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operator then takes hold of the patient's hand and the other
electrode is passed over the muscles of the neck, back, trunk, and
extremities.

When the patient is in bed, as in the regular rest treatment, this

method has to be modified, and then the best treatment is by direct
muscular faradization. Two sponge electrodes are employed. The
sponges are moistened, so that the current may pass through the
skin and reach the muscles. Both electrodes are taken in one hand,
the handle of one, pointing backward, being between the first and
second fingers, while the handle of the other is between the third and
fourth fingers. In this way the distance between the points of
application can be readily altered. The current is then applied to the
muscles everywhere, beginning with those of the feet. Muscles
should be relaxed before passing the current through them. The
whole body can be gone over in this way in the course of half an
hour.

The hydropathic treatment of hysteria is one that has much in it to be

commended. Jolly approves the systematic external application of
cold water; Chambers advocates the daily morning use of shower-
baths, holding that the bracing up of the mind to the shock of a cold
shower-bath is a capital exercise for the weak will-power of the
hysterical individual, and some admirable results have been reported
by Charcot in inveterate neurasthenics and hysterics.
Hydrotherapeutic treatment, continued perseveringly for a long time,
says Rosenthal, “diminishes the extreme impressionability of
hysterical patients, strengthens them, and increases their power of
resistance to irritating influences, stimulates the organic functions,
combats the anæmia, calms the abnormal irritability of the peripheral
nervous system, and by diminishing the morbid increase of reflex
power relieves the violence of the spasmodic symptoms. Even
chronic forms which are combined with severe paroxysms of
convulsions are susceptible of recovery under this plan of treatment.”

The hydrotherapeutic treatment may be contrasted with the

treatment by seclusion, rest, massage, and electricity. Undoubtedly,
one class of hysterical patients is greatly benefited by the latter
method systematically carried out; these have already been
described. In other cases, however, this method of treatment is
useless; in some of them it has a tendency to prolong or aggravate
the hysterical disorder, while in the same cases a well-managed
hydrotherapeutic treatment will answer admirably. This is applicable
in hysterical patients who eat and drink well, who, as a rule, preserve
a good appearance, but whose mind and muscles are equally flabby
and out of tone, and need to be stirred up both physically and
mentally.

Dujardin-Beaumetz recommends prolonged warm baths of from one

to two hours' duration, and believes that the therapeutic virtues of
these baths are augmented by infusions of valerian.

In order to obtain satisfactory results from hydrotherapy, as well as

from massage, electricity, etc., it is best to remove patients from their
family surroundings. Good sanitariums near our large American
cities where hydrotherapy and other special methods of treatment
can be carried out are sadly needed. Hydrotherapeutic treatment is
much more efficacious when conducted at a well-regulated
institution, for several reasons. Measures troublesome in themselves
are here carried out as a matter of daily routine. Numerous patients
permit of the employment of competent attendants. The change is
often of great benefit. The close personal supervision which
hysterical patients are likely to have in a hydrotherapeutic
establishment is also to be taken into consideration. Better modes of
living, proper forms of exercise, regulated diet, etc. also enter; but
still, a fair share of the good which results can be attributed to the
water treatment.

While, however, it is better to remove hysterical patients, for

hydrotherapeutic as well as for other treatment, from their family
surroundings, and to place them in some well-regulated
establishment, it is not by any means impossible to carry out such
treatment in private practice, particularly in a house supplied with a
bath-room. Many of our hydrotherapeutic institutions are in the
hands of charlatans or of individuals who are not practically well
fitted for their work. Not infrequently, however, good results are
obtained even under these circumstances. Much more can be done
in this direction with modest buildings and appliances than is
generally supposed. It is not necessary to have numerous
apartments: three or four rooms in a well-appointed house, if the
arrangements for carrying out the hydrotherapeutic treatment are of
a proper kind, will suffice for a large amount of good work. In almost
any house provided with bath-rooms with hot and cold water some
useful hydrotherapy may be attempted. The spinal douche or pour
can be used by placing the patient in a sitz- or ordinary hip-bath and
pouring the water from a spout or hose held at a certain height, the
distance being regulated according to the patient's condition. Again,
the patient sitting in a tub, water can be poured upon her, beginning
at first with a high temperature and gradually lowering it. The
shower-bath may also be used. An extemporaneous shower-bath
can be provided by an ordinary watering-pot. Whole, three-quarters,
or half baths at different temperatures can be given. One method of
carrying out the wet pack is very simple. A comforter is spread upon
the bed; next to this is placed a woollen blanket, and over the
blanket a wet linen sheet, upon which the patient rests, with the head
on a low pillow. The wet sheet, blanket, and comforter are then
wrapped closely about the patient, bottles of hot water being placed
at the feet. The cold drip-sheet method is another easily used. It
consists in placing about the patient, while sitting up or standing, a
sheet wet with cold water, and then vigorously rubbing her through
the sheet.

