merit showed, it very fully and rather ludicrously exhibited itself later on to the not little surprise and alarm of all. Previous history.?Pte. R. Hockley, aged 18 years, fancying a soldier's life enlisted on the 29th July, 1879, and was drafted out to India in January of the following year and posted with his regiment (2nd-5th) at Agra. His leaving home and parting from his relations very greatly distressed and afflicted him, so much so that he had never given over fretting since. His hahits were not regular, for, though so of intemperance, and had young, he had learned the evils indulged himself pretty freely, especially while in England. His health was said to be good ; but before his enlistment, as it was later on ascertained, he used at times, from his very " boyhood, to have fits," during which he was unconscious, and after which he usually slept. And it was further elicited that these "fits" ran in his family, in apparently every second generation,?his grand-parents and his brothers and sistei'9 being subject to them, while his father and mother were free. There is no history of petite vial. Shortly after his arrival he began to suffer much from ague, and as noted in his medical-history sheet, was consecutively 15.18,102, and 42 days in hospital, during the latter two months of which he also suffered from severe pain in his right side. His medical history sheet shows three admissions for ague, and one, the last, " for general debility, for which he received Quinine and other tonics." His having, as he believes, lost an opportunity of being invalided back to England in October?absence from which has been ever preying on his mind, has raised ill forebodings of death, and caused him to feel much dejected and depressed; but recommended by "the Board" in February, 1881, he was finally despatched to London. Present condition.?Admitted from the travelling hospital on the 12th April, 1881, on the arrival of the convalescents. Age on admission is 20 years. Body is fairly well nourished, but his face is pinched and pale (with a noticeable peculiar protrusion of the upper lip)j and exhibits quiescent suffering. Is confined to bed, and lying on his back, apparently afraid to move for pain. His whole appearance is that of serious illness; he looks very weak and low; and when questioned, replies with downcast eyes and almost immovable features, in short monosyllabic sentences, and in a low suppressed tone, halting every now and then to draw breath as if each effort taxed all his energies and pained him. Is very weak, and requires support out of bed. Complains of intense acute pain in the right hypochondrium, chiefly below the costal arch, and extending to the corresponding loin and back behind ; pain is also referred shooting to the right shoulder. States he has just lately had " shivering fits." Palpation, the mere mention of which causes great dread, produces extreme tenderness and pain over the whole hepatic area, but particularly at a local circumscribed spot, about 2 inches in diameter, immediately below margin, and at extremity of 10th rib. The intensity of the tenderness is further evinced by the abdominal muscular rigidity and straining efforts he adopts to meet the expected pressure,?such as tightly closing his lips, stopping his breath, and firmly fixing himself by clutching the sides of the bed. If during examination the expedient of carefully diverting his attention, while so engaged, be employed, he does not exhibit so much sensitiveness and deep pressure does not cause so much pain. The percussive area of hepatic dullness is increased to about two inches below the costal arch ; but there does not appear to be any detectable enlargement of the spleen. Behind, slight dulness is elicited at base of right lung, which on auscultation yields only a few dry crepitations occasionally ; and here also the respiratory murmur is weak. Owing to pain he has no rest at night. Is troubled at times with a dry hacking cough. No appetite; bowels irregular, sometimes costive, at others loose ; tongue clean and moist. Respiration is short, sharp, and quickened,?38 per minute, and is chiefly thoracic. There is no pyrexia; the skin is cool : temperature, morning 9S"2?; noon 98? ; and evening 98*2.? 1Us subsequent progress was peculiarly characteristic of hepatic abscess. The local pain and tenderness continued unabated in spite of the usual applications of turpentine stupes, leeches, and poultices till by the 17th instant, 6 days after admission, a slight bulging prominence had appeared below the sternal end of the 10th rib at the site of the greatest tenderness ; and the following was entered by Dr. Martin in the case book :??" Complains of lancinating pain at (spot above indicated) at which great tenderness and heat. I ^
CASE OF HYSTERICAL HEPSUPPURATIVE HEPATITIS, AND TERMINATING IN HYSTERO-EPILEPSY. (Hysteria in & male). By P. W. O'Gorman, Sub-Medical Department. The detailed symptoms of this interesting case are extremely characteristic; but as the epileptoid condition was not induced till a much later stage of the disease, the direct hysterical tendency was not at first suspected, though as the denoueA VERY INTERESTING TALGIA
SIMULATING
98
THE INDIAN MEDICAL GAZETTE.
