotions. Again the spasmodic phenomena of the affection may be accounted for by assuming an inordinate explosiveness of certain motor areas of the cortex, while the hypersesthetic manifestations are easily accounted for if we admit a corresponding irritability of the sensory districts.
On the other hand, abolition of irritability in cer- tain motor fibres of the brain and cord might perhaps account for the paralysis; while the anaesthetic symp- toms might with equal propriety be ascribed to loss of irritability in some portion of the sensory tract.
It is evident, therefore, from the foregoing, that most of the phenomena of hysteria may be accounted for, if we admit that in this affection cortical irrita- bility is sometimes exaggerated and sometimes unduly diminished or even totally suppressed.
I am fully aware that the foregoing theory is open to criticism, but nevertheless, on the whole it appears to be the most consistent which can be constructed in the present state of knowledge. Jolly* has expressed views with regard to the pathology of the affection, which agree in many respects with those above enunciated; and the same may be said of the theory elaborated by Ross.f
*Op. cit., p. ^qoetseq. t Op. cit., p. 862.
— 72 —
All theories which seek to explain the phenomena of the disease on the assumption of changes in the peripheral nerves are so manifestly inadequate that they require no discussion.
Diagnosis. — Much might be and has been said re- garding the various rules to be observed for the pur- pose of differentiating hysteria from the host of dis- eases which it simulates. Many of those axioms are, however, far from infallible, as most physicians of large experience can testify. We shall, therefore, ab- stain from treading the quicksands of these logical mazes, and shall content ourselves instead with a few practical suggestions of more or less universal applica- bility.
The most weighty diagnostic evidence of hysteria is unquestionably afforded by the characteristic psy- chical conduct of the patient. If the patient develop extreme mental irritability in the absence of all excit- ing causes from without, if she has lost volitional con- trol, if her intellectual faculties are devoid of vigor, if she is morbidly hilarious and lachrymose by turns, if she evinces an abnormal and continuous craving for sympathy, and if she resorts to various modes of de- ception to obtain the latter, we may be reasonably sure that we have to do with a case of hysteria.
The certainty of diagnosis is, moreover, greatly enhanced if, in addition to the foregoing, globus and some of the characteristic sensory and motor derange- ments are present.
— 73 —
When the local manifestations of the disease are the prominent feature, the most careful physical ex- amination of the affected part should be undertaken in conjunction with the general investigation. We have already alluded to this point when discussing hysterical joint affections.
The determination of the true nature of an hys- terical attack is usually simple in uncomplicated cases, especially if the previous history of the patient be ac- cessible. In the more complex phases of the disease, however, it is often impossible, to differentiate the at- tack from the seizure of true epilepsy. This point has been discussed under the head of hystero-epilepsy.
Hysteria is indeed a dexterous counterfeiter of other diseases, but, like most dissemblers, her falsifica- tions will not stand the test of analysis.
CHAPTER X.
PROGNOSIS— TREATMENT. •
Prognosis. — In cases of long duration, with a pre- vious neurotic history, the prospects of recovery are decidedly unfavorable; this is especially so when the psychical disturbances are persistent and permanent in character. On the other hand, even violent transitory mental disturbances are not necessarily of bad omen as regards eventual recovery from the purely hysterical symptoms; but it is unfortunately true that these attacks of insanity are liable to leave an ineffaceable trace behind in the form of psychical weakness, and even complete dementation.
When the disease is of short duration and the result of psychical infection (by imitation) the prog- nosis is favorable, provided that the subject can be properly isolated and placed under appropriate treat- ment.
Again, when manifest physical debility is the demonstrable cause of the disease, reinvigoration by forced feeding and rest often yields suprising results. It must be admitted, however, that the danger of re- lapse is always more or less great, unless the subject can be properly protected from the ill-directed sym- pathy of over-zealous friends.
Fore-warned is, however, fore-armed, and if the
— 75 — physician, realizing his personal responsibility in the case, presents a true picture of the possible dangers of excessive sympathy to the friends and family of the patient, much future difficulty and annoyance may be avoided.
Treatment. — The proper management of hysteri- cal cases is one of the most complicated problems in the whole range of medicine. In the first place, owing to the imitative qualities of the affection, the conscien- tious practitioner has much difficulty to persuade him self that he is really confronted by a true pathological condition, and that he is not the victim of deception pure and simple. The fact that hysterical women are, of all others, most prone to prevarication of all kinds, lends force to his scepticism. As a result of this un- certainty of mind the efforts of the attending physician are characterized by a perfunctory observance which is apt to dispel the confidence of patients and friends alike. It is therefore necessary, above all things, to evoke confidence on the part of the patient. This is best accomplished by the adoption of a manner ex- pressive of firmness, but not necessarily devoid of feeling. Above all things, anything approaching ex- aggeration of manner should be carefully avoided. If the physician be called during the progress of an hysterical attack, he should avoid alarming the friends of the patient by abrupt or unnecessarily harsh injunc- tions. A very good mode of procedure is as follows:
Cause the patient to be held firmly by those pres-
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ent, in such a manner that she is prevented from throwing herself about in a violent and aimless man- ner. Then, having loosened her clothing, particularly about the throat and neck, cold water may be dashed upon the face until there is undoubted evidence that the paroxysm is over. This is an old but effective ex- pedient. Again, a towel may be dipped in cold water and the face of the patient submitted to a species of mild flagellation. Or, the nose and mouth of the patient may be held closed so as to interrupt breath- ing— a very effective method of bringing the attack to a speedy termination. Should a faradic battery be at hand the patient may be treated with the wire brush. Care should be observed, however, not to employ cur- rents of too great intensity. Carter has laid down the following rules for treating the attack:
" The attacks will, in all probability, occur during d meal, or when there are strangers present, or at some inconvenient time and .place, and it may on this ac- count be necessary to have the patient removed to her bedroom. In such case she should be carried there as quickly as possible, placed upon the floor, and im- mediately left quite alone, the door being shut, and no one being suffered to open it on any pretext what- ever until the patient does so herself. But if the room in which the attack takes place can be spared for a few hours, it should be cleared and shut up in the same manner, and in either case especial care must be taken not to give utterence to a single expres-
— 77 — sion either of sympathy or alarm. After the lapse of a longer or shorter time, often at a meal, and sometimes not until the next morning, she will present herself as usual, and will perhaps offer some apology, or express some regret for her illness. This should be graciously received; and then every attempt on her part to return to the subject must be carefully and industriously foiled, no inquiries being made about her health, and all complaints being interrupted by the introduction of ordinary conversational topics."
The inhalation of chloroform has been proposed with a view to aborting the attack, and in severe cases some excellent results have been reported. Hypoder- mic injections of morphia and injections of opium have also been advocated for the same purpose. Ex- cept, however, in very severe attacks, these potent remedies should be discarded in favor of the more simple and available means already referred to.
In France the hystero-epileptic phase of attack is much more common than with us, and in this con- dition Jolly has seen good results from large doses of the bromide of potassium in this tetanic manifestation of the affection.
In very rare cases there is a spasm of the glottis, during the attack, of sufficient intensity to cause grave apprehension. Under these circumstances a sponge saturated with chloroform or ether may be held over the mouth and nose of the patient; or, the physician may pass his finger below the eppiglottis and draw it
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upwards. The latter expedient will, however, rarely be required. So much, then, for the hysterical seizure.
But what of the fully developed disease; what shall we do to overcome the multiform manifestations of the hysterical state ? To begin with the state of the patient in general, we must endeavor to ascertain some peccant physiological feature which will, in a measure, account, or at all events tend to perpetuate, the unstable condition of the central nervous sys- tem. Undoubtedly a most common feature of this sort is general anaemia. The best method of combat- ing this state of bloodlessness when it exists in a hysterical person is by appropriate tonics, and, above all things, by feeding and passive exercise. Should there be an inordinate accumulation of fat as well as lack of blood, we should prescribe massage, general faradization, and plenty of fresh air. Weir Mitchell has, perhaps, understood these matters as well as any recent medical writer. To the medical man who is unacquainted with this gifted writer's contributions to the subject of physiological alimentation, there remains for exploration fascinating chapters in scien- tific literature.
States of plethora are far more rare in hysteria than those of sanguineous impoverishment. A failure to recognize this fact led among the older physicians to an incredible amount of blood-letting and other de- pleting measures. As a consequence of such mistaken treatment, many hysterical persons were doubtless
— 79 — forced into a condition of premature decline, in which the outcome was not infrequently fatal to life itself. In the eyes of modern physiology all this seems in- credible enough, and it must indeed be conceded that, if we have not arrived at perfection, we are, at least, far ahead of the preceding generation of physicians in the management of many phases of hysteria.
The relation of affections of the genital organs to hysterical symptoms is a question which is liable to be presented to every practitioner who is brought ■ much in contact with the manifold neuroses which constitute such a baneful feature of the lives of women residing in great cities.
Most authors who have written on hysteria are accustomed to devote much space and ingenuity to a discussion of this interesting conjunction of symptoms. To me all this seems a useless waste of energy. In the first place, I have seen many women suffering from hysterical symptoms, in whom the reposition of a displaced uterus, or the sewing up of a lacerated cervix brought no relief so far as the neurotic manifes- tations were concerned. On the other hand, I have seen such persons improve in a most wonderful way under treatment by hyper-nutrition, massage, Franklinization, and appropriate moral restraint. By moral restraint I mean removing the patient from the vicinity of friends and family, so that there is no danger of subjecting the patient to the highly prejudicial influence of ill- advised sympathy.
— 8o —
Among the remedies which have been largely em- ployed by physicians in former times in the treatment of hysteria, I would mention galbanumand asafoetida. Since, however, modern physiological research has made itself more generally felt in practice, the tend- ency to rely upon the specific action of remedies of all kinds has grown progressively less. This applies with particular force to hysteria, where, as we have seen, general hygienic measures are asserting themselves more and more. Among the therapeutic measures of most uniformly good effect is the cold douche or sponge bath. It may be employed where there is an absence of manifest debility, and should always be im- mediately followed by vigorous frictions.
The anaesthetic manifestations of hysteria may be treated with advantage by daily applications of Farad- ism, or, still better, Franklinism. The application of metals, magnets, and the like, as recommended by certain French physicians, has no other advantage than the appeal which such devices inevitably make to the titanic imaginative powers of the patient. To me there is a kind of mediaeval quackery about such expedients, which has given rise to a feeling of repug- nance that I am quite unable to overcome. I am quite willing to thus avow my scepticism in the presence of the general alchemistic state of the whole quuestion of metallotherapy.
Narcotics and even ansesthetics may be resorted to in combating the hyperaesthesia and neuralgia
which are such a tormenting comphcation of many hysterical cases.
As to the hysterical headaches frequently met with, bromo-caffein, inhalation of the nitrite of amyl, the bromides, and chloral, in considerable doses, will be found useful.
Where paralytic complications are a marked fea- ture, electricity, particularly the static and faradic varieties, should be persistently and systematically employed. On the other hand, when we have to do with spasms, as for instance in persistent globus^ the constant galvanic current may be employed with ad- vantage. Alternate hot and cold applications also frequently render good service. When the spasm is limited to the stomach syphonage with hot water may be resorted to, provided that the introduction of the tube is attainable without too much nervous shock to the patient. In order to facilitate the entrance of the tube into the larynx, and to prevent spasm in the latter, I have found the painting of the pharynx with cocaine, and the projection of a fine spray of a strong solution of the latter into the upper air passages, an excellent expedient.
When there is spastic or paralytic retention of urine, no hesitancy should be exhibited, the catheter being at once called into requisition. In spraying the upper air passages, as above described, I have inci- dentally observed that a severe attack of globus may sometimes be arrested in this manner. This, then, is
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a brief sketch of the resources at our disposal in the treatment of this most paradoxical, aggravating, ob- stinate, and obscure neurosis.