Baths to the head may be used in some cases; cool head-baths are
most frequently applied. One method of using these baths is to have
the patient lie in such a position that the head projects a little beyond
the edge of the bed and over a basin or receptacle of some kind.
Water of a suitable temperature is then poured gently or squeezed
out of a sponge over the head. For some forms of insomnia or some
of the disorders of sleep in hysteria this treatment is a valuable
auxiliary to other measures.
For the hysterical spine cold compresses may be used along the
spine. On the other hand, hot fomentations may be found of benefit
in some cases. Where hydrotherapeutic measures are employed
attention should be paid to the condition of the circulation,
particularly in the extremities. If the feet or hands are cold, hot
applications or frictions should be used.

For certain of the vaso-motor disorders of hysteria, such as cold or

hot feet, flushings, etc., local hydrotherapeusis will be of service. In
hysterical contractures local stimulation by the douche method or by
the steam bath may be tried. For the excitable rectum cold enemata
in small quantities, so as not to be expelled, will be found to be very
efficacious. For spasmodic attacks, whether purposive or involuntary,
the use of the wet pack or the plunge-bath will sometimes be found
of good service. In neuralgias and other painful local disorders of
hysteria, frictions, fomentations, Turkish or Russian baths, and the
wet pack are often very beneficial.

When hysteria is complicated, as it very often is, with disorders of

the liver and stomach, hydrotherapeutic measures will be of added
efficacy. When it is associated with genito-urinary disorders, even
though the latter are not regarded as the cause of the former, special
beneficial effects, both local and general, can be obtained from
hydrotherapeutic measures. Locally, sitz-baths, hip-baths, douche-
baths, hot and cold injections, and foot-baths may act as revulsives,
astringents, or local tonics, while at the same time they are
measures which tend to strengthen the system as a whole.

Sea-bathing is often of the greatest value, although it is sometimes

difficult to induce hysterical patients, who are willing enough to go to
the seashore, to resort to surf-bathing. Few measures are better
calculated to bring up the tone of the nervous system of an hysterical
or neurasthenic patient than well-directed sea-bathing. Where sea-
bathing cannot be employed sea-water may be used indoors. Sea-
water establishments, where baths at various temperatures may be
had, are now to be found at all the best seaside resorts. In a few
cases the internal use of large quantities of either hot or cold water,
or of the ferruginous mineral waters, may be associated with the
external treatment.

The climatic treatment of hysteria has received little or no attention;

undoubtedly, much could be said in this connection. In a great
country like ours a climate suited to the requirements of almost every
form of disease can be had. The climate of those regions, either of
the seaboard or inland, particularly well suited to cases of lung
trouble, will often be useless, and sometimes harmful, to neurotic
patients. For a certain class of hysterical patients a sojourn at the
seashore, if not too protracted, will prove of great value. On the
whole, for most hysterical patients of the neurasthenic type the best
plan is to go first to the seashore for a few weeks, and then resort to
an inland hilly or mountainous country, but not at too great an
elevation. I have known the climate of some of the high altitudes of
Colorado to be of positive injury by depressing the nervous system.
Resorts like Capon Springs in West Virginia, out of the reach of
steam and worry, with prevailing south-west winds, are desirable
places.

The treatment of hysteria by the method of metallotherapy is worthy

of some consideration. It is a method by no means new. It was
known and practised by the ancients with rings and amulets.
Popularized at the beginning of the present century by certain
travelling charlatans, it was later, for a time, wholly ignored. In recent
years it has been received with considerable attention. One Burq for
many years practised metallotherapy in Paris disregarded or scouted
by the profession, but claiming many remarkable cures. Finally,
Charcot was induced to give him an opportunity of demonstrating the
truth or falsity of his claims at Salpêtrière.124 Cases of grave hysteria
were submitted to the treatment, and in certain instances with
striking results.
124 Lancet, Jan. 19, 1878.

