Reprinted from the Transactions of the Medical Society of the State of New York, February, 1892.] HYSTERO-EPILEPSY, WITH REPORT OF CASES. By A. Vander Veer, M.D., ALBANY. Notwithstanding the grand advances that have been made in the realm of abdominal surgery, still there remain certain condi- tions upon which it is desirous of obtaining a more complete con- sensus of opinion, especially from those having a practical experi- ence. I refer to the subject of hystero-epilepsy, which, with its train of symptoms, treatment, etc., is yet subject to further discus- sion before coming fully under the domain of the abdominal sur- geon. The term hystero-epilepsy is one perhaps in which there is not yet a complete and unanimous understanding of its meaning. Whether we look upon it as a form of hysteria the convulsive attacks of which resemble epilepsy, or whether we consider that it is a pathological condition in which the form of convulsion pre- sents a greater amount of coordination than ordinary epilepsy, or whether we consider it simply as resembling an hysterical attack, still the fact remains that the symptoms, in whatever form they present, give evidence of great nervous disturbance. That true epilepsy may be its outgrowth is, to me, a position not untenable. The abdominal surgeon not infrequently has all his sympathies aroused in the description of a case that has baffled all medical skill, and now comes the cry from the general practitioner : “ Can- not something be done in the way of operative interference that will bring the patient relief, and comfort to her friends ? ” It is not inconsistent, when we consider the relations that exist between the uterus, its appendages, and their functions, and the nervous system of the female, to realize that there is a great possi- bility of nervous derangement or nervous strain and distress being continued, not infrequently resulting in organic changes. To one who has given study and careful observation to the sub- ject of hystero-epilepsy there are certain classifications or conditions and symptoms that present themselves in such a manner as to com- mand our most profound consideration and respect. Heredity is 2 A. VANDER VEER, an element that must be considered. The girl born of exceedingly nervous parents exhibits an inheritance of temperament that cannot be overlooked. The nervous conditions that present must be con- stantly kept in mind as to the time of life. If the girl previous to her menstruation presents the train of symptoms that at times almost border upon hysteria, she is to be all the more carefully watched when the menstrual period does appear. There must now be a very careful looking into of the important considerations that may offer, especially in reference to the development of hystero- epilepsy or true epilepsy. The time of the development of men- struation, to my mind, is clear as bearing upon these cases. The girl who begins with irregular menstruation, perhaps with three, six, or twelve weeks’ intervals, continuing in this condition for two, three, or more years, is of that class of patients, the vast majority of which present sooner or later organic changes in the ovaries, as to degeneration (cystic or otherwise), or leading to a condition of malposition, or of tubal trouble, that, when carefully looked into, often present a solution of her malady. The limit of this paper will not permit me to enter into the pathology, the changes, and conditions that lead up to, and which are present in, cases of hystero-epilepsy. I have on many occa- sions endeavored to heed, listen to, and, if possible, answer the inquiry that is so frequently made : “Will operative interference not afford relief to this class of patients?” which, in many in- stances, becomes so distressing. We have but to look into our text-books, and still more to study the discussions that occur from time to time in our special societies, to know that the treatment of these cases by operative interference is far from being a satisfactory solution of the problem; and yet there has been sufficient success in this direction to embolden many in making the assertion that hystero-epilepsy is benefited by operative interference, by removal of the uterine appendages, and this line of treatment. There are others, again, who are equally well pronounced against such a pro- cedure as oophorectomy or any modifications of it. I have the following cases on record, which I desire to report somewhat briefly, and then to draw some conclusions from the same in the opening of this discussion. Case I.—Miss B., thirty-three years of age, operated upon by Mr. Lawson Tait, at the Albany Hospital, September, 1884; reported in the Medical An- nals and in the Mew York Medical Record, January, 1885. The following SURGERY IN HYSTERO-EPILEPSY. 