I can detect fluctuation. Patient very low. Pulse 130." This fluctuation seemed to become more apparent daily. A little troublesome bilious vomiting and diarrhoea ensued for about two days after, but nothing abnornal?pus or blood ?was detected in either. On the 28th April, i. e. 11 days after, at about 11-30 a.m. he had well-marked rigors, followed " by delirium, chiefly of home," of some 3 hours' duration, though the temperature did not rise, it being in the morning 973, with a pulse of 100, and in the evening 97-4.? The bulging remained unreduced, but the following was noted in the case-book two days later :?" No fluctuation can be felt though no doubt an abscess has formed." The rigors occurred regularly every day at about the same time till the 10th May. The hepatic pain which now became aggravated by the rigors was somewhat slightly relieved, and his nights rendered less restless, by hypodermic injections of morphia (gr. ?) twice a day ; while quinine and extract of hyoscyamus were also given twice daily, internally. His temperature throughout was usually subnormal, ranging from 97? to 98? ; but for the latter four or five days it rose in the evenings to 99.? The pulse was always regular, small and frequent, averaging from 100 to 130 per minute. His urine when examined had an alkaline reaction with a sp. gr. of 1030 ; but there was The general internal treatment consisted of no albumen. Am. chloride 3 ss-> ter die; and Chloral Hyd. and Pot. Bromide at bed time to procure sleep. On the 10th May he had as usual another rigor at 10 A. M., which lasted about an hour accompanied with his usual delirium. On its ceasing, at about 11 o'clock, he suddenly had a very severe attack of epileptiform convulsions, which exhibited a decidedly hysterical character, and under whose influence he remained for a great part of that day, the fit terminating at 5 P. M. This morning temperature remained 97*4? with a pulse of 100, while in the evening it rose to 100,? the highest ever registered, and due no doubt to the previous excessive exertion gone through. For treatment, 60 grs. of Pot. Bromide in two doses, followed later on by fl^. 10 of Liq. Atropia had no effect whatever. Cold water was applied to the head during the fit, and after it for the intense headache. For convenience of description I shall here, once for all, note in detail the whole of the important characteristic phenomena observed in connection with these "fits and for this purpose I would divide the symptoms intone stages. 1it stage. (Premonitory symptoms).?At first these premonitory warnings, as, indeed, the whole symptoms of the disorder, were clearer and of a more decided and distinct at a character than later period, and lasted from 1 to 5 or | of an hour, till gradually at last, at the end of about seven month?, there was no warning whatever. They consisted of somewhat undefined sensations of increasing dejection and depression, with dizziness, buzzing in the ears, dimness of vision and slight headache, soon followed by nervous twitchings of the fingers and mouth. In his endeavours to " work off" the fit, in which he very rarely quite succeeded, he would try to sleep, or urge himself to distraction, by playing at cards, &c., or pace agitatedly up and down the verandah (when at length he was able to leave his bed), till further symptoms warned him his efforts were futile. These signs usually lasted from 5 to 10 minutes, and were at first the globus hystericus, and latterly the hysterical aura : the former arising like a rolling ball from behind the the latter like a something or pubes, pelvic creeping crawling upwards from the extremities of both feet ; till arriving at his throat they ended in a choking strangulation, with intensified pain in the liver, and terminated finally in unconsciousness. But before the actual attack he always hurried himself to bed where his attendants awaited him ; but when he delayed too long a weakness and giddiness seized him, and he swayed like a drunken man, having to be hastily supported or carried to it. 2nd stage.?This stage, whose duration was but a few seconds (about ? a minute or so), was characterised by a sudden violent straining and tonic rigidity of the whole frame, resembling tetanic opisthotonos. This tonic rigidity was very extreme some 7 months afterwards, so that even the very fingers and toes would be extended and as rigid as iron, and no safe force could make any impression on the limbs. This tonic stiffness was accompanied with firm closure of jaw lips, and eyelids, turning up of the eyeballs?leaving only a part of their whites visible, and entire stoppage of respiration, soon followed by purple tumefaction and turgidity of face and neck. The spasms occasionally began in the whole
fancy
[April 1,
1882.