After having determined by a series of experiments the particular

metal to which the patient is sensitive, bits of metal may be applied
to the surface of the body in various places; this constitutes external
metallotherapy. Or the metal, in the form of powder (as reduced iron)
or an oxide or some other salt, may be administered; this is internal
metallotherapy. That certain definite effects may be produced by the
application of metals to the surface of the body is unquestionable.
Some of the results which have followed their employment are the
removal of anæsthesia and analgesia, relief of hysterical paralysis,
improvement in the circulation, removal of achromatopsia, relief of
contracture.

Many investigations in Germany, England, France, and this country

have demonstrated that the same or similar effects can be produced
by the application of other non-metallic substances, such as discs of
wood, minerals, mustard plasters, etc. Hammond, among others,
has shown this. How the results are obtained is still a matter of
dispute. On the one hand, it is claimed, principally by the French
observers, that the cures are due to the metals themselves, either by
virtue of some intrinsic power or through some electrical currents
generated by their application. On the other hand, it is asserted,
particularly by the English observers, that the phenomena are best
explained on the doctrine of the influence of the mind on the body; in
other words, by the principle of expectant attention. Some at least of
the effects are to be explained on the latter hypothesis, but it is likely
that the monotonous impressions made upon the peripheral sense-
organs by different substances applied locally may act reflexly on the
brain.

Seguin125 reports a case of convulsion and hemianæsthesia in an

adult male cured by metallotherapy; the metal used was gold. Two
ordinary twenty-dollar gold pieces were placed in the patient's
hands, and afterward on his forearm, cheek, and tongue. Nothing
else was suggested or done to him; sensibility returned, and the
staggering and other symptoms disappeared. The patient left the
hospital claiming to be perfectly well. The same author reports
several other successful cases of metallotherapy, all of them
reactions to gold. One was a girl sixteen years old with analgesia.
125 Arch. of Medicine, New York, 1882.
Not a few cases are now on record of the cure of hysterical
contracture and other forms of local hysterical disorders by the
application of a magnet. Charcot and Vigouroux cured one case of
hysterical contracture of the left arm by repeated applications of the
magnet to the right or healthy arm. Debove by prolonged application
of magnets relieved hemianæsthesia and hemiplegias—not only the
hysterical varieties, but also, it is said, when dependent upon such
conditions as alcoholism, plumbism, and even cerebral lesions.
Maggiorani of Rome studied the physiological action of the magnet
and laid down the first rules for its therapeutic use. In the case of
powerful magnets we have more room for believing that an actual,
tangible force is at work in producing the results than in the case of
simple metals.

The question has been sometimes asked whether hypnotism can be

used with success in the treatment of hysteria. Richer reports a few
cures of hysteria through this agency. Braid has put on record
between sixty and seventy cases which he claims to have cured by
the same means. This list undoubtedly includes some hysterical
cases—of paralysis, anæsthesia, aphonia, blindness and deafness,
spinal irritation, etc. Both on theoretical grounds and from
experience, however, I believe that the practice of hypnotization may
be productive of harm in some cases of hysteria, and should be
resorted to only in rare cases of mental or motor excitement.

By some, special measures during the hysterical fit are regarded as

unnecessary. Jolly, for instance, says that we must merely take care
that the patients do not sustain injury in consequence of their
convulsive movements, and that respiration is not impeded by their
clothing. Rothrock126 reports several cases of hysterical paroxysms
relieved by the application of either snow or ice to the neck. The
applications were made by stroking up and down either side of the
neck along the line of the sterno-cleido-mastoid muscles. He
believed that the most probable explanation of the results obtained
was the shock received from the cold substance, but that
supplemental to this there may have been supplied through the
pneumogastric nerve a besoin de respirer. This measure and the use
of the cold spinal douche are both to be recommended.
126 Philada. Med. Times, 1872-73, iii. 67.

Emetics are sometimes valuable. Miles127 reports several cases of

severe hysterical seizure in which tobacco was promptly efficient in
controlling the affection. He used the vinum tabaci in doses of one
drachm every half hour or hour until the system was relaxed and
nausea induced, the effects usually being produced after taking
three or four doses. Fifteen grains of sulphate of zinc may be used in
adult cases. James Allen for a case of hysterical coma successfully
used a hypodermic injection of one-tenth of a grain of apomorphia.
Recently, at the Philadelphia Hospital this remedy has been
successfully employed in two cases, one of hysterical coma and the
other of hysterical mania. Inhalations of nitrite of amyl are often of
surprising efficiency. This and other measures referred to under
HYSTERO-EPILEPSY are also applicable in the treatment of any form of
hysterical spasm.
127 Clinical Med. Reporter, 1871, iv. 25-27.