3 is a short history of the case taken from Mr. Tait’s clinical lecture upon the same: “ Subject to hysterical fits for over thirteen years. Hysteria, because patient never injures herself during attacks, or becomes drowsy afterward, as is the case with epilepsy. Fits come on before menstrual epoch; periods are fairly regular, but lacking in quantity. Health good to puberty, but bad for past twelve years. Chief symptom pain before menstruation, but relieved then. Uterus infantile and anteflexed. Such cases frequent in England, where patient’s life is one agony from commencement of menstruation. Eight ovary enlarged ; left could not be felt. Operation proved right to be cystic ; left small and shrivelled. ’ ’ Patient hysterical during convalescence, with one convulsion, with complete insensibility, six weeks after operation. Had several convulsions during first year after operation, and much of old feeling about pelvis; still, much better. I was told by Hr. Boyd during this past year of 1891-92 that this patient still had occasional convulsions, but that in a general way her condition is very much better than before the operation. Case II.—Miss M. B., twenty-four years of age, domestic, referred to my- self by Dr. La Moure. Menstruated at fourteen, and from first was irreg- ular ; had leucorrhoea and epileptiform seizures. Always vomited at men- strual period unless under influence of morphia ; the latter unable, however, to relieve pain after a few years. Four years ago was admitted to Albany Hospital, under care of Dr. Boyd, for treatment of leucorrhoea. Later has spent some time in Utica and Binghamton asylums, with little or no benefit. I operated for removal of the uterine appendages May 27, 1886. Cyst, size of cherry, in each ovary ; otherwise normal. Left ovary markedly adherent. No drainage-tube ; silk interrupted sutures to close wound. Convulsion fol- lowed operation, another in four hours, and a third one—light—on sixteenth day, at return of menstrual period. Eallied well from operation. After twenty-four hours marked tenderness of left hypogastric region developed ; in thirty-six hours a profuse, frequent, and greenish vomit, which persisted for five days. On 29th temperature reached 103£°, reaching highest point following day, 104£°. After this, symptoms improved steadily, and sutures removed on June 2d, when patient had toast and tea for first time. Nourished almost exclusively per rectum for five days. Catheter used ; bladder emptied naturally on fifth day; natural movement of bowels sixth day. Had many rectal injections to relieve accumulated gas; also used rectal tube. Hypo- dermic abscess developed on tenth day, and one stitch-hole abscess fifteenth day. Discharged June 24, 1886, appearing well, and much better in mental condition, but complained of great tenderness through pelvic region. Bi- manual examination failed to discover anything abnormal. One year after operation patient returned to hospital. Had had many attacks of vomiting, somewhat like those before operation, and came now for relief of morphine habit. Under careful restraint and discipline she eventually made a good recovery. I was told four years after the operation that she had had no return of the convulsions; was very much improved and able to do housework. This patient can be classed as one of recovery, with entire relief of the con- vulsions. 4 A. YANDER VEER, Case III.—Miss M. C., nineteen years of age; good family history. Well up to age of fourteen, when menstruation began. Epileptiform seizures soon developed, and grew gradually worse; since fifteen has had severe pain in left side. Operation performed October 6, 1886, and both ovaries and tubes removed. The former were smaller than normal; no microscopical exami- nation. Made a good recovery from operation; epileptic fits returned on eleventh day and persisted. Discharged on October 23, 1886. Later, I re- ceived the following letter from her physician, who had sent the case to me: Bensselaekville, N. Y., January 7, 18S7. Dr. Vander Yeer : In answer to yours, relative to Miss M. C.’s case : She is still having convulsions, although they are not quite so severe nor frequent as before the operation. Her intellectual faculties are certainly improved. Two months from time of last menstruation she passed through quite a stormy time mentally; refused to eat for three days, and slept but little during that period. She recovered as suddenly as she was attacked, and now averages about three convulsions a week, and general health much better than formerly. Before operation, convulsions had never been less than five or six a week for four years. Very truly, L. N. Laneiiart. After this letter was written by Dr. Lanehart the case was made very much better by the use of bromides, but then again relapsed because of the care- lessness of her mother in allowing her to eat of anything and everything she desired. When the stomach was overloaded she would have a convulsion. Also, when up late at night at parties she would have a convulsion. This cannot be said to be a case of recovery, yet the patient was somewhat better than before the operation. Beyond a doubt a case of true epilepsy. Case IY.