As a matter of course the thousand and one little exigencies liable to arise in the course of protracted treatment cannot be separately treated in a work of this kind. Enough that we have given an outline of the policy to be pursued in the treatment of the cases most commonly met with. After all has been said which can reasonably be said, it must in truth be ad- mitted that the personal ascendency which the physi- cian is able to gain over his patient must ever consti- tute one of the most important, if not the supremely important, factor of successful treatment.
EPILEPSY.
CHAPTER I.
CLASSIFICATION.— SYMPTOMATOLOGY. — SYMP- TOMS WHICH IMMEDIATELY PRECEDE THE ATTACK.— AUR/E EPILEPTIC/E.
In its typical manifestations epilepsy is charac- terized by phenomena indicative of disordered sensa- tion, motion, and intelHgence. These derangements succeed each other in the severe forms of the disease simultaneously and suddenly; in the milder cases in a certain rhythmical succession, where, as in the least grave variety, only one class of symptoms is represented.
It is customary to divide the phenomena of the disease, according to the nature of the paroxysm, into epilepsia gravior or grand mal, and epilepsia mitior or petit mal. Besides these principal divisions, which serve to denominate the more extreme and obvious forms of the disease, recent writers have recognized certain transitional and irregular varieties of the affec- tion, which, in their turn, have received a classification, albeit more or less arbitrary.
In the following description we shall consider
— 84 —
the phenomena of the paroxysm under these head- ings:
1. Grand mal, that variety of the affection in which the seizure is characterized by coma and gen- eral convulsions.
2. Petit mal, that form of the disease in which the paroxysm is alone characterized by loss of con- sciousness, the convulsive condition of the voluntary muscles being absent.
3. Epilepsy characterized by partial impairment of consciousness and circumscribed muscular spasms. This group constitutes a connecting link between the first two varieties of the disorder.
4. Irregular forms of the attack. Symptoffiatology . — We may divide the symptoms of
epilepsy into (i) such as precede the paroxysm, (2) such as occur during the paroxysm, and (3) such as are observable during the intervals of the attacks. In the following description we shall follow in many re- spects the admirable classification of the phenomena of the disease adopted by Nothnagel, a writer whose clear clinical insight is only equaled by his masterly experimental researches upon the pathology of this most interesting disorder.
-Premonitory Syjfiptoms. — These may be divided into such as give warning of an impending attack some hours or days before its occurrence, and such as im- mediately precede the seizure — the so-called mim epilepticce. The distant premonitions usually assume
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the character of mental disturbances in the form of irritability, loss of memory, confusion of ideas, and unusual depression or exaltation, vertigo, and head pains.
Symptoms ivhich immediately precede the Attack: Attrce EpilepticcB. — The aura may affect the sensory, vaso-motor, secretory, motor, and psychical functions.
In a considerable proportion of cases the subject is able to give from memory an account of the aura which preceded the attack. Sometimes, however, con- sciousness is affected so suddenly that the patient re- tains but a shadowy recollection of the occurrences which immediately preceded the seizure.
The immediate prodromes occur more frequently and exhibit greater variety than the remote warnings; indeed they possess such multifarious characteristics that any attempt at exhaustive enumeration of the phenomena would necessarily be at once imperfect and unnecessary.
In the following description, therefore, we shall simply aim at giving a general account of the charac- teristics of these premonitory symptoms, trusting to the individual experience of the reader to amplify his acquaintance with this interesting class of mani- festations.
The setisory aura consists in tickling sensations, or burning, lacerating pains, which usually begin at the extremity of a limb, in the toes and fingers, and extend upward toward the breast and head. Some-
— 86 —
times, on the contrary, a loss of sensation is experi- enced in circumscribed localities, such as a portion of a limb, or one side of the face. This diminution of sensibility may often be recognized by the aid of the sesthesiometer, or by thermic tests. Again, in a certain percentage of cases, the subject complains of isolated pains in the head, either at the vertex or upon one side of the cranium.
Vaso-motor disturbances manifest themselves by sudden redness or pallor of the affected localities. These circulatory disturbances are, moreover, often preceded by sensations of burning, numbness, or by a chill, which, beginning in the fingers and toes, creeps up the spine toward the head and shoulders.
Acting upon the observation that in certain cases the vaso-motor prodromes assume an unusual degree of prominence, recent authors have sought to dis- tinguish a separate variety of the affection, the so- called epilepsia vasomotoria. There is evidently, never- theless, but scant justifications for such a classification, inasmuch as, if we recognize an epilepsia vasomotoria, we are equally compelled to distinguish a large number of sub-varieties of the affection, according to whether the prodromes are characterized by a predominance of this or that special symptom. It is evidently more logical, therefore, to abstain from attempting to estab- lish further subdivisions of the disease on the score of any mere peculiarity of the aura.
The vertigo and faintness often observed as a
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forerunner of the paroxysm are, doubtless, attri- butable to disturbances of the vaso-motor condi- tions of the cerebral circulation, and not, as some authors maintain, to dilatation of the abdominal vessels.
The secretory aura manifests itself in an inordinate secretion of tears, perspiration, or saliva. Saliva- tion is indeed often enough observed, whereas unusual activity of the lachrymal glands is more rarely met with. Nothnagel has frequently remarked profuse perspiration as an immediate precursor of the attack.
AurcB of the Special Senses. — The auras of hearing consist of buzzing, roaring, barking, hissing, and ring- ing. Sometimes sepulchral voices are heard calling in a strange and unintelligible manner, or warning the subject of impending doom. At times also low, musi- cal sounds are heard, which may be gay or melancholy in character. A patient of mine complained that im- mediately before the attack he heard the notes of a dirge, ''and then all was darkness."
Where the aurse are visual, the phenomena con- sist in colors, flashes of light, and balls of fire. In some cases the subject finds himself surrounded by grotesques or awful shapes, which, with outstretched claws, leer at and mock him. In yet other instances he conceives himself to be in the midst of wild beasts, or hideous reptiles, prepared at any moment to devour him.
Aurse of the sense of smell are usually, though not always, of a disagreeable character. In some cases the patient declares that just previous to the at- tack he is overwhelmed by the odor of dead animals or cess-pools. Sometimes, however, pleasant odors, such as the perfumes of flowers, are described.
The aurae of taste are characterized by various forms of perversion. Sometimes the patient experi- ences a salty or metallic taste; at others a sensation of sweetness is noted, which causes him to smack his lips with pleasure.*
The motor aura exhibits itself in various ways. In a considerable percentage of cases, tonic, or more fre- quently clonic, spasms are observed affecting certain groups of muscles. Thus, one side of the face is fre- quently affected by the spasmodic contractions, where- as in others the spasm begins in the hand and ascends to the face. Sometimes the muscles of the tongue are involved, the subject becoming suddenly speechless. In other cases, again, the muscles of the eyes are im- plicated, giving rise to squint. These are the cases in which the subjects complain of double vision.
Visceral Aurce. — These are exceedingly common and consist of sensations of heat, cold, rumbling, or straining which are usually referred to some organ contained within the abdominal cavity. The so-called
* Frank, cited by Nothnagel, has recounted an instance of this sort.
epigastric aura is a sensation referred by the patient to the region of the stomach. The attack is also pre- ceded in some cases by straining at stool and on urinating.
The psychical aura is of frequent occurrence, and may consist of an emotional disturbance manifesting itself in fear or disgust, or in derangement of the intel- lectual faculties assuming the form of confusion of ideas. It is often very difficult to classify this cate- gory of phenomena, for the reason that the description given by the patient is so imperfect as to admit of no certain conclusions. Thus, complaints are often made of a strange indescribable sensation of confusion or vacancy, which the patient recalls with evident diffi- culty. These cerebral phenomena should always be inquired after by the physician, as they constitute an interesting and frequently observed type of premoni- tory symptoms.
CHAPTER II.
THE MANIFESTATIONS OF THE EPILEPTIC PAR- OXYSM—GRAND MAL
Epilepsia Gravior, or Grand Mai. — It is custom- ary among most writers to divide the epileptic attack into two or even three stages. During the first stage of the attack the patient lies in an unconscious con- dition, and his muscles are thrown into a state of tonic spasm. Unconsciousness persists during the second period of the paroxysm, and at the same time the toxic contractions are succeeded by clonic con- vulsions. The third period is characterized by cessa- tion of the spasms and final restoration of conscious- ness.
It will be well to consider somewhat more in de- tail these various stages of the paroxysm.
First Stage. — As already noted, there is entire loss of consciousness during this period of the seizure. Sometimes the loss of volitional power is so sudden that the subject falls to the ground, as if stricken by some unseen power. At others, consciousness disap- pears less rapidly and the patient is enabled to sink upon a chair, lounge, or bed, thus avoideng the danger of falling against some object which might cause him serious injury. It has frequently happened, when the loss of consciousness has been sudden, that patients
— 91 —
have fallen against a stove or even into the fire itself, and have thus sustained frightful injuries. Owing to the pro- found coma, they feel not even the remotest sensation of pain, and are consequently unable to rescue them- selves. When the patient has been under observa- tion, great pallor of the face has been noted, which at- tains a maximum degree of intensity at the moment the subject sinks into unconsciousness. Some patients utter the so-called epileptic cry immediately before falling. This cry is of so strange and piercing a char- acter that animals and men are frequently thrown into a state of consternation upon hearing it. The feel- ings aroused by this cry, when heard among the wards of an insane asylum, are certainly anything but agree- able, even to those long accustomed to the sound. During or after the fall the muscular system is thrown into a condition of tonic spasm. The dis- tribution of the latter is subject to considerable varia- tion. Sometimes there is opisthotonus; at others but one half of the body is involved and curvature takes place in a lateral direction. In severe cases the spasm is general, involving the entire muscular sys- tem. The muscles of mastication are violently con- tracted, causing the jaws to close with such violence as to break the teeth or produce severe laceration of the tongue, should the latter chance to be implicated. The most varied and hideous distortions are produced; the pupils are dilated and fail to react to light; the eyeballs are deviated and the head and neck are flexed
— 92 —
in a backward direction, or rotated when the action of certain groups of muscles prevails over that of their antagonists. The muscles of both the upper and lower extremities are also involved. The forearm is flexed or extended; the thumb and fingers are bent into the palm; the lower extremities are violently ex- tended and the foot is incurvated. The muscles of the throat and those concerned in respiration are also involved in the spasm, and breathing is arrested. Reflex action is impaired or absent in many cases. As already noted, the tonic contractions are not always so universal as the foregoing description would imply, and in some cases they involve certain groups of muscles only. Nor does the paroxysm always begin with tonic muscular contractions. Sometimes these are wholly wanting, clonic spasms setting in at once.
Second Stage. — As already noted, the prominent characteristics of this stage of the attack are the clonic spasms, which set in in from two to forty-five seconds after the inception of unconsciousness. With the advent of the clonic convulsions a remarkable change takes place in the appearance of the patient. The pallid aspect of the face gives place to a dark, livid hue, while at the same time the veins are seen to be enormously distended. If the radial pulse is ex- amined at this time, it will be found to be feeble or quite imperceptible, though both carotids are seen to pulsate violently. The majority of the mus- cles of the head, trunk, and extremities are involved
— 93 — in the convulsive seizure. Owing to the preponderant action of certain groups of muscles over the corre- sponding antagonists, the most remarkable postures are produced. In a considerable number of cases, one side of the body is seen to be more affected than the other; and this is said to hold true even in those cases where the convulsions are general.* Sometimes the violence of the spasms is so great as to cause dis- locations, fractures, and severe wounds of the head and extremities. The teeth are violently ground to- gether, and the tongue, becoming implicated, is severely lacerated. In a large number of cases the patient is seen to froth at the mouth, and the saliva discharged is tinged with blood derived from wounds of the tongue and raucous membrane of the mouth. At the same time the contents of the seminal vesicles, rectum, and bladder may be evacuated, the contents of the latter being frequently ejected with great vio- lence.