the head and neck, during which the latter would be twisted to one side, usually the left, and the pillow violently gripped between the teeth. Once, and once only, did he bite his left arm thus removing a of his flannel shirt a along with piece portion the size of a rupee. It was often noticed that this commenced cold with a stage shivering, and quiverinsr of the lips. 3rd stage.?The second stage was soon and abruptly succeeded by relaxation of the muscular contraction, and restoration of breathing. He would lie quiet for a short period (about i a minute or more), breathing hurriedly and laboriously, with mouth half open and eyes slightly closed?their whites alone visible, while the facial hyperemia subsided, and then, suddenly, he would have strong violent clonic convulsions of the whole body, with powerful frantic efforts to rise out of bed. There would be grinding and champing of the teeth; a general workiDg of the features and eyes, short panting respiration, and often a foaming at the mouth, occasionally tinged with blood. But the tongue was never bitten ; the fists were clenched with the thumbs outside ; there was never any involuntary discharge of urine or faeces, nor any vomiting ; but perspiration was usually profuse. These clonic spasms were never very markedly severe ; and their ordinary duration extended to about a minuet or two, and then gradually merged into the hysterical condition, the exact period of transition being uncertain. ith stage.?This was marked by sudden fresh startings. He would suddenly grow extremely violent, attempting to spring upright, twisting, throwing, and swinging his limbs about in the most surprising and extraordinary manner, and writhing in the most horrible contortions, displaying a power and strength which astonished every body. This violence had to be restrained, at first, by 6 to 8 men who were?and to their own surprise?but barely able to hold him down in bed. These actions were usually accompanied with short, gruff, hoarse stertorous growling noises. During this phase of his condition he exhibited great hatred, anger and ferocity towards even his best friends, ail(l much more particularly he seemed, at these times, so towards natives, against whom to bear a special antipathy, for the bare sight of one would The greater the restraint the rouse his rage to a degree. to relieve himself ; and greater was the force he employ^ when he had succeeded in loosening an arm or leg, the blows dealt all round were very sending many a one reeling to the floor, and rendering it difficult to secure the limb again. Keflex actions were perfect during this phase. Any collection of saliva would be at once spat out on the by-standers. The pupils were regularly dilated, and responded slightly to light ; the conjunctivas were very sensitive, instantly yielding to the touch ; and cold water sprinkled on the face caused him to shrink and the features to contract. At length these actions were not permitted, the patient either endeavouring to snap with his teeth at the approaching hand, or making fresh frantic efforts to rise up. -N?r would he allow his pulse to be felt, quietly watching for, and strenuously striving to seize the hand placed near his ; and nearly broke the fingers of a couple who were incautious enough to accidentally give him the opportunity- When the Carb. Ammonia phial was applied to his nostrils he deliberately ceased breathing, but at length getting a whiff of its contents, made strong efforts to snap at, and seize, the phial with his teeth ; and a spoon with which was administered an unpleasant draught was in revenge nearly bitten in two. The patient never once spoke, nor did he ever make any signs or gestures. When spoken to, especially kindly, he appeared at times to understand ; and when spoken of, within his hearing, he generally controlled himself sufficiently to quietness and appeared to listen eagerly. This stage lasted the longest, from about 10 to 15, or 30 minutes. 5th stage.?After the longer or shorter repetition of the whole hystero-epileptical phenomena, he would gradually relax his violence ; and the subsidence of the fit would usually be marked by gentle convulsive sobbing, or moisture of the red and hyperaemic, accomeyes which now always turned panied with a beating motion of the hand either on each side of his bed or on his breast. Shortly after, he would open his eyes in bewilderment, and quietly taking in everything and understanding the purport of his attendants' presence, would inform them he was " now all right," and request to be left alone ; he would then fall into a delirious sleep with, his eyes half closed. The delirious wanderings were always of " home," and " mother", and other relatives ; and if aroused he would suddenly start up in alarm, soon sinking back again ^
powerful,
^
April
1, 1882.]
