There is a large and important field of psychotherapeutics in a class of cases so closely related to epilepsy that it is often extremely difficult to make the differential diagnosis between the two varieties of seizure. Fifteen years ago, while I was at the SalpÊtriÈre, there was much discussion of a variety of attack called hystero-epilepsy, in which the patients' symptoms were such that it was difficult if not practically impossible to decide whether the case was true epilepsy or merely hysteria. Personally I do not think there is any third, intermediate variety deserving a separate term. The attacks are either hysterical, or, to use a less objectionable name, neurotic, or they are genuinely epileptic, that is, due to some as yet not well-defined change in the brain, and therefore not likely ever to be completely relieved. To decide whether a given case is neurotic or epileptic, however, is sometimes quite out of the question until long and careful study of it has been made. It is true that such signs as full loss of consciousness, biting of the tongue, the so-called epileptic cry, involuntary urination, dangerous falls and the like in the midst of an attack, have often been declared to be signs of true epilepsy, but there are cases in which one or other of these signs has been present, yet the subsequent course of the affection has shown them to be functional and not organic in origin.

Neurotic Simulation of Epilepsy.—Nearly every physician who has reasonably large experience with neurotic patients has seen cases in which there were recurrent attacks of loss of consciousness that came on sometimes at most inopportune moments, that rendered the patient quite incapable of caring for himself for the moment, yet lacked many of the signs of true epilepsy. Teachers sometimes complain of a complete lapse of memory that begins without warning and then recurs at intervals, making their work very difficult. Preachers sometimes bring the story of having lost the thread of their discourse and forgetting absolutely what they were talking about, there being a complete blank for some seconds at least. Occasionally such lapses are associated with falls that resemble fainting spells and seem to be accompanied by complete loss of consciousness. Usually after them there is a distinct tired feeling and an inclination to sleep, though, as a rule, there is a more marked tendency to want to get away from observation. Some of the cases are much more severe than those described and the conclusion that they are true epilepsy seems inevitable, yet they recover so completely that this conclusion is negatived.

Occasionally such attacks occur only when the patient has been strenuously exerting mind or body for a much longer period than usual. In teachers it is likely to occur toward the end of the year or in the midst of the hard work about examination time. In students this same period is likely to be a favorite starting point for the attacks and they recur oftener at this time than at others. Very often there is a story of some digestive disturbance in connection with the attacks. At times it seems possible to trace them to some interference with the cerebral circulation through a distended stomach pressing upward through the diaphragm and interfering with the heart action. In such cases stomach resonance will sometimes be found as high as the fifth rib {539} and the apex beat may be pushed out to the nipple line or beyond it. This may be true though there are no signs of valvular lesions and no symptoms or physical signs of dilatation or hypertrophy of the heart.

The Suggestive Element.—Analysis shows the real course of the trouble in these cases. The sufferer is usually following a sedentary occupation, not getting much exercise or diversion and prone to introspection. Many symptoms of themselves of no importance have been emphasized by concentration of attention on them. Especially is this true of any heart irregularity. The patient has dreaded for some time lest the feeling of pressure in the precordia and of discomfort in the heart might not sometime interfere with him in the midst of his teaching or preaching duties. Some day when he is feeling much worse than usual, in the midst of his work, there comes over him the feeling that now his intellect is going to stop action because there is something the matter with him. The sudden concentration of his attention on this with the fear of the consequences and the uncomfortable feeling that he will not be able to go on with his flow of ideas, cuts off the thread of what he is thinking about and puts but one single object before him—this possibility of failure of mental action. Usually the first attack is only such an interruption as is thus indicated. The fear of subsequent attacks, the worry over what has happened, the dread that some serious mental affection or nervous disease is at work emphasizes introspection and subsequent attacks are even more likely to be serious, and especially to last longer than the first.

The more the cases are studied the more the conclusion comes that in many of these instances it is nothing more than auto-suggestion that is responsible for the mental lapse. It is true that some physical condition may be the occasion, though the mental state is the active immediate cause. Suddenly concentrated attention on the dread of mental interruption inhibits mental action and what was dreaded follows almost necessarily. It is a sort of auto-hypnotism in which the patient's train of thought is interrupted by a momentary or longer hypnotic state the causes of which can be traced. Even when there is a real organic lesion of the heart, the lapses of memory and even of reasoning power that occasionally occur, have often seemed to me to be due rather to the patient's dread than to any real physical condition. I cannot think that there is a sufficient interruption of the cerebral circulation, even though only for a moment, to cause such a lapse. It is a question of nerve interferences rather than of blood supply. If the blood were diverted, even though only for a moment, or if there was a stoppage, the consequences would be more serious and more lasting than they are.

What evidently happens is some disturbance of neurotic connections within the brain brought on by sudden dread or emotion. The will has lost control or has seriously disturbed the conducting apparatus. The best proof that this is what happens and that it is not the result of organic change is found in the fact that when the physical occasion, that is, the digestive disturbance or the heart palpitation which is the initial factor in these states, is relieved, the attacks do not take place. Patients in whom they have occurred even for years cease to have them. This improvement does not begin, however, until their solicitude over their condition has been lessened by a confident declaration to them that they are suffering from merely functional and local reflex conditions apart from the brain itself. Usually it needs to be made clear {540} to them, too, that their anxiety in the matter means much more for the continuance of the attacks than any physical condition.