This stage of the attack usually lasts from two to four minutes; in some instances, however, the clonic spasms persist five or even ten minutes. The condi- tion of the pupil is variable, being sometimes consid- erably dilated, at others contracted.
Third Stage. — Usually a cessation of the convul- sions is accomplished gradually, but in exceptional cases the spasm ceases suddenly. The spasmodic contrac-
* Nothnagel.
— 94 — tions grow less and less and finally disappear, respira- tion is attended with less difficulty, the cyanotic appearance of the face is sensibly diminished,the limbs become relaxed, the pulse becomes stronger, and at length consciousness is more or less completely re- stored. Sometimes, however, the patient passes from a condition of semi-consciousness into a deep sleep, and does not awaken for hours.
Westphal f has arrived at the conclusion that an elevation of temperature after the attack is rare.
Williams | found that the temperature might rise as much as 3° F. after severe convulsions.
The accounts given by various authors as to changes in the composition of the urine are conflict- ing-i
After the paroxysm has subsided the subject usually suffers from great physical exhaustion, mental confusion, derangement of memory, and in rare in- stances from paresis, or hemi-paresis.
f "Archiv. fiir Psychiatric und Nervenkrankheiten," vol. i.
X "Medical Times," 1867, vol. ii.
II Vide Ebstein, " Deutsches Archiv. fiir klinische Medi- cin, vol. xi.
CHAPTER III.
THE MANIFESTATIONS OF THE EPILEPTIC PAR- OXYSMS CONTINUED.— PETIT MAL.— SEIZURES CHARACTERIZED BY LOSS OF CONSCIOUSNESS AND LOCAL SPASMS.
Epilepsia Mitioi' {Petit Mai). — This form of the disease is characterized by transitory loss of conscious- ness, unaccompanied by foaming at the mouth, pulsa- tion of the carotids, marked cyanosis, or manifest spasmodic contractions of the voluntary muscles. Persons subject to attacks oi petit mat suddenly relin- quish the employment in which they may happen to be engaged, remain perfectly motionless for a few seconds, and then resume their former occupation. If engaged, for example, in speaking, such persons sud- denly pause in the most unaccountable manner in the middle of a sentence; but, after an interval of a few seconds, conversation is again resumed. If walking upon the street, they suddenly stop, but do not usually fall, unless the period of unconsciousness should be unusually long. In some instances, however, auto- matic actions are not immediately interrupted, and the patient continues the occupation in which he may happen to be engaged. Thus, musicians have been known to continue playing during an attack of petit
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nial without the audience becoming in the sHghtest degree cognizant of anything unusual in their conduct.
In the majority of cases the aurae are entirely absent, or so slight in character as to escape the obser- vation or recollection of the patient. The most com- mon warnings consist in flashes of light, darkness before the eyes, and dizziness. Numerous sensations, already referred to as constituting aurse, may, it is true, occur in the entire absence of true epilepsy. But, when these symptoms occur with a certain periodicity, and are accompanied, moreover, by mental confusion, the suspicion of epilepsy is justified. The diagnosis becomes doubly sure if at such times an involuntary discharge of fasces and urine take place.
In a large number of cases no evil after-effects are observed, and the patient remains entirely oblivious of his previous condition. Sometimes, however, even when the attack has been slight, symptoms are ob- served which are apparently entirely out of proportion to the magnitude of the exciting cause. The patient becomes dull and sleepy, or suffers from headache, depression or irritability. Memory is also more or less impaired, especially for recent occurrences. These symptoms often persist for several hours; but they do not constitute the entire list of mental accidents to which these apparently insignificant attacks of epilepsy may give rise. Thus, the terrible disorder known as epileptic mania is one of the most common results of these mild attacks of epilepsy. To this point we shall have occasion to refer hereafter.
« — 97 —
Epileptic Seizures Characterized by Loss of Consci- ousness and Local Spasm; Transition Forms. — This vari- ety of epilepsy constitutes a veritable connecting link between the major and the minor forms of the affection. In its general characteristics there is a pronounced re- semblance to petit mal, with the addition, however, of marked spasmodic phenomena. It rarely happens that tonic and clonic spasms set in simultaneously, or follow each other, as in grand mal. In the majority of cases, on the contrary, but one or the other form of spasm is found to exist. The location and extent of the spasmodic phenomena are subject to considerable variation, and to enumerate all the clinical possibilities would be next to impossible. Sometimes the tongue is rolled about from side to side, while the jaws are alternately opened and shut, as in chewing. In some patients, on the other hand, the attack manifests itself merely by spasm of the facial muscles, strabismus, or closure of the eyelids. Again, in a not inconsiderable number of cases there may be movements of the lips, violent contortions of the muscles of the face, local spasms in the extremities, or more rarely in the trunk, and (according to some writers) arrest of respiration, owing to spasm of the respiratory muscles. Where the spasm is located in the extremities there is rigidity of the same, or some of the fingers or toes are ex- tended or bent, or, where the convulsions are clonic in character, the affected parts are moved backward and forward, with a pendulum-like motion. Sometimes
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there are clonic and tonic spasms which are more general in character, and which at first sight would suggest the major form of epilepsy. But, as a matter of course, an absolutely sharp demarkation between the various forms is not always easily discernible, and it is consequently necessary to bear in mind the rela- tive value of this or, indeed any other classification.
It has been alleged by some writers that the loss of consciousness is by no means absolute in this form of the seizure. Nothnagel, on the other hand, is of the opinion that in the great majority of cases an ar- rest of consciousness takes place, which, although often only very transient is still complete.
CHAPTER IV.
MASKED EPILEPSY.
Irregular Forms of the Attack [Larvated, or Mask- ed, Epilepsy). — In this form of the disease the par- ox5''sm is quite as well marked as in grand 7?ial, the only difference being that, instead of the violent con- vulsive movements of the latter, certain "automatic " mental and motor phenomena are evolved, which, though often apparently systematized, take place while the subject is in a state of partial or entire un- consciousness.
The following case, which occurred in my own experience, is a good illustration of this phase of the disease:
A. v., a young unmarried woman, aged twenty- five years, was brought to my office about a year ago, suffering, as her friends imagined, from the premoni- tory symptoms of insanity. On inquiry, I learned that the family history on both the father's and mother's side was good so far as the existence of mental trouble was concerned, and the only neuro- pathic evidence discoverable was afforded by the girl herself, who complained of being " nervous " and "fidgety," and somewhat lacrymose and emotional at times. These attacks, were, however, in no wise trace- able to menstruation.
Upon examination, the organs of the thoracic and
abdominal cavities were found to be in a healthy con- dition, and, having noted this fact in my case-book, I was about continuing my examination of the patient, when suddenly she arose and, without the slightest warning, spat upon the floor, at the same time dropping her muff, which she had been holding in her hand. For an instant after this she stood with an expression of indescribable horror, as if trans- fixed, her face meanwhile wearing a chalky appear- ance. In a moment, however, all was over, and she resumed her seat, as if nothing unusual had happened. The mother of the girl, who was present, began subse- quently to reprimand her in the severest terms, at the same time observing, with an expression of ex- ultation: " There, you crazy, nasty thing, the doctor has caught you now, and he will send you to an insane asylum." Upon close questioning, the patient denied in the most emphatic and convincing manner all knowledge of what had occurred, and I am thoroughly persuaded that she told the truth. From her mother I learned that she had formerly had many similiar attacks, during some of which she had shown a tend- ency to destructiveness, breaking any object upon which she chanced to lay her hands. Several orna- ments and pieces of furniture had been destroyed in this way, on account of which she had become very unpopular in her family, the members of which would gladly have seen her relegated to an asylum, as I soon ascertained.
Sometimes the acts perpetrated by persons suffer- ing from this masked type of epilepsy are far more compUcated. I can recall a case illustrative of this complex mental automatism, occurring in the family of an intimate friend. The following are the principal points of interest connected with this case:
C. E., a neurotic lad of eighteen, of delicate frame, came under my observation some two years since. The principal reason for consulting me, as his father explained, was because the boy's " memory " seemed to be affected, and because of certain other mental traits which excited the apprehension of his parents and teachers. On questioning the father of the lad, I learned that the latter was in the habit of running away from school and from his home, remain- ing absent sometimes for days at a time. So annoy- ing had these frequent occurrences become that the parents of the boy had finally been induced to attach a leathern placard to his coat bearing his address as well as a request to the police to return him to his home when found. Indeed, he had been returned by the police on sundry occasions; but the most singular part of the transaction was the fact that he denied in the most obstinate manner all knowledge of his singular peregrinations — a statement which he reso- lutely maintained in the face of the severest chastise- ment. This was the more remarkable since his veracity upon all other topics was unquestioned. On examining the lad, I found his back, ankles, and thighs
covered with scars, which upon inquiry I learned were the result of inhuman beatings received at the hands of his guardians, who considered him to be at once a truant and a liar. With tears in his eyes he declared, with the most convincing sincerity, that he had no re- collection whatever of the occurrences for which he had been punished.
Such cases as this are far more common than is generally supposed, as doubtless most practitioners of large experience can testify.
CHAPTER V.
"THALAMIC" EPILEPSY. — JACKSONIAN EPI- LEPSY.—SENSORY EPILEPSY.
Under the designation of "Thalamic Epilepsy," Hammond* has published an interesting case, the chief characteristics of which are " conscious hallucinations, followed by unconsciousness, but unattended by mus- cular spasm. This form of affection is comparatively rare."
With regard to the frequency of the attack, in common epilepsy the greatest variations are ^en- countered. Thus, in some cases a year may elapse without the appearance of a single paroxysm, while in other cases the seizures may occur thrice or even half a dozen times daily. Sometimes, again, they exhibit a well-marked periodicity, whereas, in not a few cases no kind of regularity is discern- able. In yet another class of cases the subject has hardly time to emerge from one convulsive attack before he is beset by another, the paroxysms following each other in such rapid succession that there is finally no apparent restoration of consciousness between the seizures. This condition is known as the status epilep- ticus — a phase of the disease which has received con- siderable attention from French writers, notably from
* "On Thalamic Epilepsy," "Archives of Scientific Med- icine," August, 1880.
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Bourneville.* This writer's subdivision of the condi- tion seems to me, however, unnecessary. The main points to bear in mind are that this form of the attack is, generally speaking, of graver import than the ordinary seizures, that hemiplegia develops in a con- siderable number of cases, that bed-sores may be developed over the sacrum, and that finally a condition of maniacal excitement with hallucinations, or depres- sion and coma, may succeed the convulsions.
I have seen cases in which from twenty to fifty seizures occurred in the course of twenty-four hours.
• The arrest of these convulsions is immediatel}'' attained by the application of pressure to the carotids, which is best accomplished with an appropriate instru- ment, f
So-called "■ Jacksoma7i" Epilepsy. — There are cer- tain forms of local or unilateral spasm, occurring usually without loss of consciousness, which have been carefully investigated by Dr. Hughlings Jackson, and
*" Etudes clinique et thermometriques sur les maladies du systeme nerveux," 1873.
f " Prolonged Instrumental Compression of the Carotids as a Therapeutic Agent," by J. Leonard Corning, M. D., ."Medical Record" of February 18, 1882. Also "Philadelphia Medical News " of June 17, 1883. " Brain Rest," by J. Leon- ard Corning, M. D., G. P. Putnam's Sons, New York, 1883. "Carotid Compression," Anson D. F. Randolph & Co., New York, 1882. "Brain Exhaustion," by J. Leonard Corning. M. D., D. Appleton & Co., New York, 1884.