THE HEALTH
OF THE EUHOPEAN ARMY IN INDIA IN 1880.
to the same state. In an hour or two he would have quite recovered. Red petechias soon after made thier appearance on face and neck. The durations of the whole fit varied greatly. The first occupied 6 hours, and the second 4 or 5 ; and others following soon reduced themselves from 3 to 1? hours ; till latterly they passed off within 5 to 10 minutes ; and there were times shortly before he left India, when unknown to him he was mildly attacked at night asleep, and only detected by his attendants hearing his bed shake. The periodicity of the attacks was peculiar. The fits were at first pretty regular as to hour, but as time advanced and the symptoms lessened in severity, time varied likewise, and he was attacked each time a little later on than the one previous.* The attacks were of the tertian type, occurring every 2nd day, free of the interim
being perfectly
any symptom,
though
would very occasionally affect him daily for a few days. On the day following the first fit, the 11th May, the patient appeared much exhaustd, with a general feeling of malaise and tiredness, and complained of severe aggravated stabbing pain in his right side and loins. He had two bilious, formed stools, but there was not the slightest trace of was there pus or blood as was expected ; nor any vomiting, or coughing beyond the usual dry He had no fit this day, >but they regularly recurred every 2nd day, at about the same hour. Since the first attack his hands always kept shaking and twitching nervously. & week later, his hacking cough (hysterical) became troublesome, causing him to spit up small quantities of blood, though no abnormal sounds were heard in the chest. This spurious hemoptysis was soon checked by an application of croton liniment. With an effort to prevent a fit on the 22nd instant, besides the usual chloral and bromide at bed-time, gave him another 40 grain dose at 5 A. M., and another at 7 a. m., but did not check the fit in the least, the duration being even longer than usual?4 hours. All other medicine being omitted, from 22nd May to 20th June gave, in progressively increased doses, altogether 140 grains of Ext. nux vomica ; and from 21st June to 29th July, 788 minims of Liq. Strychinaj. But these drugs had not the slightest effect in controlling the fits ; nor did they exhibit any symptom whatever of accumulation. After the 29th July he received no treatment. Not long after, the local neuralgia and dyscesthesia began to abate; and within another month the patient was able, by a deal of cheering-up and encouragement, to gradually leave his bed for the easy-chair, and then to take quiet strolls in the compound ; and finally, by he was perfectly well enough but for his tertian attack, and often indulged in miles-long rambles "down-khud" oq the days he was " free." He was invalided home in November last. His more rapid recovery, after the treatment was stopped, may with some truth be attributed to the less attention that was paid him, and the greater indifference with which "he and his symptoms were regarded after the novelty of the sensation" had worn off ; for I often observed, without appearing to do so, that when unwatched, in the seclusion of his private room, he appeared to be remarkably free from the severity of the symptoms, the presence of the medical officer and his following always conjured up as if by magic ; and from being often in the quietest mood possible, he would suddenly lapse to the That there was certainly no deception verge of agony. cannot be doubted for a moment, for hysteria is a real disease its however anomalous and symptoms. Summary.?The chief causes in this case were clear and distinct:?(1) hereditary transmission, (2) malaria, and (3) mental dejection and depression. The case is a markedly perfect one of hysteria, and exhibited through its course most, if not all, the symptoms attributed to it in the opposite sex. The influence which malaria exerted over the epileptiform attacks is also remarkable as affecting the nervous system. The hepatic condition was rather puzzling from the very beginning, though some chief signs of organic disease and suppuration appeared to be absent: the temperature was persistently subnormal j the patient often lay on his left, but could not rest on his right side ; and though taking so little food, instead of wasting and emaciating, looked remarkably well. On the other hand we had great pain and tenderness ; apparent bulging and fluctuation of a certain localised area ; and, lastly, rigors ; and hysteria was not dreamt of. It is no wonder, then, that the serious com-
they
hacking.
_
September,
paradoxical
*
Characteristic of malaria,
99
plication of the first powerful fit was a source of the utmost dismay. Ludicrous as it may now appear, all dreaded some grave, if not fatal, injury to the liver-abscess and many an ominous shake of the head but too plainly predicted early death ; but though the scanty sputum, urine, and stools were minutely and assiduously scanned day after day, neither pus nor blood would reward the anxious vigilance of the most expectant; and the further continuance of the fits without any resultant danger soon finally set the matter at rest. I trust the rarity of such an exclusive complaint as marked Hysteria in a male, and especially that of rarer Hystero-epiconcomitant its lepsy,?with simulations, may prove a sufficient apology for my usurpation of so much valuable space in the foregoing details. With respect to the latter considering such a commingling of various symptoms, I find it hard to assign it an exact place in M. Charcot's subdivisional "
classification.
Agra,
21st February, 1882.