For hysterical convulsions occurring during pregnancy an enema of

asafœtida, camphor, the yolk of an egg, and water, such as has
been recommended by Braun of Vienna, will often be found promptly
efficacious.

Fagge128 mentions a procedure which he had often seen adopted by

Stocker—namely, pressure upon the arteries and other structures on
each side of the neck.
128 British Medical Journal, March 27, 1880.

For hysterical paralysis faradism and galvanism hold the chief place.
Metallic-brush electricity should be used in the treatment of
anæsthesia.
Whenever, in local hysteria, particularly of the paralytic, ataxic, or
spasmodic form, it is possible to coax or compel an organ or part to
perform its usual function long unperformed or improperly performed,
treatment should be largely directed to this end. Thus, as Mitchell
has shown, in some cases of aphonia, especially in those in which
loss of voice is due to the disassociation of the various organs
needed in phonation, by teaching the patient to speak with a very full
chest an involuntary success in driving air through the larynx may
sometimes be secured. Once compel a patient by firm but gentle
means to swallow, and œsophageal paralysis begins to vanish.

Mitchell makes some interesting remarks upon the treatment of the

peculiar disorders of sleep, which he describes and to which I have
referred. When the symptoms are directly traceable to tobacco, he
believes that strychnia and alcohol are the most available remedies,
but gives a warning against the too liberal use of the latter. A
treatment which was suggested to him by a clever woman who
suffered from these peculiar attacks consists in keeping in mind the
need of breaking the attack by motion and by an effort of the will. As
soon as the attack threatens the patient should resolutely turn over,
sit up, or jump out of bed, and move about, or in some such way
overcome the impending disorder. Drugs are of little direct use.
Small doses of chloral or morphia used until the habit is broken may
answer, but general improvement in health, proper exercise, good
food, and natural sleep are much more efficient.

Fagge says that he has seen more benefit in hysterical contracture

from straightening the affected joints under chloroform, and placing
the limb upon a splint, than from any other plan of treatment.
Hammond129 (at a meeting of the New York Neurological Society,
Nov. 6, 1876) reports a case of supposed hysterical contracture in
the form of wry neck, in which he divided one sterno-cleido-mastoid
muscle; immediately the corresponding muscle of the other side
became affected; he cut this; then contraction of other muscles took
place, which he kept on cutting. The case was given up, and got well
spontaneously about two years later. Huchard130 entirely relieved an
hysterical contracture of the forearm by the application of an elastic
bandage.
129 Philadelphia Medical Times, vol. vii., Nov. 25, 1876.

130 Revue de Thérapeutique, quoted in Med. Times, vol. xiii., June 16, 1883.

A lady with violent hysterical cough was chloroformed by Risel of

Messeberg131 for fourteen days at every access of the cough, and
another for eight days. In both the symptoms were conquered. Nitrite
of amyl is useful in similar cases.
131 Allg. Med. Centralzeitung, Oct. 9, 1878.

Graily Hewitt132 reports a case of hysterical vomiting of ten months'

duration, caused by displacement of the uterus, and cured by
reposition of that organ. The same authority, in a paper read to the
London Congress, advanced the opinion that the exciting cause of
attacks of hysteria and hystero-epilepsy was a distortion of the
uterus produced by a flexion of the organ upon itself, either forward
or backward. He believed the attacks were the result of reflex
irritation. He recited eighteen cases, all of which were relieved.
Flechsig133 favors the gynæcological treatment of hysteria, including
castration or oöphorectomy. He reports three cases with good
results. His article favors the idea that any morbid condition of the
genital organs present ought to be remedied before treating the
hysterical symptoms. Zeuner,134 on the other hand, refers to a
number of cases in which gynæcological treatment gave either
entirely negative results or was productive of positive injury to
hysterical patients. He quotes Perreti,135 physician to an asylum for
the insane, who gives the details of a number of cases in which
gynæcological examinations or treatment were directly productive of
injury. He mentions a case of a female patient who had delusions
and hallucinations of a sexual type in which the physician was the
central figure. He reports cases in which proper constitutional
treatment, without gynæcological interferences, led to a full recovery.
Playfair, also quoted by Zeuner, states that he has often known the
condition of hysterical patients to be aggravated by injudicious
gynæcological interference. Oöphorectomy will be more fully
discussed under HYSTERO-EPILEPSY.
132 Med. Press and Circ., June 2, 1880.