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which, in accordance with the views entertained by that observer with respect to their pathology, have found a place in medical literature under the designa- tion of "Jacksonian Epilepsy." Since the spasms in question are almost invariably due to organic intra- cranial disease, their extended consideration would be out of place in a work of this character. But, since most recent systematic writers are in the habit of devoting some attention to them in connection with the discussion of the pathology of epilepsy, I have decided to give a brief sketch of their principal char- acteristics, reserving their more extended discussion for a future occasion. While so doing, I can not, how- ever, refrain from protesting against the inconsistency of a pathology which would designate phenomena of this class as epileptic. There is, indeed, no more pathological similitude between these local spasms and true idiopathic epilepsy than exists between the latter and the contractions evoked by the electric current when applied to the motor centers in the cortex.
It is true that Jackson was anticipated by Bravais* as far as the description of these unilateral convulsions is concerned, but it was reserved for the former clini- cian to thoroughly elucidate the morbid physiology of the affection. The researches of Dr. Jackson in this important field are recorded in a series of papers, which have received a wide and merited attention.
* " Recherches sur les symptomes et le traitement de I'epilepsis hemiplegique," These, Paris, 1827.
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"Jacksonian epilepsy" is characterized by the occurrence of partial convulsions, which may be limited to one extremity or to one side of the face, or which, beginning in one extremity, may extend to the other, or even involve half of the body. In rare instances the spasm may extend to the opposite side as well.
As we have already seen, consciousness usually remains unaffected, or, where unconsciousness takes place, it is only evident toward the end of the attack, so that the patient is afterward able to recall what has taken place before and during the greater portion of the seizure.
This form of epilepsy owes its origin to coarse disease situated in or near the cortex. The most fre- quent cause of the disease is a syphilitic gumma, but localised cicatrices, wounds, tubercle, meningo-ence- phalitis, and indeed all forms of circumscribed irrita- tive lesions of the cortex, may give rise to the spasms.
When we consider the grave nature of such lesions it is not surprising that the limbs affected by the convulsions may subsequently become the seat of temporary or even permanent paralysis. The latter eventuality is prone to occur where the" lesion, which at first may have been merely irritative in character, ultimately destroys that portion of the cortex in which it is situated, or against which it impinges. This as- sociation of the unilateral convulsions with secondary paralysis has given rise to the designation often en- countered in medical literature of hemiplegic epilepsy
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("epilepsia hemipleique "). But why should there be convulsions associated with these profound cortical lesions ? Dr. Hughlings Jackson's explanation of this interesting pathological fact is at once ingenious and plausible. He believes that the ganglia in the imme- diate vicinity of the lesion are kept in a state of mor- bid irritability, and that consequently they are unduly supplied with blood. As a result of this hyper-irriga- tion, the ganglion cells absorb an excessive amount of nutriment, so that their superfluous energy finds a vent in sudden explosions, the products of which are the convulsions. These explosions are followed by exhaustion and inertia of the nerve-centres involved, and consequent temporary paralysis of the previously convulsed muscles ensues. As we have already had occasion to observe, however, irritative lesions of this character may eventually destroy the motor centres in the cortex near which they chance to be situated, and with the result of causing permanent paralysis of the muscles over which the centres in question preside.
Sensory Epilepsy. — This variety of the affection has been referred to by Sommers and others, and in a recent article Dr. Allan McLane Hamilton* has recorded several cases illustrative of the manifold phases of this form of epilepsy. In the first case there
*"A Contribution to the Study of Several Unusual Forms of Sensory Epilepsy which are probably dependent upon Lesions of the Occipital Cortex," by Allan McLane Hamilton, M. D., "Medical Record," April 4, 1885.
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were sudden hemiopia, supra-orbital neuralgia, unila- teral anaesthesia of extremities, tongue, and gums, temporary speech disturbance, and loss of conscious- ness. In another case there were hemianopsia, frontal headache, hemianaesthesia, temporary mutism, and loss of consciousness.
The researches of Krause, D. J. Hamilton, Starr, Munk, and Wernicke have done much to shed light upon the morbid physiology of these exceptional forms of epilepsy; but, as the discussion is still by no means closed, I shall refrain from entering further into the consideration of this interesting but obscure mani- festation.
CHAPTER VL
CAUSATION.
The most potent predisposing cause of epilepsy is probably found in a hereditary neuropathic tendency transmitted from the father, mother, or both. Some- times, however, this hereditary tendency is not readily discoverable, owing to the fact that one or even several generations have escaped. This circumstance accounts, doubtless, in a measure for the conflicting statistics adduced in favor of or against the theory of hereditary influence. When carefully collected and impartially interpreted, there can be little doubt, how- ever, that statistics go far to prove the great getio- logical importance of heredity in this as in other neuroses. It should be borne in mind, in this connec- tion, that it is not absolutely necessary to trace a series of epilepsies occurring in successive generations in order to prove a hereditary influence. On the con- trary, all that is required is proof of the existence in the family of a well-marked neuropathic diathesis, ex- perience having shown that such a morbid tendency may exhibit itself in almost any form of organic or functional nervous disease. Regarding the subject from this standpoint, Herpin* found, out of two
* " Du pronostic et du traitement curatif de I'^pilepsie," Paris, 1852.
hundred and forty- three epileptics, well-marked here- ditary tendencies in forty-three cases.
The cases reported by Petit* of healthy children occurring in families in which both parents were epileptic have been cited as testimony calculated to destroy the integrity of the theory of hereditary influ- ence. They possess, however, no value whatever so far as the rebuttal of the evidence upon which that theory is founded is concerned, since at most such facts only go to show that one or more generations may escape from the baneful pre-natal influences — a fact already sufficiently understood by all medical statisticians.
Echeverria's opinion that phthisis in the parents has a tendency to cause epilepsy in the offspring seems to us well founded, though controverted by Noth- nagel,f who regards the association of the two diseases as explained by the great frequency of phthisis. The fact that a certain condition of instability of the cen- tral nervous system is engendered by the malnutrition consequent upon scrofula, anaemia, and chlorosis, and that such an unstable condition often eventuates in epilepsy, is indirect evidence of the correctness of Echeverria's position. Consanguineous marriages also appear to predispose to the occurrence of the dis- ease in the offspring.
*Gaz. med. de Paris," i8, i860. f Op. cit., p. 202.
Alcohol has been considered an important aetio- logical factor, but evidence on this point is conflicting. There is no doubt, it is true, that chronic alcohoUsm and epilepsy are frequently associated; but whether the former is the outgrowth of the latter, or whether the epilepsy is to be regarded as the result of the alcoholic excesses, is difficult of determination.
Age is unquestionably an important predisposing factor in epilepsy. In one hundred and thirty-eight cases analyzed by myself, I found that in 25 per cent, the disease began under eight years, in 5 1 per cent, between eight and twenty-five, in 13.5 per cent, be- tween twenty-five and thirty-five, and in 10.5 per cent, between thirty-five and fifty.
Gower's* statistics differ somewhat from my own; but since they were derived from the analysis of a larger number of cases, they are perhaps more exact. Of 1,450 cases analyzed by this observer, 12.5 per cent, began during the first three years of life, 29 per cent, under the tenth year, 46 per cent, between ten and twenty, and 15.7 per cent, between twenty and thirty.
Sex has a less obvious influence upon the occur- rence of the disease than was formerly supposed. The older writers believed that the disease was more com- mon among males than females, but their views do
*Vide " British Medical Journal," March 6, 1880, as well as subsequent communications.
not seem to have been derived from a careful analysis of statistics, and are apparently nothmg more than arbitrary assertions. As to recent writers, the opinion is quite generally expressed that the disease is more frequent among males than among females, while one or two observers believe that the proportion between the two sexes is about equal. For my own part, I have no hesitancy in expressing the belief that the disease is at least as common among males as among females. Of 72 cases of epilepsy which I have re- cently seen in asylum, dispensary, and infirmary prac- tice, 41 occurred in men and 31 in women.
It is possible that the relative frequency of the disease in the sexes may vary somewhat with age; but, be that as it may, there is no doubt that in ordinary hospital practice the disease is somewhat more fre- quent encountered among males than among females.
The factors which may be classed as exciting causes of the disease are undoubtedly numerous. We shall, however, discuss only the more frequent and im- portant of the latter, since to attempt to enumerate them all would be alike devoid of theoretic or practical advantage.
In former times much importance was ascribed to sexual excesses in the production of the disease; but in more recent times a reversal of this decision is ap- parent in some quarters, so that at the present day it is quite in accord with fashion to undervalue, and even to deny altogether, the setiological importance of this factor.
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From my own observations in connection with this matter, I can not help believing that modern writers have been too hasty in their conclusions.
It is an undoubted fact that the great majority of epileptics are addicted to the practice of masturbation, and that the habit is quite as prevalent among female as among male patients. Many recent writers, never- theless, regard the vice as one of the manifestations of the disease, and not as one of its causes. The question is, however, a difficult one to decide, and arbitrary assertions for or against the proposition are evidently inadmissible. But, after all, the most im- portant question to decide is not whether epileptics masturbate during the disease, on account of the lat- ter, but whether they were addicted to the vice pre- vious to the advent of the epileptic symptoms.
Out of seventy-two cases of epilepsy which I in- vestigated with regard to this point, 84 per cent, afforded histories of excessive masturbation previous to the first paroxysm. In one case localized spasms began in the left hand, after the practice had been continued for about three years, and in course of time the convulsions became general. There were no para- lytic symptoms, and the patient, a young man of twenty-eight, denied having had syphilis. In the face of such evidence, I cannot help believing that we are justified in inferring that a causal connection really does exist in some cases between persistent masturba-
9 z
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tion and the development of that instability of the central nervous system which is so characteristic of the epileptic state. Cases in which the first epilep- tic paroxysm was developed during coitus certainly lend strength to the argument. The conclusion is indeed inevitable that sexual excesses constitute a far more frequent predisposing and exciting cause of the affection than is admitted by Nothnagel* and other excellent writers.
' Epilepsy is frequently evoked by such psychical
disturbances as sudden fear, grief, pecuniary and other forms of anxiety, and indeed by all violent appeals to the emotional mechanism. Such occurrences un- questionably constitute some of the prolific exciting causes of the disease; but it is exremely problematical whether the epileptic symptoms would have been evoked were the central nervous system not already in a state of morbid receptivity.
Epilepsy is also prone to develop in the course of or subsequent to the occurrence of the febrile disturb- ances of infancy. It is also frequently developed after injury to a nerve, or as the result of reflex irrita- tion induced by teething and other causes.
Sometimes the disease is traceable to some cranial injury of such apparent insignificance that it has been speedily forgotten, and only the most careful inquiry serves to elicit the fact. This applies with particular
* Op. cit., p. 203.
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force to young children afflicted with local or general spasms — cases in which we are compelled to rely upon the equivocal testimony of nurses and other ignorant persons. Some of the most severe cases of localized epilepsy (hemi-epilepsy) which have come under my observation 'occurred in young children who had been dropped by nurses, or had met with some other form of accident at the hands of servants. In all such cases there is probably always more or less indirect injury to the brain, with consequent development of grave organic lesions, though, it is true, there may be no ex- ternal indication of injury.
Blows upon the cranium are not liable to eventu- ate in epilepsy, according to some writers, unless they are of sufficient severity to cause unconsciousness. This appears to me an altogether too sanguine view of the matter, since I have seen at least two cases of epi- lepsy in children which developed soon after blows of so slight a nature as to be almost forgotten. There is little doubt in my own mind that the most insignificant concussion about the head, even when unaccompanied by evidences of abrasion, may, sooner or later, develop epileptic symptoms. This observation applies with particular force to infancy and early childhood, when the non-resistent character of the cranial bones facilitates the transmission of sudden shocks to the brain.