CASE OF HYSTERICAL HEPSUPPURATIVE HEPATITIS, AND TERMINATING IN HYSTERO-EPILEPSY. (Hysteria in & male). By P. W. O'Gorman, Sub-Medical Department. The detailed symptoms of this interesting case are extremely characteristic; but as the epileptoid condition was not induced till a much later stage of the disease, the direct hysterical tendency was not at first suspected, though as the denoueA VERY INTERESTING TALGIA
SIMULATING
98
THE INDIAN MEDICAL GAZETTE.
I can detect fluctuation. Patient very low. Pulse 130." This fluctuation seemed to become more apparent daily. A little troublesome bilious vomiting and diarrhoea ensued for about two days after, but nothing abnornal?pus or blood ?was detected in either. On the 28th April, i. e. 11 days after, at about 11-30 a.m. he had well-marked rigors, followed " by delirium, chiefly of home," of some 3 hours' duration, though the temperature did not rise, it being in the morning 973, with a pulse of 100, and in the evening 97-4.? The bulging remained unreduced, but the following was noted in the case-book two days later :?" No fluctuation can be felt though no doubt an abscess has formed." The rigors occurred regularly every day at about the same time till the 10th May. The hepatic pain which now became aggravated by the rigors was somewhat slightly relieved, and his nights rendered less restless, by hypodermic injections of morphia (gr. ?) twice a day ; while quinine and extract of hyoscyamus were also given twice daily, internally. His temperature throughout was usually subnormal, ranging from 97? to 98? ; but for the latter four or five days it rose in the evenings to 99.? The pulse was always regular, small and frequent, averaging from 100 to 130 per minute. His urine when examined had an alkaline reaction with a sp. gr. of 1030 ; but there was The general internal treatment consisted of no albumen. Am. chloride 3 ss-> ter die; and Chloral Hyd. and Pot. Bromide at bed time to procure sleep. On the 10th May he had as usual another rigor at 10 A. M., which lasted about an hour accompanied with his usual delirium. On its ceasing, at about 11 o'clock, he suddenly had a very severe attack of epileptiform convulsions, which exhibited a decidedly hysterical character, and under whose influence he remained for a great part of that day, the fit terminating at 5 P. M. This morning temperature remained 97*4? with a pulse of 100, while in the evening it rose to 100,? the highest ever registered, and due no doubt to the previous excessive exertion gone through. For treatment, 60 grs. of Pot. Bromide in two doses, followed later on by fl^. 10 of Liq. Atropia had no effect whatever. Cold water was applied to the head during the fit, and after it for the intense headache. For convenience of description I shall here, once for all, note in detail the whole of the important characteristic phenomena observed in connection with these "fits and for this purpose I would divide the symptoms intone stages. 1it stage. (Premonitory symptoms).?At first these premonitory warnings, as, indeed, the whole symptoms of the disorder, were clearer and of a more decided and distinct at a character than later period, and lasted from 1 to 5 or | of an hour, till gradually at last, at the end of about seven month?, there was no warning whatever. They consisted of somewhat undefined sensations of increasing dejection and depression, with dizziness, buzzing in the ears, dimness of vision and slight headache, soon followed by nervous twitchings of the fingers and mouth. In his endeavours to " work off" the fit, in which he very rarely quite succeeded, he would try to sleep, or urge himself to distraction, by playing at cards, &c., or pace agitatedly up and down the verandah (when at length he was able to leave his bed), till further symptoms warned him his efforts were futile. These signs usually lasted from 5 to 10 minutes, and were at first the globus hystericus, and latterly the hysterical aura : the former arising like a rolling ball from behind the the latter like a something or pubes, pelvic creeping crawling upwards from the extremities of both feet ; till arriving at his throat they ended in a choking strangulation, with intensified pain in the liver, and terminated finally in unconsciousness. But before the actual attack he always hurried himself to bed where his attendants awaited him ; but when he delayed too long a weakness and giddiness seized him, and he swayed like a drunken man, having to be hastily supported or carried to it. 2nd stage.?This stage, whose duration was but a few seconds (about ? a minute or so), was characterised by a sudden violent straining and tonic rigidity of the whole frame, resembling tetanic opisthotonos. This tonic rigidity was very extreme some 7 months afterwards, so that even the very fingers and toes would be extended and as rigid as iron, and no safe force could make any impression on the limbs. This tonic stiffness was accompanied with firm closure of jaw lips, and eyelids, turning up of the eyeballs?leaving only a part of their whites visible, and entire stoppage of respiration, soon followed by purple tumefaction and turgidity of face and neck. The spasms occasionally began in the whole
fancy
[April 1,
1882.