133 Neurol., 7 Abt., 1885, Nos. 19, 20.

134 Journ. American Med. Ass., Chicago, 1883, i. 523-525.

135 Berliner klinische Wochenschrift, No. 10.

HYSTERO-EPILEPSY.

BY CHARLES K. MILLS, M.D.

DEFINITION.—Hystero-epilepsy is a form of grave hysteria

characterized by involuntary seizures in which the phenomena of
hysteria and epilepsy are commingled, and by the presence in
unusual number and severity, between the paroxysms, of symptoms
of profound and extensive nervous disturbance, such as paralysis,
contracture, hemianæsthesia, hyperæsthesia, and peculiar psychical
disorders.
SYNONYMS.—Hystero-epilepsy has long been known under various
names, as Epileptiform hysteria, by Loyer-Villermay and Tissot; as
Hysteria with mixed attacks, by Briquet; as Hysteria major or Grave
hysteria, by Charcot. The term hystero-epilepsy has been used with
various significations, and often without due consideration, and for
these reasons some authorities advise that it should not be used at
all. Gowers,1 for instance, refers to epileptic hysteria, hysterical
epilepsy, and hystero-epilepsy as hybrid terms which tend rather to
hinder than to advance the study of the nature of these convulsive
attacks and their relations to other forms of hysteria. He holds that it
is a clear advantage to discard them as far as possible, and
suggests the use of the term hysteroid, as proposed by W. W.
Roberts, or that of co-ordinate convulsions, as describing accurately
the character of the attack. These suggested terms do not strike me
as improvements upon those which he wishes the profession to
avoid. The word hysteroid, while good enough in its way, is certainly
objectionable on the ground of indefiniteness. Co-ordinate is
proposed, because the convulsive movements are of a quasi-
purposive appearance; that is, they are so grouped as to resemble
phenomena which may be controlled by the will. This meaning of co-
ordinate, however, as applied to the disorder in question, would not
be easily grasped by the average physician. When it is impossible to
name a disease from the standpoint of its pathological anatomy, the
next best plan is to use a clinical term which in a plain common-
sense manner gives a fair idea of the main phenomena of the
affection. Hystero-epilepsy, if it means anything, means simply a
disorder in which the phenomena of both hysteria and epilepsy are
to some degree exhibited. Certainly, this is what is seen in the cases
known as hystero-epileptic. In forming the compound the hysterical
element is, very properly, expressed first, the disease being a
hysteria with epileptic or epileptoid manifestations, rather than an
epilepsy with hysterical or hysteroid manifestations. A study of the
definition of hystero-epilepsy which has been given will show that it
is intended to restrict the application of the term in the present article
to cases with involuntary or non-purposive attacks, the voluntary or
purposive having been considered in the last article.
 1 Epilepsy and other Chronic Convulsive Diseases: their Causes, Symptoms, and
Treatment, by W. R. Gowers, M.D., F. R. C. P., etc., London, 1881.

HISTORY.—The greatest impulse to the study of hystero-epilepsy in

recent years has been given by the brilliant labors of Charcot and his
pupils and assistants in his famous service at La Salpêtrière. In his
lectures on diseases of the nervous system2 (edited by Bourneville),
and in various publications in Le Progrès médical and other journals,
Charcot has reinvestigated hysteria major with great thoroughness,
and has thrown new light upon many points before in obscurity. He
deserves immense credit also for the work which he has stimulated
others to do. Bourneville, well known as the editor of some of
Charcot's most valuable works, has published, alone or with others,
several valuable monographs upon hysteria and epilepsy.3 The most
valuable work on hystero-epilepsy, however, because the most
elaborate and comprehensive, is the treatise of Richer.4 Richer was
for a time interne in the Salpêtrière Hospital, and with Regnard
pursued his investigations under the superintendence and direction
of Charcot. His book is a volume of more than seven hundred pages,
containing a vast amount of information and profusely illustrated, in
large part by original sketches by the author. Charcot himself has
written for it a commendatory preface.
2 Leçons sur les Maladies du Système nerveux. A portion of these lectures have been
translated by G. Sigerson, M.D., and published by the New Sydenham Society of
London, and reprinted in 1878 and 1879 in Medical News.

3 Bourneville, Recherches clinique et therapeutique sur l'Épilepsie et l'Hystérie, 1876;

Bourneville et Voulet, De la Contracture hystérique-permanente, 1872; Bourneville et
Regnard, Iconographie photographique de la Salpêtrière. I have made special use of
the second volume of the last of these works.