—Sent by Dr. Eugene Beach, Grloversville, N. Y. Miss K. S., thirty-three years of age ; good family history ; never strong ; menstruated at twelve; never very irregular, but severe dysmenorrhoea. After fifteen, epileptiform seizures accompanied menstruation, in a few years taking on the form of mental aberration. Much worse for past few years. Appen- dages removed January 13, 1887 ; ovaries in a state of cystic degeneration. Incision closed with six deep and two superficial silk sutures. Kallied well from operation, but severe pain followed, and one-half grain of morphine given hypodermically the first half-hour. Bowels moved twice the third day—once by enema, once by rectal tube. Later, rectal tube occasionally passed with good results in relieving gas. Urine drawn for five days. Nausea troublesome for a week, but no vomiting save a little mucus soon after oper- ation. Temperature reached highest point, 1011°, on third day, but bowels moved, and it declined, rising again on twelfth day to 101°, due to time of menstruation. Stitches removed on sixth and seventh days. This case has been a marked success in many respects; no severe epileptiform seizures, but occasionally will have ‘petit mal attacks, with partial loss of conscious- ness. Feels that she has been very much benefited by the operation. These last notes taken December, 1890. A peculiarity in regard to this case is that a younger sister, suffering very much in the same way, has applied for the SURGERY IN H YST ER O-E PILE PS Y. 5 operation her sister underwent, and would be content if she receives as much benefit as the former did. Case V.—Sent me September 19, 1890, by Dr. Curran, of North Adams, Mass. Miss M. M., nineteen years of age; cook by occupation. Family history good, with the exception of one sister developing an abscess in the arm, six or eight years ago, from which she has never entirely recovered. Patient had, when two years of age, what were designated as “worm fits,” about six in number. She then enjoyed immunity for three years. At the age of five years she again suffered from seizures of similar kind. These continued until patient was about ten or eleven years of age. Never had an aura before convulsions, attacks coming on suddenly, with a feeling of faint- ness. At times she was conscious throughout attack, again unconscious. After the age of eleven, seizures became less frequent, but of longer dura- tion. Intervals between seizures from two to four weeks. About one year ago had an attack of peritonitis; since then complains of pain in ovaries. Attacks are now both more frequent and prolonged, and a single one may last five hours. Seizures now accompanied by convulsions, during which she bites her tongue. These paroxysms bear apparently no relation to the men- strual period. Pain of a lancinating character in both ovaries frequently precedes the attack, but more often comes on ten or fifteen minutes before attack ceases. Patient, as previously, may or may not be conscious during seizures. Intense cephalalgia is the sequel of every attack, the pain passing through eyes to top of cranium. Menstruation is painful during second and third days, lasts four or five days, and is copious. Appetite good and bowels regular. No increased desire for micturition, except when ovarian pain is severe. Patient went home about September 29th, having been in hospital for ten days under treatment. I declined to do an operation, believing the case to be one of true epilepsy. She returned on January 13, 1891, no bet- ter, and herself and mother desiring much that the appendages be removed. Previous to their coming I had received the following letter from Dr. Curran relative to her condition : Nohth Adams, Mass., December 29, 1890. My dear Doctor : It is now nearly six weeks since I have written you regarding Miss M.’s case. She improved quite well under treatment of large doses of acid, hydrobromic. dilute 33 h percent. The epileptic seizures were less frequent, and nearly a month passed without any fit, but still suf- fers from pain in ovaries. For the past four or five weeks she has been taking over two teaspoonfuls of the acid, but dose now causes headache, dizziness, and nausea, with occasional attacks of vomiting. She is having several severe attacks of epilepsy a week, with great ovarian pain and irri- tation. When the fits now come on they are more