Even where no history of a blow is forthcoming, there is strong presumptive evidence that there has
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been contusion of some kind. Many cases of epilepsy, occurring after slight abrasions about the head, have been ascribed to "reflex" causes; but it is probable that, in a considerable percentage of such cases, there is more or less direct disturbance of the cerebral sub- stance itself, although some time may have elapsed before the appearance of the first paroxysms. In all such cases great care should be exercised in forming an opinion, as to causation, since the prognosis will manifestly be much less favorable when the paroxysms are traceable to direct injury than when they are really of reflex origin.
CHAPTER VII.
EXPERIMENTAL RESEARCHES.
The most important experimental investigations relative to the pathogeny of epilepsy are those of Marshall Hall, Sir Astley Cooper, Kussmaul and Tenner, Landos. Nothnagel, Brown-Sequard, West- phal, Magnan, Hitzig, and Ferrier.
Before discussing the varfous theories of the dis- ease, which are directly or indirectly the outgrowth of these investigations, it will be advisable to review the experiments themselves, in order the better to appre- ciate how much objective matter is really embodied in these hypotheses.
Even among the ancients there is an evident ten- dency to appropriate the results of the rough experi- ments at hand to the elucidation of the theory of dis- ease. Thus, Hippocrates* taught that convulsions might arise as well from fulness as from want of blood. He was, doubtless, guided in these statements by ob- servations made upon animals condemned to die in the shambles, coupled, perhaps, with considerations derived from practical experience at the bedside. Kellie,f who made a series of experiments upon sheep, and Pioray,J who conducted similar investigations
* "Aphorisms," sec. vi, 48.
fVide "On Bloodletting," by Marshall Hall.
^''Archives generales de medecine," January, 1826.
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upon dogs, found that copious blood-letting was fol- lowed by convulsions. Marshall Hall* and Travers were, however, among the first, if not the first, to note the resemblance between the convulsions produced by rapid bleeding in man and other warm-blooded ani- mals and the spasms of epilepsy.
Although, as already noted, the ancients and older medical writers had formed opinions relative to the role played by the intra-cranial blood-stream — theories which, even at the present day, bear evidence of a high degree of perspicuity — it is commonly con- ceded that the fundamental experiments undertaken by Sir Astley Cooperf in 1831 really paved the way for the scientific study of epilepsy. These experi- ments consisted in ligation of the vertebral and carotid arteries; of both carotid arteries; of both vertebral arteries. Then, ligation of the carotids first and of the vertebrals nine days afterward; of the carotids and subsequent compression of the vertebrals; and, finally, ligation of the vertebrals and subsequent compression of the carotids.
Of these experiments, that in which the carotids were first ligated, and the vertebral arteries immedi- ately afterward compressed, is perhaps the most im-
* Op. cit.
f " Some Experiments and Observations on tying the Carotid and Verteoral Arteries," by Sir Astley Cooper. "Guy's Hospital Reports," 1836, vol. i, p. 458 et seq. The ex- periment, cited at length, is continued on pages 465, 466.
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portant; and I cannot therefore do better than quote the same, in the words of Sir Astley Cooper himself:
" As tying the vertebral arteries is a difficult ex- periment, it occurred to me that I might compress them with my fingers, after tying the carotids, and produce the same effects.
"I tied the carotid arteries; respiration was some- what quickened, and the heart's action increased, but no other effect was produced. In five minutes the vertebral arteries were compressed by the thumbs, the trachea being completely excluded. Respiration al- most directly stopped, convulsive struggles 'succeeded, the animal lost consciousness, and appeared dead. The pressure was removed, and it recovered with a con- vulsive inspiration. It lay upon its side, making vio- lent convulsive efforts, breathing laboriously, and its heart beat rapidly.
" In two hours it had recovered, but its respira- tion was laborious.
" The vertebrals were compressed a second time. Respiration stopped; then succeeded convulsive struggles, loss of motion and apparent death.
" When let loose, its natural functions returned with a loud inspiration, and with breathing excessively labored.
" In four hours it was moving about and ate some greens.
In five hours the vetebral arteries were com- pressed a third time, and with the same effect.
" In seven hours it was cleaning its face with its paws.
" In nine hours the vertebral arteries were com- pressed for the fourth time, and with the same effect upon its respiration.
" After thirteen hours it was lively.
" In twenty-four hours the vertebral arteries were compressed for a fifth time, and the result was the same — namely, suspended respiration, convulsions, loss of motion and consciousness. On the removal of pressure, violent and laborious respiration ensued, and afterward the breathing became very quick.
" After forty-eight hours, for the sixth time, the compression was applied, with the same effect."
These experiments of Sir Astley Cooper have shown, then, that ligature of both carotids and simul- taneous compression of the vertebrals give rise to uncoti- sciousness, suspension of respiration, and convulsions.
Subsequently Kussmaul and Tenner * repeated these experiments in a much more perfect manner up- on dogs, cats, and rabbits, and succeeded in conclu- sively demonstrating that rapid and profuse haemor- rhage is followed by violent and general convulsions. " If," however, " haemorrhage takes place slowly, and the vital powers are gradually consumed, death ap-
*Moleschott's " Untersuchungen," Band ii, p. 248, 1857. Also "Epileptiform Convulsions caused by Profuse Bleeding," etc.. by Adolf Kussmaul and Adolf Tenner. The New Syden- ham Society, London, 1859.
pears then to ensue with swooning, drowsiness, de- lirium, and vascular irritation without convulsions."
" More than twenty rabbits, which we either killed intentionally by rapid bleeding, or which ex- pired while being experimented upon, died under general convulsions like those observed in epilepsy, and which we shall afterward more fully describe. Not one of those which we saw die bleeding was ex- empt from convulsions. These convulsions did not differ in any respect from those we observed in several dogs and cats that died from bleeding, or from those described as occurring in men dying from haemor- rhage."*
Kussmaul and Tenner have also shown that an interruption in the conveyance of arterial blood to the brain of a rabbit produces epileptic fits with as much certainty as general haemorrhage. Referring to the point, they state that " no difference, moreover, could be discerned between the fits observed in death from bleeding and those which occurred in about one hun- dred rabbits whose carotid and subclavian arteries were tied or compressed below the origin of the vertebral arteries."
And again: "Lastly, we become convinced, by observation of more than a dozen rabbits, that the fits produced by compression of the above-mentioned arteries resemble in every way those brought on acci-
* Op. cit., p, 2, foot-note.
dentally or intentionally in the identical * animals by profuse haemorrhage after circulation has been re- stored to the head."
* The Italics are ours.
CHAPTER VIII.
EXPERIMENTAL RESEARCHES CONTINUED.
I can not refrain from giving a description of the convulsive paroxysms induced in rabbits after ligature of the great arteries of the neck, in the eloquent language of Kussmaul and Tenner. The quotation is made from the paper already referred to:
" General convulsions usually followed in from eight to eighteen seconds after complete withdrawal of arterial blood. We killed six rabbits solely for the purpose of determining in what space of time convulsions would come on. After the arteries had been laid bare, and the ligatures had been passed lound, we allowed the animals to rest undisturbed in an erect position for a quarter of an hour, without making any experi- ments by compression. One of us then as quickly as possible, tied the left subclavian and innominate arteries, while another, watch in hand, observed the time when the symptoms first manifested themselves.
" In a very strong male rabbit, two years old, general con- vulsions came on three seconds after the innominate had been tied : and this is the shortest period that we have noticed in any. In two female white rabbits, four weeks old, the convul- sions appeared after an interval of twelve seconds; in a female gray rabbit, two or three years old, in ten seconds; in a male of the same age, in sixteen seconds; and in an old strong fe- male, from four to five years old, in forty-five seconds. None of these animals lost during the operations any considerable quantity of blood.
" Out of a hundred strong rabbits, we met with four only
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in which, after perfect closure of the above-named vessels, con- vulsions did not appear till after four to six minutes, and one only, as already mentioned, in which they did not appear at all after the lapse of ten minutes, and until the aorta had been opened."
The occurrence of convulsions is always preceded by various motor phenomena, which have been ex- haustively described by KussmauL* The most im- portant of these are as follows:
1. " Immediately after stoppage of the blood the various sphincter muscles of the face contract, especi- ally, and in a very striking manner, those of the iris and eyelids; then, in the order of their distinctness, the conchse of the ears, the nostrils, and the mouth. The jaws, which are generally already closed, become spasmodically locked. Then, usually a little before, but sometimes simultaneously upon the occurrence of general convulsions, the pupils and the fissures of the eyelids, ears, and nostrils are widened, sometimes the mouth also, very distinctly. The adductors of the lower jaw seem also for a few moments to become paralyzed; but during the attack the jaw becomes locked, either uninterruptedly or in broken succession, by the alternate occurrence of spasmodic and more feeble abductions and stronger adductiofis ."
2. '' Convulsive efforts are almost invariably made to turn the pupils toward the internal angles
* Vide article by Adolf Kussmaul in " Zeitschrift des Wurtzburg. phys. med. Vereins."
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of the eyes, after which the eyeballs generally roll about, first inward, forward, and downward, then out- ward, backward, and upward, until at length the pupils are turned toward the external angles of the eyes, and are wholly or partially concealed by the upper eyelids."
3. " The eyeballs are first drawn back into the sockets, and again become prominent as the pupils di- late."
4. " Respiration is at first accelerated, but short- ly afterward, a little while before the approach of the general convulsions, it becomes prolonged and deep."
5. " The muscles of the neck generally become paralyzed and unable to bear the weight of the head, which sinks down upon the breast or side, the ani- mals afterward falling down in a swoon on their fore feet, occasionally on their hind ones. The symptoms of paralysis are the more distinct and constant the greater the time that elapses before general convul- sions come on."
" The signal for general convulsions is given by a tonic contraction of the muscles of the neck. Then commences a terrible scene, the more surprising by contrast if preceded by swooning. The head is drawn violently backward, the pupil becomes uncommonly enlarged, violent lock-jaw ensues, and the animal, if strong, is generally flung forward with great force to a distance even of from one to two feet, and some-
126
times over the shoulders of the observer seated before it. The legs are alternately contracted and extended by clonic convulsions in the most violent way; the en- larged pupil appears again fixed in the centre of the palpebral fissure, as the eyeball is again rolled some- what inward; respiration is scarcely to be perceived, while the heart continues throbbing very vigorously. The clonic convulsions gradually subside, assuming more the appearance of tetanus, and eventually disap- pear altogether, passing away as they do so from the front to the back. First, the muscles of the neck and fore legs become paralyzed, while the back part of the body is bent forward and the hind legs are tetanically extended until these movements also cease. The duration of these attacks was, according to several ob- servations, from eighteen seconds to two minutes.
" Very frequently, after a pause of from fifteen to seventy-five seconds, a second attack comes on, always weaker and shorter than the first, and often limited to the hinder part of the body, in the form of tetanic convulsions; sometimes, however, affecting, the whole body, under the form of clonic convulsions. We once observed such a second attack to last, in an exception- al case, two minutes. Sometimes, indeed, convulsions, in which the hind legs become tetanically stretched, recur even for a third and fourth time, at intervals of from fifteen to thirty seconds. They returned in the strongest and most regular manner in those animals whose arteries were tied forthwith, and whose
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strength had not been previously exhausted by experi- ments of compression. Toward the end of the attacks, urine and faeces were sometimes voided; at other times no such voiding took place, even when the bladder was full.
" In rabbits, cats, and dogs, dying from haemor- rhage, the convulsions are of exactly the same char- acter.
"These convulsions present precisely similar features to those of epilepsy in their complete form, as the following enumeration of the most important symptoms will show:
1. " The animals fall down before general con- vulsions come on, and completely lose the spontaneous use of their muscles."
2. " They give the observer the impression of their being perfectly unconscious."
3. " Not one of the many animals operated upon cried out, so long as the circulation was interrupted, either before or during the spasmodic attack, and two only while the latter was abating. Subsequently, however, they began to cry piteously directly arterial blood began to flow again, or, at all events, soon after- ward. From the want of power to cry, and from the gradual swelling of the veins of the brain during the attack, to which we shall direct attention further on, we infer that spasm of the glottis (laryngismus) took place."