4 Études cliniques sur l'Hystero-épilepsie, ou Grande Hystérie, par le Dr. Paul Richer,
Paris, 1881.

No article on hystero-epilepsy can be written without frequent use of

this work of Richer, and also of the numerous contributions of
Charcot. To them we are indebted for new ways of looking at this
disease, as well as for an almost inexhaustible array of facts and
illustrations of the diverse phases of this disorder.

While the curious, grotesque, or outrageous manifestations now

known as hystero-epileptic have been discussed with more or less
minuteness by authors from the time of Sydenham to the present,
usually, and more especially in all countries but France, these
manifestations have been studied as isolated phenomena. Charcot
and Richer, however, present a comprehensive view of hysteria as a
disease of a certain typical form, but often manifesting itself in an
imperfect or irregular manner. This regular type is characterized
particularly by a frequently- or infrequently-recurring grave attack,
which is divided into distinct periods, and these periods into phases.

This regular type of grave hysteria once understood, a place of

advantage is gained from which to study the disease in its imperfect,
irregular, and abortive forms. Whatever its pathology may be, such
striking symptoms as loss of consciousness with spasm,
hallucinations, and illusions show at least temporary disturbance of
the integrity of the cerebrum.

Hystero-epilepsy of imperfectly developed or irregular type is a not

uncommon affection in this country, but the disease in its regular
type is comparatively rare.

VARIETIES.—Hysteria and epilepsy, so far as seizures are concerned,

may show themselves in two ways in the same patient; but I believe
that it is best that the term hystero-epilepsy should be restricted in its
application, as Charcot, Bourneville, and Richer have advised, to the
disorder in which hysterical and epileptic symptoms are commingled
in the same attack—what is spoken of by the French as hystero-
epilepsy with combined crises. The other method of combination is in
the affection known as hystero-epilepsy with separate crises, in
which the same patient is the victim of two distinct diseases, hysteria
and epilepsy, the symptoms of which appear independently of each
other.
The fact that hysteria is at times associated with true epilepsy is
often overlooked. A patient who is known to have had pure hysterical
seizures of the grave type has also a genuine paroxysm of epilepsy,
and thus the medical attendant is deceived. I will dismiss the
consideration of hystero-epilepsy with separate crises with a few
paragraphs at this place, devoting the rest of the article to the
disorder with combined crises.

The coexistence of hysteria and epilepsy, with distinct manifestations

of the two neuroses, has been most thoroughly considered by
D'Olier.5 Beau in 1836, and Esquirol in 1838, first showed this
coexistence. Landouzy in 1846 first made use of the name hystero-
epilepsy with separate crises.
5 Memoir which obtained the Esquirol prize in 1881, by M. D'Olier, interne of the
hospitals of Paris, on “Hystero-Epilepsy with Distinct Crises, considered in the Two
Sexes, and particularly in Man,” translated and abstracted by E. M. Nelson, M.D., in
the Alienist and Neurologist, April, 1882.

In France the distinct existence of hysteria and epilepsy in the same

individual is not, according to D'Olier, a very exceptional fact. Beau
has reported it 20 times in 276 cases. The different modes of
coexistence have been summed up by Charcot as follows: “1,
Hysteria supervening in a subject already epileptic; 2, epilepsy
supervening in a subject previously hysterical; 3, convulsive hysteria
coexisting with epileptic vertigo; 4, epilepsy developing upon non-
convulsive hysteria (contracture, anæsthesia).”

The following case, now in the Philadelphia Hospital, illustrates the

first of these modes of combination: S——, aged thirty-nine, female,
a Swede, came to this country in 1869. She said that her mother had
fits of some kind. The patient had her first fit when she was four
years old. Her menses did not come on until she was nineteen. With
the appearance of her periods she had fainting-spells off and on for
two years, and in these spells she would fall to the ground. After two
years she improved somewhat, but still would have an occasional
seizure like petit mal. Four years ago she had a severe fit, in which
she bit her tongue. This was a paroxysm of true epilepsy. It was
witnessed by the chief nurse in the hospital, a competent observer.
Since then she has had attacks of some kind every month or oftener.
She rarely had a true epileptic seizure. Often, however, she had
hysterical and hystero-epileptic attacks. These paroxysms have
been witnessed by myself and by the resident physician and nurse.
Rarely they were epileptic, frequently they were hysterical. Mental
excitement will often induce an hysterical spasm.