severe than ever. What would you advise to be done ? She is still anxious to chance the success of an operation for relief of the pain she suffers in ovaries. Yours very truly, Chas. J. Curran, M.D. After careful explanation regarding her chances, oophorectomy was per- formed January 19, 1891. Wound did not do well. Superficial stitches removed on fifth day because of angry condition of wound. One deep suture removed on seventh day. All remaining sutures removed on 6 A. VANDER VEER, ninth day. On removal of second stitch above, great yawning of wound and profuse discharge of fetid pus. More or less gaping followed throughout course of wound. Dressing : bichloride 1 to 2000 lotion, dry iodoform pow- der, plaster straps, and iodoform gauze. Patient has always complained of considerable pain shooting from right to left, corresponding exactly to former ovarian pain. Great increase of pain January 31st. February 1st, epilep- tiform seizure. February 2d, two in morning, four in evening. Between February 2d and 3d, morphine, gr. }, and sodium bromide (gr. xx.) were administered. No convulsions that night. On February 3d, 9 P. M., bro- mide, gr. xl., in two doses. February 4th, again complained of pain in same region. Recurrence of attack feared and bromide (gr. xl.) exhibited; remained free. Wound free and granulating rapidly. February 18th, repeated attacks of great severity. Returned home February 28, 1891. Her family physician, Dr. Curran, informed me, November 9th, that she had improved since operation, and at that date seizures were very rare. On the 24th he wrote me that on examination he found patient had not been doing so well; that she had on an average one attack, with several fits, more or less severe, every five or six weeks. The fits are accompanied with great pain in the abdomen, especially on right side. The day prior to an attack she experiences considerable pain in right ovarian region. There is some soreness in abdomen after fits and great headache. There has been no menstruation since first month after operation, although with a very severe epileptic attack there may be a slight staining of the linen with blood. January 7, 1892, Dr. Curran writes that she has just recovered from a very severe attack of epilepsy; that for past two menstrual periods she has flowed profusely, and with this advent comes a terrible pain in region of right ovary, and then the fits. She is greatly discouraged regarding her condi- tion. This patient does not present a satisfactory improvement. This is also a case of true epilepsy. Case VI.—History given by Dr. Quackenbush, Schenevus, N. Y., the family physician. Mrs. J. W>, twenty-four years of age; married at six- teen ; has given birth to two children; had two miscarriages. Has had hysterical fits of an epileptic character ever since menstruation began; family history obscure, parents having died when she was a child. Menstru- ation normal until after miscarriages ; children born previously ; both births normal, recovering with no ill effects. First miscarriage about April 4, 1890; pregnancy three months advanced. She admits leaving bed two days after- ward. Dr. Quackenbush was called to see her the following July, and found her suffering from acute metritis ; temperature at its maximum being 104°. From general deportment he questioned her relative to pregnancy, suspect- ing foul play, but each time she misled examination. He became fully sat- isfied that this was the state of affairs, however. She improved after three weeks’ illness, under treatment with morphine and warm antiseptic douches, but was left with following conditions: Left side extremely tender to the touch and enlargement of uterus on right side in about region of junction of Fallopian tube. Tenderness would not admit of examination of interior of uterus, and suspecting abscess the doctor determined to wait for future developments. In two weeks a prominent enlargement manifested itself in right side, fluctuating in character. She suffered severe cutting pains, when SURGERY IN IIY STE R O-E P IL EP S Y. 7 suddenly there seemed to be a giving way—as she expressed it—and dis- charge of pus per vaginam, followed later by the expulsion of a decayed fcetus of three months’ growth. She recovered from this condition with no after- treatment beyond antiseptic douches. Her condition remained nervous ; she was feeble, unable to get about, could not stand erect, and was very tender on pressure over the ovaries and tubes. After correspondence with Dr. Quackenbush over history just related, I advised her being admitted to the Albany Hospital for preparatory treatment with a view to removal of the ovaries and tubes. On bimanual examination I found all the evidence of pus tubes with very marked tenderness of the ovaries. Pressure