the head and neck, during which the latter would be twisted to one side, usually the left, and the pillow violently gripped between the teeth. Once, and once only, did he bite his left arm thus removing a of his flannel shirt a along with piece portion the size of a rupee. It was often noticed that this commenced cold with a stage shivering, and quiverinsr of the lips. 3rd stage.?The second stage was soon and abruptly succeeded by relaxation of the muscular contraction, and restoration of breathing. He would lie quiet for a short period (about i a minute or more), breathing hurriedly and laboriously, with mouth half open and eyes slightly closed?their whites alone visible, while the facial hyperemia subsided, and then, suddenly, he would have strong violent clonic convulsions of the whole body, with powerful frantic efforts to rise out of bed. There would be grinding and champing of the teeth; a general workiDg of the features and eyes, short panting respiration, and often a foaming at the mouth, occasionally tinged with blood. But the tongue was never bitten ; the fists were clenched with the thumbs outside ; there was never any involuntary discharge of urine or faeces, nor any vomiting ; but perspiration was usually profuse. These clonic spasms were never very markedly severe ; and their ordinary duration extended to about a minuet or two, and then gradually merged into the hysterical condition, the exact period of transition being uncertain. ith stage.?This was marked by sudden fresh startings. He would suddenly grow extremely violent, attempting to spring upright, twisting, throwing, and swinging his limbs about in the most surprising and extraordinary manner, and writhing in the most horrible contortions, displaying a power and strength which astonished every body. This violence had to be restrained, at first, by 6 to 8 men who were?and to their own surprise?but barely able to hold him down in bed. These actions were usually accompanied with short, gruff, hoarse stertorous growling noises. During this phase of his condition he exhibited great hatred, anger and ferocity towards even his best friends, ail(l much more particularly he seemed, at these times, so towards natives, against whom to bear a special antipathy, for the bare sight of one would The greater the restraint the rouse his rage to a degree. to relieve himself ; and greater was the force he employ^ when he had succeeded in loosening an arm or leg, the blows dealt all round were very sending many a one reeling to the floor, and rendering it difficult to secure the limb again. Keflex actions were perfect during this phase. Any collection of saliva would be at once spat out on the by-standers. The pupils were regularly dilated, and responded slightly to light ; the conjunctivas were very sensitive, instantly yielding to the touch ; and cold water sprinkled on the face caused him to shrink and the features to contract. At length these actions were not permitted, the patient either endeavouring to snap with his teeth at the approaching hand, or making fresh frantic efforts to rise up. -N?r would he allow his pulse to be felt, quietly watching for, and strenuously striving to seize the hand placed near his ; and nearly broke the fingers of a couple who were incautious enough to accidentally give him the opportunity- When the Carb. Ammonia phial was applied to his nostrils he deliberately ceased breathing, but at length getting a whiff of its contents, made strong efforts to snap at, and seize, the phial with his teeth ; and a spoon with which was administered an unpleasant draught was in revenge nearly bitten in two. The patient never once spoke, nor did he ever make any signs or gestures. When spoken to, especially kindly, he appeared at times to understand ; and when spoken of, within his hearing, he generally controlled himself sufficiently to quietness and appeared to listen eagerly. This stage lasted the longest, from about 10 to 15, or 30 minutes. 5th stage.?After the longer or shorter repetition of the whole hystero-epileptical phenomena, he would gradually relax his violence ; and the subsidence of the fit would usually be marked by gentle convulsive sobbing, or moisture of the red and hyperaemic, accomeyes which now always turned panied with a beating motion of the hand either on each side of his bed or on his breast. Shortly after, he would open his eyes in bewilderment, and quietly taking in everything and understanding the purport of his attendants' presence, would inform them he was " now all right," and request to be left alone ; he would then fall into a delirious sleep with, his eyes half closed. The delirious wanderings were always of " home," and " mother", and other relatives ; and if aroused he would suddenly start up in alarm, soon sinking back again ^
powerful,
^
April
1, 1882.]