PATHOLOGY.—Holding that hystero-epilepsy is a form of grave

hysteria, the remarks which have been made in the last article on the
probable nature of severe convulsive attacks will be applicable here.
In hystero-epilepsy with the typical grave attack we have the highest
expression of that disturbance of cerebro-spinal equilibrium which
constitutes the pathology of hysteria.

ETIOLOGY.—It will also be unnecessary to go at length into the

discussion of the predisposing and exciting causes of hystero-
epilepsy. In general, its predisposing causes are those of hysteria of
any form. Certain causes or conditions, however, predispose to
certain types or forms of hysteria. The Latin races are more inclined
to the hystero-epileptic form of hysteria than are the natives of more
temperate or colder climates. Bearing upon this point, I have already
quoted the letter of Guiteras with reference to hysteria and hystero-
epilepsy in Cuba and semi-tropical America. Forms of religion which
cultivate to an extreme degree the emotional or the sentimental side
of human nature tend to produce hystero-epilepsy.

With reference to sex it may be said that hystero-epilepsy prevails to

a greater extent among females than males, even proportionately to
a larger degree than some of the other marked phases of hysteria. It
does, however, occur in men and boys, although rarely. Richer
records, from the practice of Charcot, a case in a lad of twelve years.
Several cases have fallen under my own care.

Ten years since I saw a case of hystero-epilepsy, which in some

respects closely simulated tetanus, in a youth nineteen years old. He
was well until seventeen years of age, when he slightly wrenched his
back. Shortly afterward he felt some pain between the shoulders.
From that time, at irregular intervals, generally of a few days only, he
was subject to attacks of dull pain, which seemed to run up the spine
to the head. About two months after this injury he first had a
spasmodic attack. A spasm would come on while he was quietly
sitting or working. The body assumed the backward-arched position.
As his father described the case, there was always space enough
under his back for a baby to crawl through. Generally, he would have
more than one seizure on a given occasion. He would sometimes
have as many as six or seven in one hour. On coming to, he would
stare and mutter and work his mouth and lips, at the same time
pointing around with his hands and fingers in a wild way. Sometimes
he would sleep for several hours afterward if not disturbed, but his
sleep was not of a stertorous character. He said that he could feel
the attacks coming on; his body felt as if it was stretching, his head
going back. He thought he was not conscious during the whole of the
attacks, but between the spasms he could take medicine when
directed. When first examined he had decided tenderness on
pressure over the second, third, and fourth dorsal vertebræ.
Pressure in this region would sometimes bring on a convulsive
paroxysm. When first seen he had been for three months having
seizures every two or three weeks. He was under observation for
several months, during which time he was treated with faradization
to the spine, the hot spinal douche, tonics, and bromides, and made
a complete recovery.

W. Page McIntosh6 has reported several cases of hystero-epilepsy in

the male, one of which is doubly interesting because it was in a
negro. This patient was twenty-one years old, stout, and previously
in good health. He complained of intense pain in the stomach, and
soon passed into a violent convulsion. To show the importance of
diagnosis in these cases, it is interesting to note that the doctor first
thought of strychnia-poisoning, then of acute indigestion, next of
tetanus. Soon, however, he decided that he had a case of hysteria.
The patient had other convulsions on the day following the first
attack. The seizures were evidently hystero-epileptic or hysterical.
He was not unconscious, and believed that on a recent previous
evening he had been conjured by an old negress. The spell was to
work in three days, which it did. The doctor counter-spelled him with
a hypodermatic syringe, after which he promptly recovered.
McIntosh reports another case in a man forty years old and the
father of six children, who was laboring under strong mental
excitement because of the sufferings of a dangerously ill child. His
whole form was convulsed, and his body underwent a variety of
peculiar contortions. He had had similar attacks before, and had
subsequent recurrences.
6 Med. News, vol. xlviii., No. 1, Jan. 2, 1886, pp. 5-8.

The following case was observed in the Philadelphia Hospital: W. F.

——, aged twenty-eight years, married, has one child. His seizures
began seven years ago, when he had an attack while playing a
game of pool. At this time he had, according to his account, a
sudden feeling of giddiness or vertigo in which he fell over and had a
spasm, during which he thinks he was unconscious. After the seizure
he suffered from headache, but had no disposition to sleep.