Almost invariably patients somewhat resent this suggestion. Their response to this explanation of their ailment usually is that the attacks come on them when they are not particularly expecting them and that there is first some physical symptom which might readily be taken for a sort of aura to a genuine epileptic attack and then the attack itself comes on. It is this preceding symptom, pain or discomfort, or whatever else it may be, that provokes the suggestive element and brings about the state of quasi-hypnosis, which is the main part of their attack.

Neurotic Syncopal Attacks.—Some of the cases of pseudo-epilepsy are very mild, though if the word epilepsy has been mentioned there naturally arises a feeling of dread in patient and friends with consequent unfavorable suggestion. A type not infrequently seen has for its main symptom a period, usually of but short duration, in which there is an intense tired feeling so that even the eyelids droop and require effort to lift them. During such attacks the respirations may slow down to fifteen or below, though usually the pulse is inclined to be rapid. The feeling of fatigue is almost entirely subjective, in the sense that, if patients are required to do something, they are able to accomplish it by a little urging, though a moment before they were sure that they could not. Such attacks are invariably functional, have no organic basis and do not deserve the name of epilepsy. If called hysterics this will cause the patient, who is often a woman, to rouse herself and so gradually overcome them. They are really a loss of confidence in one's power to do things and a passing astasia-abasia. The use of the word hysterics may cause the patient to lose the sympathy of her friends, though she may need it; for often there is an underlying pathological condition not in the nervous but in the somatic system. Sometimes the patients are anemic, sometimes they have an abortive form of Graves' disease, and sometimes they are low in nutrition.

These conditions give the indication for treatment. What is needed is, of course, improvement of the general condition, but, above all, a restoration of the patient's confidence in herself. Once it is made clear to her that the attacks are largely subjective, that is, are due to a feeling of prostration because of the fear that she is unable to do something, then the intervals between the attacks will gradually grow longer. It is important that long hours of sleep should be advised with plenty of fresh air, and that whatever disturbances of the digestive system are present should be carefully treated.

Pseudo-Epilepsy and the Menopause.—A number of these cases of pseudo-epilepsy occur at the menopause. They seem particularly likely to occur in women who have not much to occupy themselves with. Childless women who have no cares and enjoy every luxury sometimes seem to have these pseudo-epileptic attacks as equivalents for the flushings of the ordinary menopause. During "a rush of blood to the head" they lose control of themselves. Occasionally mothers who have two or three daughters and who get their menopause late in life, that is, well after fifty, are especially likely to suffer in the same way. The solicitude of those near them seems to eliminate some of their power of inhibition and makes them think overmuch of themselves. If then they keep much at home, as women at this time are prone to do, have few {541} diversions of mind, little fresh air and exercise, there is an accumulation of unused nervous energy which dissipates itself in explosive attacks very like epilepsy. It is with regard to these that the term hystero-epilepsy almost seems justified. Just as soon as occupation and diversion of mind and relaxation of the solicitude of friends for them is secured they begin to get better.

The differential diagnosis of these cases is made from the absence of certain of the pathognomic signs of true epilepsy. The tongue is not bitten, involuntary urination does not take place, and when the patient falls she does not hurt herself as a rule, though occasionally the fall may result in accidental abrasions or bruises, but these are quite trivial. If stress is laid upon the fact before these patients that they do not present any or all of the symptoms of epilepsy, some of them are likely to occur a little later. Slight abrasions on the tongue will be noted and the sputum will become a little bloody. Even very cleanly women will sometimes wet themselves. It is not a deliberate attempt at deception, but their curious psycho-neurotic condition causes suggestion to act upon them. Their attacks are really auto-hypnotic and during these the remarks made by the physician occur as suggestions and then are accomplished. If the suggestions in this matter have been carelessly made by previous physicians the attacks will so closely simulate true epilepsy that it will often be almost impossible to differentiate them with assurance.

In the preliminary diagnosis of these cases, as well as of all other cases of pseudo-epilepsy, we must, as far as possible, avoid the use of the word epilepsy, even of hystero-epilepsy. The unfavorable suggestion attached to such terms will have the worst possible effect. There is no need to fear that the patient will be any less taken care of, if the disease is called by some other name, for instance, neurotic paroxysms or nervous attacks.

Cure by Suggestion.—Such patients are often cured by remedial measures of one kind or another that are administered with the confident declaration that they will get well. A number of cases of epilepsy which were really of this character have been reported cured by Eddyism. A number also have been very favorably influenced by osteopathic treatment. Needless to say, the reports of such cured cases have not been diminished in significance by the publicity bureaus of these various cults. Mental healing has relieved a number more. Usually this relief has been afforded these cases after they had tried regular physicians who had treated them in the ordinary way with bromides, without doing anything more than causing them to miss a few attacks for a temporary period of relief, if even that, giving them bromism and further increasing their solicitude about themselves by unconsciously emphasizing their ideas as to how serious epilepsy can be. The cures of these cases are not due to the various treatments to which the patients proclaim their debt of gratitude, but to the confident assurance given them that their condition is not serious, and will be cured. After analysis of their attacks has shown them to be neurotic and not genuinely epileptic, the regular medical practitioner can readily do as much and even more; for psychotherapy has much more to do in affording relief in these cases than any other form of treatment. It must be applied with confidence and the results are often most favorable.{542}