caused much distress and hysteroid seizures. Preliminary treatment was carried out, patient not improving. Section was done November 22, 1890. Many adhesions found, pyosalpinx and cirrhosed ovaries on both sides. She con- valesced so rapidly that she was discharged in two weeks after the operation. Dr. Quackenbush writes me that she is now in perfect health, has never had a return of epileptiform seizures, and weighs forty pounds more than she ever did. All of the hysterical symptoms she has had ever since menstrua- tion first began have entirely disappeared, and she is in fact a perfectly healthy woman. On close questioning it was evident that a surgical needle had been used to produce an abortion, but singular that she should recover as she did from a severe attack of metritis and foetus remain in utero. Neither tube gave evidence of ectopic gestation. Of this number of cases I think it is fair to assume that cases I. and IV. are decidedly improved, and have remained so suffi- ciently long to insure safety and comfort for their continued life. Cases III. and V. may be looked upon as doubtful improve- ment ; yet, on the other hand, they can very consistently be classed as true epilepsy. Surely cases II. and VI. can be placed in the column of absolute cures. It is also true, and must not be over- looked, that there were here decided pathological changes in the organs removed. Did time permit, I would like to present the record of cases that have offered for operation, yet in which there seemed so little evi- dence of organic change in the uterus or its appendages as to hardly warrant operative interference. However, these cases have gone on enduring much from medical and gynecological practice, with- out benefit in many instances, and only a few cures. When we study the conditions such as are associated with dis- eased ovaries, we know full well that an increase in size is often an evidence of disease ; we know that cases of attempted suicide or mutilation of the body—when an autopsy was held—showed that the trouble was entirely referable to the ovaries being changed to an abnormal size. We know that in our cases of hysteria we have perversion of the senses, hallucinations, loss of memory, and 8 SURGERY IN HYSTERO-EPILEPSY. other conditions and manifestations of hysteria that are but the forerunners of insanity. The removal of these pathological and physiological causes that have produced hystero-epilepsy have led to cures. We know this to be a fact, that chorea is likely to become more severe under the disturbances of menstruation and pregnancy ; also that epileptiform seizures are likely to become more severe at such a time. We know full well that melancholia is often only relieved when the misplaced uterus is put in proper position and retained. Eminent authorities state that hysteria and mania are often relieved when the genital organs are put in a healthy condi- tion, after all other lines of treatment have failed. Removal of uterine polypi and retained placenta have relieved cases of mental aberration and approaching hystero-epilepsy. We might cite other cases, but I am not desirous of advocating or disapproving the removal of the uterine appendages for mental disturbances of any kind. Dr. Thomas Keith has pronounced against operative interference; Mr. Lawson Tait has adduced evi- dence in its favor. I trust the subject may be more fully discussed by those who are to follow. I should like to see the subject of the uterus and its appendages thoroughly reinvestigated, as regards any pathological change, in the case of women confined in insane asylums; also particularly in relation to cases of epilepsy occurring at puberty,, and where we have reason to believe this condition is associated with masturbation. A careful and thorough review of all disturb- ances of the nervous system, in the early development of the female, seems to me very important; these cases may result in hys- teria, this condition proving far worse later in developed insanity. I am bound myself to a formula something like the following: That when a female gives the history of early nerve strain; that when her menstruation has been decidedly irregular; that when associated with pelvic disturbances she evinces a pathological train of symptoms bound to a condition of hystero-epilepsy, when a thorough and intelligent course of medical treatment has failed, and the case is fully explained both to the patient and her friends in all its bearings, and when consent has been given either by the former or the latter, then I am willing to operate. If the patient is in that condition of mind unable to decide for herself, and friends are willing, or if she has no friends, I would then take the advice of the celebrated English jurist, and treat her as an infant.