4. " The pupils are dilated during the attacks,
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and, to judge from several experiments, appear rigid, the eyeballs bemg motionless. Before and subsequent to the attacks, however, and when • at the very last gasp, the pupils being at the same time very much en- larged, the eyes of some animals that were accurately examined appeared sensible to the influence of light."
5. " The attacks commence with a toxic spasm of the neck (trachelismus.)"
6. " Respiration ceases, while the heart con- tinues beating."
7. " The limbs are seized with strong clonic con- vulsions, and become at last spasmodically stretched."
Besides the experiments above referred to, Kuss- maul and Tenner inaugurated a series of researches which had for their object the more precise localiza- tion of the cerebral regions from whence general con- vulsions arise.*
The modus operandi in these researches was as fol- lows: Various districts of the brain were cut out, and a comparison of the effects produced by compressing the great arteries of the head before and after the operation was instituted. In this manner the follow- ing conclusions were arrived at: That anaemia of those parts of the brain situated in front of the crura
*On the Mode of Procedure for Determining the Cerebral Region from whence General Convulsions after Profuse Haemorrhage Arise," by Adolf KussmuU and Adolf Tenner. "The New Sydenham Soc," 1859, vol. v, p. to et seq.
129 —
cerebri produces unconscioueness, insensibility, and paralysis, if spasms occur with these symptoms, some excitable parts behind the thalami optici must have likewise undergone some change.*
This portion of their experiments is, however, open to criticism, since the sources of error are numer- ous. Among the latter, I will only mention the com- plications liable to arise from opening the skull — a procedure inevitably accompanied by changes in pres- sure, and, in this case, by escape of the cerebro-spinal fluid, and no little hsemorrhage.
I shall take occasion to refer at length to the further conclusions arrived at by Kussmaul and Tenner relative to the pathology of epilepsy in the subsequent paragraph on the mechanism of the epileptic seizure.
Landois has conducted some interesting experi- ments, which show the relation of venous hyperemia of the brain and superior portion of the spinal cord to epileptoid convulsions, f
The mode of procedure in these researches was as follows: The right thoracic cavity was opened and the superior vena cava exposed in such wise that it
* Vide under head of General Summary, op. cit., p. 105.
f " Ueber den Einfluss der venosen Hyperamie des Gehirns und des verlangerten Markes auf die Herzbewegung, nebst Bemerkungen liber die fallsuchtartigen Anfalle,"von Dr. Leonard Landois. " Centralblatt fur die medicinischen Wis- senschaften," p. 146, 1867.
was possible to close the lumen of the same by means of an ordinary artery forceps. Artificial respiration was instituted, in order to neutralize as far as possible the respiratory derangements unavoidably arising from opening one side or the thorax.
Among other phenomena, Landois observed, after closure of the superior vena cava (in the rabbit): i. Retardation of the heart's action; and, 2, "Complete epileptoid seizures."
The latter observation is one of great importance from a pathogenic point of view, since we are thus made aware not only that cerebral anaemia is capable of producing epileptoid convulsions (as shown by Kussmaul and Tenner), but that profound venous hypersemia of the central nervous system is equally provocative of the same phenomena.* We can readily understand, moreover, why the convulsions are per- petuated during the second stage of the epileptic attack — that period of the seizure when the brain is evidently in a state of profound venous engorgement.
In 1868, Dr. H. Nothnagelf drew attention . to the fact that, although it had long been known that irritation of the floor of the fourth ventricle gave rise to irregular general convulsions, no attempt had been
* " Die Entstehung allgemeiner Convulsionen von Pons und von der Medulla oblongata aus," von Dr. D. Nothnagel. "Archiv. fiir pathologische Anatomie und Physiologie und fUr klinische Medicin," Bd. xliv, p. i, 1868.
f Op. cic, pp. 146 and 147.
— 131 — made to locate the district in question with greater pre- cision. That more exact researches in this regard were really necessary was proved by the fact that ex- periments, undertaken in the light of the popular con- ception with regard to the '•convulsive" functions of the floor of the fourth verticle, frequently failed to produce any spasmodic phenomena whatsoever.
Accordingly, Nothnagel instituted a series of ex- periments with a view to determining with greater precision the locality in the medulla whose irritation is followed by general convulsions.
The technique of these experiments was extremely simple. The animal was placed upon the abdomen and secured with appropriate appliances. The soft parts were then divided so as to expose the occipital portion of the head between the crista and protuber- antia occipitalis. Then the skull was pierced by means of a strong needle (care being taked to avoid the openings for the vasa emissaria Santorini). Finally, penetration of the organs within was effected by means of a fine needle. This procedure was followed by compulsory movements, general epileptoid convulsions, or the animal remained perfectly quiet, according to the part penetrated. Confirmatory evidence was sub- sequently afforded by post-mortem examination.
In this simple manner Nothnagel was able to de- termine with great exactness the boundaries of what he has expressively termed the "convulsion center" {Krampfbezirk). The lower limit of this district is
— 132 —
situated at the upper portion of the alcz cineretz; the upper limit lies somewhat above the locus cceruleus; the inner limit is constituted by the outer lateral border of the eminenticz teretesj the outer limit is more difficult to locate, but the upper boundary line appears to be formed by the locus cceruleus, whereas, below it corre- sponds to the inner border of the tuberculum acusti- cum.^
The depth of the district is very difficult to deter- mine, as the slightest movement on the part of the hand of the operator causes the needle to penetrate unduly the yielding nervous tissue. When the needle penetrates the above mentioned district (the "convul- sion center"), the following phenomena are observed:
"At the moment of penetration severe opisthot- onus and tetanic extension of the spinal column take place. Although firmly secured, the animal makes spasmodic movements with the extremities. When released it presents the spectacle of the most pro- nounced epileptoid convulsions. The extremities are the seat of violent irregular contractions, the posterior being sometimes more affected than the anterior limbs. At the same time the entire animal is thrown from side to side. ... In from one-half to three minutes the violence of the paroxysms subsides, and the ani- mal remains quiet, but the extremities still continue extended and the spinal column is perfectly rigid." A
* Op. cit., p. 5.
— ^33 —
blow upon the table is sufficient to again evoke the convulsions, but the latter sometimes break forth anew spontaneously.
From these experiments, Nothnagel concludes that the central point of departure of general convul- sions is to be sought for in the pons. The lower limit of that portion of the central nervous system which is the point of departure of general epileptiform convul- sions is represented by a transverse section situated at the lower boundary of the pons.*
These, then, are the experiments upon which Nothnagel has founded his theory of epilepsy. I shall take occasion to again refer to the latter in the subse- quent paragraph on the nature of the paroxysm.
In 1850 Dr. JBrown-Sequard f succeeded in de- monstrating that certain lesions of the spinal cord in mammals are followed in a few weeks by convulsions bearing a strong resemblance to those of epilepsy. After a long series of experiments on guinea-pigs, he found, moreover, that all the lesions of the cord enumerated below are capable of evoking these con- vulsive phenomena:
I. Complete or almost complete transverse sec- tion of one lateral half of the cord
* Op. cit., p. 9.
f Vide "Comptes rendus de la Societe de biologic," 1850, vol. ii; "Archives generales de medecine," 1856, vol. i (v. serie, tome 7), p. 143; "Lancet," 1861; "Bull, de 1' Academic de med. de Paris," Jan., mals," etc., 1857.
— 134 —
2. Simultaneous transverse section of the poste- rior columnSjOf the posterior horns of gray matter, and of a portion of the lateral columns.
3. Transverse section of the posterior columns, or of the lateral columns, or of the anterior columns alone.
4. Complete transverse section of the cord.
5. Simple puncture of the cord.
Of these lesions, the first two are apparently those which are most liable to develop the convulsive condi- tion.
That portion of the cord situated between the seventh or eighth dorsal and the third lumbar verte- brae is most susceptible to wounds. Lesions of this region are particularly prone to develope the convul- sive condition.
In the majority of cases, the convulsive symptoms appear during the third week subsequeut to the lesion.
Sometimes the convulsions appear without the aid of extraneous excitation. As a rule, however, they are readily evoked by irritation of certain circum- scribed portions of the integument. That portion of the body the irritation of which causes convulsions has been termed by Brown-Sequard the ^'' epileptogenous zone''
This author has also shown that section of the more important nerve-trunks, such as the internal popliteal and sciatic, and also lesions of the crura cere-
— '35 — bri or corpora quadrigemina, are particularly prone to develop the epileptic condition.*
The offspring of animals affected by epilepsy caused by lesions of the nervous system may develop the epileptic condition, as Dr. Brown-Sequard has conclusively demonstrated.
A suggestive circumstance in connection with the epileptogenous zone is the fact that the latter is always situated on the same side as the lesion of the spinal cord or nerve; but, when the crus cerebri is injured, it is found on the opposite side of the lesion.
Westphal,f while endeavoring to determine whether the epileptoid convulsions previously de- scribed by Brown-Sequard might be determined by certain injuries to the skin, discovered the interesting fact that, when a guinea-pig receives a blow, or a series of blows upon the head, the animal is at once seized with a violent convulsive attack. The convul- sions thus induced resemble in every respect those produced by Brown-Sequard in the same animal by injuries to the nerves or spinal cord. The seizure takes place immediately after the blow, or after the lapse of a few minutes. When the convulsions have subsided, the animal appears to recover its normal condition; and attempts to cause a renewal of the
* " Researches on Epilepsy," etc., by Brown-Sequard, 1857. Also articles in journals already referred to.
f " Ueber kiinstliche Erzeugung von Epilepsie bie Meer- schweinchen," Berliner klinische Wochenschrift, No. 38, 1871.
— 136 —
seizure by irritating that portion of the skin which Brown-Sequard has called the " epileptogenous zone " are without avail. A different state of things is, how- ever, observed to exist after the lapse of a few weeks; for, if now the animal is irritated by pinching, par- ticularly in the neighborhood of the lower jaw, an at- tack of convulsions is immediately produced.
The susceptibility to a convulsive condition evoked by blows is hereditary, like the corresponding state which Brown-Sequard succeeded in establishing by means of injuries to the spinal cord and nerve- trunks. f
Dr. V. Magnan J and M. Challand § have shown in animals that absinthe, when introduced into the system, produces convulsions of an epileptoid char- acter. The following experiment, performed by Dr. Magnan on a dog, is most interesting, as showing the possibility of producing hallucinations as well as epileptic attacks by the administration of absinthe: " In a dog weighing thirty-one pounds, into whose stomach we injected five grammes (about seventy-five minims) of essence of absinthe at 9:15 a. m., we ob-
t Op. dtp. 45 r.
I "On Alcoholism, the Various Forms of Alcoholic Delirium and their Treatment," by Dr. V. Magnan, London, 1876, p. 26.
§ Challand. "' Experiments made at the Hotel Dieu at Professor Behier's Clinique," cited by Dr. Magnan in his monograph on " Alcoholism," p. 26 et seq.
— 137 —
served a first attack of epilepsy at 9:45 a. m.; ten minutes later a second attack occurs, followed by a slight degree of stupor; quickly becoming himself again, the animal continues playful, answers a call, walks and runs easily. Quite suddenly, and without any provocation, he raises himself on his feet, with hair bristling, angry look, eyes injected and brilliant; he fixes his gaze on a wall which is completely bare, and on which there is nothing to draw his attention; bending down with the paws forward and the neck stretched ready to spring, he advances and recoils alternately, barks furiously, and gives himself up to a furious battle; clashing his jaws, and making sudden movements as if to seize an enemy, he shakes his head from side to side, clinching his teeth as if to tear his prey. By degrees he becomes calm, but still looks several times in the same direction, growling, and then regains confidence completely."