From that time until the present he has been subject to these spells,
though the paroxysms are very irregular in frequency. Sometimes he
will have several attacks in a day; again, he will be free from them for
days, and perhaps for two or three weeks, but never for more than a
month at a time. They have come on him while walking in the street,
and on several occasions he has been taken to different hospitals.
He was admitted to the Philadelphia Hospital four times. On his first
admission he only remained over night; on his second and third he
remained for two or three weeks. On the last admission he remained
four weeks, and had spasms every day and night after admission.
He had, by actual count, from five to six hundred after he went in;
and in one evening, from seven P.M. to midnight, he had no less than
thirty-eight. These seizures, which were witnessed by myself and
two resident physicians, differed but little from each other, although
at times some were more violent than others. They began with a
forced inspiration; then the patient straightened himself out and
breathed in a stertorous or pseudo-stertorous manner. The pulse in
that stage became slow, and at times was as low as 48 per minute.
The temperature was normal or subnormal. The arched position was
sometimes taken, but the opisthotonos was not marked. The
paroxysm ceased by an apparent forced expiration, and the
breathing then became normal; the patient remained in a somewhat
dazed condition, which was only momentary. During the attack the
patient said that he was unconscious of his surroundings. In the
interval between the attacks he suffered from headache and from
pain over the region of the stomach. He also had tenderness on
pressure over the lumbar vertebræ. He never bit his tongue.

Age has some influence in the development of hystero-epilepsy. It is

of most common occurrence at the period of pubescence; it is rare in
old age, but occurs with comparative frequency in middle life; or,
rather, it should be said that middle-aged hystero-epileptics are not
uncommonly met with, individuals who have for many years been
subject to the attacks. In young children, girls or boys, it is certainly
rare.

With reference to the exciting causes of hystero-epilepsy, it will only

be necessary to say that of those which have already been
enumerated in the general discussion of the etiology of hysteria, a
few, such as domestic troubles, abnormal sexual excitement, and
painful menstruation, are likely to induce the paroxysm, but fright,
excitement, anxiety, sudden joy, and other psychical disturbances
are the most frequent of the exciting causes of the seizures. A threat
or a blow has been known to precipitate an attack. The use or abuse
of alcohol is sometimes an exciting cause. Reflex irritation, such as
that from intestinal worms, and digestive disorders sometimes
produces hystero-epileptic attacks in children.

SYMPTOMATOLOGY.—In considering the symptoms of hystero-epilepsy

the subject must be approached from several points of view. In the
first place, the disorder can be divided (1) into the regular or typical
grave attack; and (2) into the irregular attacks. These irregular
seizures can be greatly subdivided, but their discussion will be
confined to those types which have been most observed in this
country, although I do not think that any variety of hystero-epilepsy is
distinctively American; and this is what might be supposed from the
largeness of our country and the different nationalities of which it is
composed.

I have seen but few cases of hystero-epilepsy of the regular type.

One of these was first described at some length in the American
Journal of Medical Sciences for October, 1881. I will here give the
case, with illustrations, somewhat condensed from the accounts as
first published.7
7 For the opportunity of studying and treating this case I was under obligations to
Charles S. Turnbull and J. Solis Cohen, the patient having been for several months
under their care at the German Hospital of Philadelphia. Carefully prepared notes of
the case were furnished to me by H. S. Bissey and H. W. Norton, resident physicians
at the hospital. I was also under great obligations to my friend J. M. Taylor for a series
of sketches of the positions assumed by the patient at different stages of the attack.

R——, æt. 21, single, was first admitted to the German Hospital Nov.
13, 1879. Between her ninth and twelfth years she had had several
attacks of chorea. During childhood she was often troubled with
nightmare and unpleasant dreams; she often felt while asleep as if
she were held down by hands. She was frequently beaten about the
head and body. Her menses did not appear until she was nearly
eighteen. Before and at her first menstrual epoch she suffered
severe pain and cramp. During the first year of her menstruation,
while at Atlantic City, the flow appeared in the morning, and she went
in bathing the same afternoon. She stayed in the water two hours,
was thoroughly chilled, and the discharge stopped. Ever since that
time she had only menstruated one day at each period, and the flow
had been scanty and attended with pain. When about eighteen she
kept company with a man for five months, and after having put much
confidence in him learned that he had a wife and two children. This
episode caused her much worriment. She positively denied
seduction. She became much depressed. September 2, 1879, she
was seized in a street-car with a fainting fit. On coming to, she found
her left arm was affected with an unremitting tremor. Seven weeks
later she was admitted to the German Hospital. She had severe