THE HEALTH
OF THE EUHOPEAN ARMY IN INDIA IN 1880.
to the same state. In an hour or two he would have quite recovered. Red petechias soon after made thier appearance on face and neck. The durations of the whole fit varied greatly. The first occupied 6 hours, and the second 4 or 5 ; and others following soon reduced themselves from 3 to 1? hours ; till latterly they passed off within 5 to 10 minutes ; and there were times shortly before he left India, when unknown to him he was mildly attacked at night asleep, and only detected by his attendants hearing his bed shake. The periodicity of the attacks was peculiar. The fits were at first pretty regular as to hour, but as time advanced and the symptoms lessened in severity, time varied likewise, and he was attacked each time a little later on than the one previous.* The attacks were of the tertian type, occurring every 2nd day, free of the interim
being perfectly
any symptom,
though
would very occasionally affect him daily for a few days. On the day following the first fit, the 11th May, the patient appeared much exhaustd, with a general feeling of malaise and tiredness, and complained of severe aggravated stabbing pain in his right side and loins. He had two bilious, formed stools, but there was not the slightest trace of was there pus or blood as was expected ; nor any vomiting, or coughing beyond the usual dry He had no fit this day, >but they regularly recurred every 2nd day, at about the same hour. Since the first attack his hands always kept shaking and twitching nervously. & week later, his hacking cough (hysterical) became troublesome, causing him to spit up small quantities of blood, though no abnormal sounds were heard in the chest. This spurious hemoptysis was soon checked by an application of croton liniment. With an effort to prevent a fit on the 22nd instant, besides the usual chloral and bromide at bed-time, gave him another 40 grain dose at 5 A. M., and another at 7 a. m., but did not check the fit in the least, the duration being even longer than usual?4 hours. All other medicine being omitted, from 22nd May to 20th June gave, in progressively increased doses, altogether 140 grains of Ext. nux vomica ; and from 21st June to 29th July, 788 minims of Liq. Strychinaj. But these drugs had not the slightest effect in controlling the fits ; nor did they exhibit any symptom whatever of accumulation. After the 29th July he received no treatment. Not long after, the local neuralgia and dyscesthesia began to abate; and within another month the patient was able, by a deal of cheering-up and encouragement, to gradually leave his bed for the easy-chair, and then to take quiet strolls in the compound ; and finally, by he was perfectly well enough but for his tertian attack, and often indulged in miles-long rambles "down-khud" oq the days he was " free." He was invalided home in November last. His more rapid recovery, after the treatment was stopped, may with some truth be attributed to the less attention that was paid him, and the greater indifference with which "he and his symptoms were regarded after the novelty of the sensation" had worn off ; for I often observed, without appearing to do so, that when unwatched, in the seclusion of his private room, he appeared to be remarkably free from the severity of the symptoms, the presence of the medical officer and his following always conjured up as if by magic ; and from being often in the quietest mood possible, he would suddenly lapse to the That there was certainly no deception verge of agony. cannot be doubted for a moment, for hysteria is a real disease its however anomalous and symptoms. Summary.?The chief causes in this case were clear and distinct:?(1) hereditary transmission, (2) malaria, and (3) mental dejection and depression. The case is a markedly perfect one of hysteria, and exhibited through its course most, if not all, the symptoms attributed to it in the opposite sex. The influence which malaria exerted over the epileptiform attacks is also remarkable as affecting the nervous system. The hepatic condition was rather puzzling from the very beginning, though some chief signs of organic disease and suppuration appeared to be absent: the temperature was persistently subnormal j the patient often lay on his left, but could not rest on his right side ; and though taking so little food, instead of wasting and emaciating, looked remarkably well. On the other hand we had great pain and tenderness ; apparent bulging and fluctuation of a certain localised area ; and, lastly, rigors ; and hysteria was not dreamt of. It is no wonder, then, that the serious com-
they
hacking.
_
September,
paradoxical
*
Characteristic of malaria,
99
plication of the first powerful fit was a source of the utmost dismay. Ludicrous as it may now appear, all dreaded some grave, if not fatal, injury to the liver-abscess and many an ominous shake of the head but too plainly predicted early death ; but though the scanty sputum, urine, and stools were minutely and assiduously scanned day after day, neither pus nor blood would reward the anxious vigilance of the most expectant; and the further continuance of the fits without any resultant danger soon finally set the matter at rest. I trust the rarity of such an exclusive complaint as marked Hysteria in a male, and especially that of rarer Hystero-epiconcomitant its lepsy,?with simulations, may prove a sufficient apology for my usurpation of so much valuable space in the foregoing details. With respect to the latter considering such a commingling of various symptoms, I find it hard to assign it an exact place in M. Charcot's subdivisional "
classification.
Agra,
21st February, 1882.