Finally, it is worthy of note that both Ferrier and Bartholow have succeeded in evoking epileptoid convulsions by the direct application of the faradaic current to the brain. Convulsions have also been caused by injury to the cortical motor areas. f In all experiments of this nature, in which electricity is em- ployed for the purpose of exciting the nervous sub-
* Op. et loc. cit.
f " Untersuchungen tiber das Gehirn," 1864, and other writings of Hitzig.
- 138 -
stance, it should be borne in mind that the localiza- tion of the current is a matter of so much difficulty that great caution should be exercised in drawing con- clusions as to the relative functional importance of neighboring districts.
Having thus reviewed in succession those experi- mental researches which are best calculated to shed light upon the intricate questions of pathology in- volved, it now remains to discuss the mechanism of the attack itself — a task which will be greatly facili- tated by the preliminary knowledge at our disposal
CHAPTER IX.
PATHO-ANATOMICAL FINDINGS.
So various have been the changes recorded by pathologists in epilepsy that, if an attempt were made to construct an explanation of the seizure upon such a basis, it would be found to resemble in intricacy a veritable Gordian knot. There is, in truth, hardly an organ in the entire body which has not been found diseased in this affection. Ignoring the morbid changes in the viscera, which are evidently of colla- teral importance, it will be well for the completeness of the argument to bestow a glance upon the more striking appearances found in the brain, medulla, and the remaining portions of the cord, and their appen- dices.
First of all, then, it has been affirmed that the weight of the brain is increased in epilepsy;* but, on the other hand, equally positive statements are at hand which go to show that, in some cases at least, the weight of the organ is decreased. f
Unequal proportions of the two hemispheres has also been alleged, but is certainly by no hieans so fre- quently met with as was formerly supposed.
Meynert and others have found sclerosis of the
* Echeverria, "On Epilepsy," New York, 1870.
f Meynert, " Vierteljahrasschrift fiir Psychiatric," 1867.
— 140 —
cornu Ammonis, but I believe he rightly considers this change of secondary origin only. But I would go a step further and maintain that the lesion in question can not possess the slightest importance whatever, so far as the development of the paroxysm is concerned, since, when this portion of the brain is removed, con- vulsive phenomena are neither evoked nor increased when they already exist.
Without entering upon a recapitulation of the various tumors which have been found associated with epileptic phenomena, I will content myself with enumerating some of the further and more obvious changes about the cord and brain which have been noted within the last few years: (i) atheroma and aneurism of blood-vessels; (2) dilatation of the vessels of the superior portion of the cord; (3) temporary or permanent anaemia of the brain, resulting from general causes or from local vaso-motor insufficiency; (4) in- crease in quantity of the cerebro-spinal fluid; (5) thick- ening of the meninges of the brain.
Of these changes, the latter must be regarded as of most importance, since it is found in a considerable number of cases. But, though cortical function is in- terfered with in all true cases of epilepsy, it would be a decided mistake to ascribe such alterations to men- ingeal changes, since in a by no means insignificant number of cases neither they nor indeed any other morbid appearances are discernible, even upon the closest and most improved methods of scrutiny.
— 141 —
There is consequently no question in my own mind that, where these evidences of meningitis do occur, they are, like most of the other changes recorded, to be regarded as of purely secondary origin — to be ac- counted for, perhaps, by the violent circulator}" fluctua- tions which are so characteristic of the disease.
Still, when once established, these thickened membranes have an undoubted influence upon the prognosis. Thus, in three cases of severe epilepsy, with psychical complications, in which I have made post-mortem examinations, these thickened and ad- herent members were a prominent feature. In such cases there is, I believe, little or no chance of either recovery or benefit, since the derangements in cortical nutrition caused by such lesions must of necessity be profound in character, and practically irremediable.
CHAPTER X.
THE MECHANISM OF THE EPILEPTIC SEIZURE.
Enough has already been said concerning the various morbid anatomical findings in epilepsy to prove conclusively that there is absolutely nothing either characteristic or constant in their occurrence. Consequently, if epilepsy is to be regarded as a malady /(?r se, and not as a mere symptom of multi- tudinous forms of central nervous disease, we must look elsewhere for an adequate explanation of the true nature of the affection. Undoubtedly the most consistent theory of the disease is based upon con- siderations derived from experimental physiology and pathology.
Without anticipating further, however, it will be well to review briefly the more prominent hypotheses relative to the nature of the disease which have been advanced by various writers on the subject from time to time.
According to Marshall Hall,* the mechanism of
* The following are the principal writings in which Mar- shall Hall has embodied his views relative to the pathology of epilepsy: " Essays on the Theory of Convulsive Diseases and Derangements of the Nervous System;" "Synopsis of Cerebral and Spinal Seizures of Inorganic Origin and of Paroxysmal Form;" " Synopsis of Apoplexy arid Epilepsy, with Observa- tions on Trachelismus, Laryngismus, and, Tracheotomy," 1852; " On the Neck as a Medical Region," " Lancet," 1849; "Me- moirs on the Nervous System," London, 1837.
— 143 — the seizure may be formulated somewhat as follows: (i) excitation of a sensory nerve or direct central ex- citation, which gives rise in the first place to reflex spasm of the muscles of the neck, causing compression of the cervical veins with consequent comatose symp- toms; and, secondly, to a reflex tonic spasm of the muscles of the larynx, closing of the rima glottidis (laryngismus), causing asphyxia with consequent con- vulsions In other words, the condition of uncon- sciousness is ascribed to venous engorgement, and the convulsions to general asphyxia.
Plausibility was lent to that portion of the theory which assumes contraction of the muscles of the neck as the cause of the venous stasis by the experiments of Reynolds This observer found that contraction of the cervical muscles actually did produce stasis of the veins of the neck, with concomitant cerebral dis- turbances. But, on the other hand, Kussmaul and Tenner* have shown, by conclusive experiments, that occlusion of the larynx is capable of producing both coma and convulsions. As a consequence, they refuse to accept the first portion of Hall's theory. It may be well to add in this connection that both of these ob- servers guided by clinical and experimental data, ar- rived at the conclusion that the phenomena of the affection, and particularly the unconsciousness, could
^^^^"^the Nature and Origin of Epileptiform Convulsions caused by Profuse Bleeding." by A. Kussmaul and A. Tenner. "New Sydenham Society," 1859.
— 144 —
not be accounted for by any merely local anatomical lesion, since the concomitant participation of the cere- brum was evidently a sine qua no7i. Moreover, they conclude that it is not necessary to assume a constant or gross change appreciable by the pathological ana- tomist, but that a pervasive functional change of tran- sient duration is sufficient to account for the pheno- mena of the ordinary epileptic seizure. Such a per- vasive, transitory change they perceive in cerebral anaemia — a condition which, as is well known, consti- tutes a prominent feature of the first portion of the epileptic attack. Besides this clinical fact, they ad- duce the evidence afforded by their own experimental researches, to which extended reference has already been made, by which it was conclusively shown that, when the brain of an animal is suddenly deprived of arterial blood, either by ligation or compression of the four great arteries which supply the brain, or by bleed- ing, epileptic convulsions and coma are invariably pro- duced."^ These observers also endeavored to cause
* These researches, as we have already seen, were, to a certain extent, anticipated by Sir Astley Cooper (vide " Guy's Hospital Reports," vol. i, 1836), who succeeded in demonstra- ting upon rabbits that ligation of both carotids and compres- sion of the vertebrals gave rise to convulsions, suspension of respiration, and unconsciousness. The experiments of Kuss- maul and Tenner were, however, more thorough, and were conducted upon cats and dogs as well as rabbits (vide Moles- choot's " UnterVsuchungen," 1857, Bd. ii. pp. 247, 248 et seq. ; also, " Epileptiform Convulsions caused by Profuse Bleeding," by Adolf Kussmaul and Adolf Tenner, " The New Sydenham Society," London, 1859).
— 145 — convulsions by faradization of the sympathetic nerves. Only in one case, however, were their efforts success- ful; but, had the interrupted galvanic current been employed, it is possible that more uniform results might have been obtained. These failures are, how- ever, not to be accepted as absolutely negative, or as fatally damaging to the general argument advanced by these gentlemen, since their experiments with arterial compression and ligation served to show that the profound cerebral anaemia resulting therefrom invariably evoked general convulsions and uncon- sciousness.
But, while recognizing the important part played by cerebral anaemia in the i7nmediate production of the epileptic attack, Kussmaul and Tenner do not fail to note that behind all this there must be an ultimate morbid state — an epileptic " condition " or an epileptic " affection " which is responsible for the occurrence of all the phenomena concerned in the produc- tion of the seizure. In speaking of this " proximate " or ultimate cause of the attack they proceed to state "that the proximate cause of the attacks can not be one of long duration, but an alteration merely of a temporary kind. ... It must be quickly de- veloped to its full fextent, and pass during the attack through its different phases, and, when the latter are over, cease completely or nearly so. How otherwise is it reconcilable that, after an attack, the patient so frequently, and often for so long a time, recovers the
— 146 —
full use of the action of the brain ?" And again: "It can be no visible alteration of the brain, anatomically demonstrable, that can act as the proximate cause of an epileptic attack. . . . Every physician of the present day, who is at all judicious, will relinquish the hope, cherished with childish confidence by certain schools and times, that pathological anatomy is destined to give an explanation of the nature and seat of epi- lepsy, and he will only expect that result from the progress of the experimental physiology of the nerves. Material alterations in the brain and its membranous and osseous coverings are, it is true, most frequently found in those who have died from epilepsy and eclampsia, and are often enough recognized as the cause during life. Often, however, in spite of most careful examinations, no anatomically demonstrable alterations are found in the structure of the brain, and those which do exist must be generally regarded, es- pecially in epilepsy, as produced by interruptions to the circulation and nutrition during the attacks, par- ticularly if the latter have frequently been repeated and for a long time. Most of the patients suffering from this disease for years afford the usual appear- ances found in chronic diseases of the brain. . . ." But " not one of all the anatomical alterations in whose train epilepsy frequently appears — such as cicatrices, tubercles, and atrophy of the brain, or premature coalescence of the sutures of the skull, with lessening of its cavity — leads invariably to this disease."
— 147 —
The " disposition," then, " is nothing else but that state of the brain which forms the basis from which the attacks arise, and can scarcely be conceived of otherwise than as a very slight alteration of the whole brain, or of a narrowly circumscribed district, while the alteration which is the cause of the attacks must always affect the whole substance of the brain, or at all events the greatest part of it, and that, more- over, in an energetic manner."
The following is a general summary of the more important conclusions which Kussmaul and Tenner derived from their long series of experiments:
1. " The convulsions appearing in profuse hem- orrhage of warm-blooded animals (including man) re- semble those observed in epilepsy."
2. "When the brain is suddenly deprived of its red blood, convulsions ensue of the same description as those occurring subsequent to ligature of the great arteries of the neck."
3. '' Epileptic convulsions are likewise brought on when the arterial blood rapidly assumes a venous character, as, for example, when a ligature is applied to the trachea."
4. " It is highly probable that in these cases the attack of spasms depends upon the suddenly inter- rupted nutrition of the brain. It is not caused by the altered pressure which the brain undergoes."
5. "Epileptic convulsions in haemorrhage do not proceed from the spinal cord."
5- "Neither do they proceed from the cere- brum."
7. "Their central seat is to be sought for in the excitable districts of the brain lying behind the thalami optici."
8. "Anaemia of those parts of the brain situated in front of the crura cerebri produces unconsciousness, insensibility, and paralysis in human beings; if spasms occur with these symptoms, some excitable parts be- hind the thalami optici must have likewise undergone some change."
9. " Anaemia of the spinal cord produces paraly- sis of the limbs, of the muscles of the trunk, and of respiration. When the anaemia suddenly attains its greatest intensity, then only, and even then but rarely, do slight trembling of the limbs precede paralysis. The sphincter ani acts analogously to the constrictor muscle of the face in anaemia of the brain^that is, it contracts spasmodically before it relaxes."
A more explicit account of the experiments from which Kussmaul and Tenner derived these conclusions has already been given in the paragraphs on "Experi- mental Researches." These experiments constitute, without doubt, one of the most brilliant chapters in the whole range of experimental pathology, and it is diffi- cult to conceive how a theory of epilepsy possessing the slightest title to consistency could have been for- mulated had they never been undertaken.
While it is doubtful whether some of the opinions
— 149 —
expressed by these gifted authors can at present re- ceive unqualified indorsement, there is no denying the great perspicuity displayed throughout the entire argument. When interpreted, moreover, from the broad standpoint of more recent scientific acquisitions, their importance to scientific medicine can hardly be overestimated.
Finally, I will add that I have been able to con- firm many of the statements and conclusions of Kuss- maul and Tenner by researches conducted on human beings. As I shall have occasion to refer at some length to these researches in other portions of this article, I will content myself with merely indicating the titles of the more important papers and mono- graphs in which they are embodied.*
* Vide "Medical Record, ' February 18,1882. Article on "Sleep," "Medical Record " July, 1872. Monograph on "Carotid Compression," Anson D. F. Randolph & Co., New York. 1882. Paper read before the New York Neurological Society, June 6, 1882, and subsequently published in the " Phil- adelphia News" of June 17, 1S82, and also in the "Ameri- can Journal of Neurology and Psychiatry," 1882. A paper on " Electrization of the Sympathetic and Pneumogastric Nerves, with Simultaneous Bilateral Compression of the Carotids," " New York Medical Journal," February 23, 1884. Monograph on "Brain Rest," G. P. Putnam's Sons, New York, 1883. A treatise on " Brain Exhaustion," with some preliminary con- siderations on cerebral dynamics, by J. Leonard Corning, M. D., D. Appleton & Co., 1884. "The Electro-mechanical Tonus of the Cortical Blood-vessels," a paper read before the New York Neurological Society, and subsequently published in the " Medical Record," February, 1885.
— 15° —
Nothnagel,* as we have already seen, has formu- lated a theory of the paroxysm, which is the outgrowth of a series of experiments performed with the object of determining the role played by the medulla oblongata and pons varolii in the evolution of general convulsive phenomena. In the course of these investigations this observer ascertained that there is a limited spot in the floor of the fourth ventricle, the irritation of which (with a needle, etc.,) causes tonic and clonic spasms of the entire system of voluntary muscles. This spot has been appropriately designated by him as the " convulsion center."
According to Nothnagel's theory, the convulsions of the epileptic paroxysms are due to irritation of this circumscribed locality.
But, while such irritation is sufficient to evoke the spasms, it is not adequate to account for the uncon- sciousness. Accordingly, to overcome this difficulty, Nothnagel assumes a concomitant irritation of the neighboring vaso-motor center. As a result of this irritation the arteries of the brain, as well as those of the rest of the body, are contracted, causing anaemia; and it is to this cerebral anaemia that the unconscious- ness is due. The co-ordinate excitation of the vaso- motor and " convulsion centre " constitutes, then, ac- cording to this theory, the essential pathological fea- ture of the typical paroxysm.
* "Uber den epileptischen Anfall," von H, Nothnagel. Volkmann's " Sammlung klinischer Vortrage," Leipzig, 1872.
— 151 —
But, while this is assumed to be the course of events in typical cases, it does not serve to explain the occurrence of variations in the character of the seizure.
Accordingly, with a view to rendering the theory as broad as possible, Nothnagel furthermore assumes that the centres above referred to are in a certain sense independent of each other, so that one may be irritated without the other. Thus, when the "con- vulsion center" is irritated alone, the paroxysm is characterized by convulsions without unconsciousness; whereas, when the " vaso-motor center " is excited mental disturbances and loss of consciousness are the prominent features.
This is certainly an ingenious method of avoid- ing a logical dilemma; but, unfortunately, the extreme contiguity of the two centres renders their indepen- dent irritation exteremely improbable, since any mor- bid changes affecting the one would be practically cer- tain to involve the other.
CHAPTER XI.
CONCERNING THE NATURE OF THE IRRITATION
—THEORIES OF NOTHNAGEL. TODD
AND HUGHLINGS JACKSON.
With regard to the nature of the irritation which calls forth the activity of the above-named centers, Nothnagel confesses that little can be said with cer- tainty.* He believes, however, that in epilepsy " the convulsions do not depend upon an anaemia of the pons, acting as an excitant upon the convulsion centre;"f though admitting that anaemia of the pons can occasion convulsions, as shown by certain of Kuss- maul's experiments.
As to the second stage of the attack, Nothnagel believes that the intense venous hyperaemia is attribut- able to the violent contractions of the muscles of the neck, which, pressing upon the large veins, impede the return of the venous blood to the heart. The continuance of unconsciousness, as well as the con- vulsions, are to be ascribed to this venous hyperaemia, one of the effects of which is to cause irritation of the "convulsion center."
It now remains to consider briefly that theory of
*Von Ziemssen's "Cyclopaedia," article " Epilepsy," by H. Nothnagel, vol. xiv; p. 269, seventeenth line from the top. fOp. cit., p. 268.
— '53 — epilepsy which ascribes the essential feature of the dis- ease to a discharge or explosion of nerve force. Dr. Robert B. Todd* was the first to regard the disease from this point of view. It is impossible to read the paper in which this gifted writer formulates his views upon this, one of the most intricate chapters in pathol- ogy, without experiencing a sense of admiration for the perspicuity and logical adroitness displayed.
Dr. Todd considers that the abnormal explosive- ness of nervous tissue, which is the principal factor in his theory of epilepsy, is due to the gradual accumula- tion of a morbid material in the blood. This foreign substance finally becomes so abundant as to cause the discharge of nerve force from the brain, by which the phenomena of the fit are produced.
This theory of epilepsy was suggested to the mind of Dr. Todd from the fact that the disease oc- casionally occurs with renal affections. " Upon this fact of the dependence of attacks of epilepsy upon renal disease," he says, " I have been enabled to con- struct a theory of the cause of epileptic fits generally." Continuing the argument, he adds: " I hold that the peculiar features of an epileptic seizure are due to the gradual accumulation of morbid material in the blood, until it reaches such an amount that it operates upon
*A Clinical Lecture on a Case of Renal Epilepsy, and on the Treatment of Epilepsy in General," by Robert B. Todd, M. D., Medical Times and Gazette, Aug. 5, 1854.
— 154 — the brain in, as it were, an explosive manner; in other words, the influence of this morbid matter, when in sufficient quantity, excites a highly polarized state of the brain, or of certain parts of it, and these discharge their nervous power upon certain other parts of the cerebro-spinal center in such a way as to give rise to the phenomena of the fit. A very analogous effect is that which results from the administration of strych- nine, which is best seen in a cold-blooded animal like the frog. You may administer this drug in very minute quantities for some time without producing any sensible effect; but, when the quantity has ac- cumulated in the system up to a certain point, then the smallest increase of dust will immediately give rise to the peculiar convulsion phenomena. The animal is thrown into a series of paroxysms of opistho- tonos, which exactly imitate the phenomena which we often witness in tetanus, as it affects man and some of the higher animals."*
This, then, is Dr. Todd's conception of the causa- tion of the paroxysm — the so-called humoral theory of epilepsy.
The theory enunciated by Dr. Todd has been modified and developed by Hughlings Jackson. f Ac- cording to Dr. Jackson, epilepsy, " defined from the paroxysm, is a sudden, excessive, and rapid discharge of gray matter of some part of the brain; it is a local
*0p. et loc. cit.
f "West Riding Lunatic Asylum Medical Reports," 1873.
— 155 — discharge. To define it from the functional altera- tion, we say there is in a case of epilepsy gray matter which is so abnormally nourished that it occasionally reaches very high tension, and therefore occasionally explodes. The two definitions are different faces of the same thing."
The discharge, beginning at the cortex, is propa- gated along the course of the centrifugal nerve chan- nels. As to the loss of consciousness, Dr. Jackson feels justified in ascribing it to the transitory exhaus- tion of nervous energy, consequent upon the previous inordinate discharge.
The fact that in a considerable number of epilep- tics the paroxysm is ushered in by a psychical warning, or an aura of special senses, has been urged as strong evidence in favor of the proposition that the discharge begins in the convolutions. And, in truth, it must be acknowledged that it is difficult to conceive how a primary functional implication of the medulla or pons Varolii could evoke phenomena which, by common consent, are conceded to be the expression of the ac- tivity of the highest centres.
According to this theory, then, the protoplasm of the ganglion cells is in an unstable, super-explosive condition, attributable, perhaps, to excessive nutrition (as the result of expanded blood-vessels, etc.). Jack- son has not, however, remained content with explain- ing the modus operandi of the ordinary epileptic par- oxysm, but has also sought to render his theory sufifi-
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ciently comprehensive to account for the evolution of irregular forms of the attack. Accordingly, it is assumed that in one class of cases certain portions of the gray matter may be affected, while in a second class of cases other portions may be involved. The various modifications of the seizure are, therefore, ex- plained by a consideration of the physiological pro- perties of the group of nerve-cells involved in each case.
While heartily indorsing the main features of this theory, I cannot accept it in all its details, for the very excellent reason that cerebral physiology is not as yet sufficiently developed to admit of such pathological refinements.
CHAPTER XII.
PROGNOSIS— TREATMENT.
From the very earliest periods of recorded history- epilepsy has been regarded as a grave disease. Doubts of its curability have been expressed, even at the present day; this, however, according to such ex- cellent authorities as Herpin and Nothnagel, is the extreme of pessimism and is not sustained by clinical experience.
When the disease begins early in life, say before the eighteenth year, the prognosis, all things being equal, is more favorable than when the disease comes on late in life.
In those cases where the first attack is traceable to a peripheral cause, the prospects of recovery, pro- vided we succeed in removing such cause, is greater than when we have to do with a gross central lesion.
Long intervals between the attacks are considered of favorable import by some, but by others they are believed to presage a doubtful recovery.
The character of the seizure has no great influ- ence on the prospects of recovery; and in forming an opinion on that question we may apply about the same course of reasoning to a case of grand mal as to one of minor epilepsy.
The principal methods of treating the disease in
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vogue at the present day resolve themselves into surgical procedures (medicinal) measures and dietetic expedients.
By resort to surgery we remove an offending cicatrix, the irritation emanating from which may cause the explosive condition resulting in the seizures. The same means also enable us to elevate a depression in the skull, and to remove by the aid of the trephine irritating substances from the surface of the meninges, Happy results soon followed such applications of surgery; but unfortunately the number of cases sus- ceptible of such treatment is relatively small, so that in the majority of cases we have to rely upon the in- troduction of chemicals into the system, and upon careful regulation of the diet to prevent or diminish the frequency of the seizures.
The chemicals which have been employed as medicines in the treatment of epilepsy aie legion. Among those which, at one time or another, have en- joyed a wide celebrity I would mention the following: Valerian, wormwood, hyoscyamus, belladonna, oxide of zinc, nitrate of silver, and in the form of inhalations, chloroform, ether, and the nitrite of amyl. During the last ten years the bromides have become the fashion- able remedies in epilepsy. At one time great things were expected from electricity, and while these expec- tations have not been entirely realized, it must be con- ceded that great benefits are occasionally witnessed from the application of the constant galvanic current
— 159 — about the head. I, myself, have frequently witnessed diminution of the number of seizures subsequent to prolonged applications of weak galvanic currents to the head. The faradic current, on the contrary, is of no particular use even in the treatment of epilepsy.
The first question which naturally suggests itself to the physician in connection with the treatment of epilepsy is: "What shall we do when the