CHAPTER 9 - APPENDIX OF CASE HISTORIES

This appendix summarizes forty cases individually. In all of them, except case 20, the symptoms and signs were reproduced by hyperventilation. Case 20 was too apprehensive to risk precipitating laryngeal stridor by overbreathing.

Case 18 is given in more detail than the others, not only because it is so representative of the syndrome but because the patient was an extremely reliable and intelligent observer.

E.M. stands for European male.

E.F. stands for European female.

C.M. stands for Coloured male.

C.F. stands for Coloured female.

1. J.N. - 36 years (E.M.)

This patient was an epileptic. He said that for about 2 years he had been rather worried because of his epileptic attacks and because of domestic tension. During this period he often got the feeling "as though his chest had closed in" and he felt compelled to rush out of the house to get fresh air. These attacks lasted about 10 minutes.

One week before coming to the hospital he got this feeling of not getting enough air. It was so acute that he actually tore his collar open "to let in the air". He then became very dizzy and staggered like a drunk man clutching a fence to keep on his feet. He was not conscious of any paresthesia. This attack lasted about 45 minutes.

Three weeks later he reported back to out-patients to say that he had started to get an attack like his previous one but had immediately breathed into his hat and within a few minutes all his symptoms had disappeared.

2. S.B. - 42 years. (E.F.)

The patient stated that she was perfectly well until 6 months before our interview. One night, while preparing for bed, she developed a "funny feeling over my heart as though something had stopped there”. When she got into bed a few minutes later she got a "dead feeling" in all the fingers of her left hand and a cold feeling in the left ear and over part of the left side of her face. Her head felt "drunk". She thought she was having a "heart attack'' and got very frightened. She woke her husband, who gave her some brandy and the attack passed off. She said the one thing lasted about 10 minutes and that when she got the cold feeling in the left ear she tested her hearing with a clock and found it defective on the left side. She was not conscious of any respiratory abnormality and her husband did not remark on any "but then he is so nervous that he would be too upset to notice anything clearly". Since that time she had had one or two attacks per month - always when she had just gone to bed and she had had a worrying day. She had to sit up in bed when she got the attacks. Fatigue also precipitated attacks.

The only abnormality discovered on examination was mild diabetes. A hyperventilation test carried on for 8 minutes reproduced all the symptoms including objective diminution of hearing on the affected side. Pulse rate increased from 90 to 120. She said that her heart always beat fast with the attacks.

3. Mrs. W. - 22 years. (E.F.)

This woman complained that for about 3 months she had been getting a "tight feeling in her chest" and she felt she had to get outside to get fresh air. Associated with this she would get a stabbing feeling in the left precordium and her heart would beat very fast. On one occasion she developed "pins and needles'' in her fingers and her hands got stiff. She thought she always breathed fast on these occasions "but the doctor told me that was just imagination". Her hands had been clammy for some time. During the last 2 years, she had lost about 20 lb. in weight but said it was due to her poor appetite. She preferred cold weather but did not find hot weather intolerable. She was admitted to the hospital as a case of thyrotoxicosis and her B.M.R. was found to be raised.

She had been married for 4 years and had three children. "If I had not been pregnant I would never have married my husband". The marriage was very unsatisfactory. He lived apart in a hotel except at weekends and was unfaithful to her.

4. Mrs. W. - 29 years. (E.F.)

Her trouble had lasted 5 years. She had noticed that if she became upset her breathing would become quick and shallow. She would become giddy and would feel a numbness creeping up her arms and round her mouth. The attacks lasted a few minutes.

When she became pregnant two years later the attacks recurred. They never wakened her from sleep but often occurred before she fell asleep. She was particularly prone to get attacks if she was very tired or worried about anything.

She had a lot of financial and domestic trouble and was terrified of having more children.

5. G.S. - 37 years. (E.F.)

This patient complained that for the previous 3 weeks she had experienced periodic attacks of giddiness associated with a “pins and needles" sensation in the right hand. She was not conscious of any respiratory difficulty at these times but had always been a prodigious sigher. In addition, she felt tired all the time. She was afraid to climb upstairs in case she got a giddy turn and fell.

She was a widow with three children and had always lived with her mother until a few months before. She felt lonely without her mother and was obviously very dependent. She mentioned spontaneously that it was her mother's absence that was making her ill.

6. W.C. - 24 years. (E.M.)

This patient had had a mastoidectomy and then became worried that his other ear was also affected. He haunted E.N.T. surgeons and was constantly and very transiently reassured. At that time he began to get attacks when in bed about 11 p.m. The first attack consisted of giddiness and a tingling sensation in the left ulnar distribution. He would then get a fishy taste in his mouth and a sharp pain under the sternum which shot up to his shoulder and round his neck. He also got a sharp pain in his left hypochondrium and if he palpated his abdomen would hear a "lot of gurgling". The attacks lasted 10 to 15 minutes and then he would be unable to sleep without a sedative.

7. B.C. - 54 years. (E.M.)

This man was a constant visitor to Neurology O. P. D. because of tinnitus in both ears. He had no sign of organic disease apart from arteriosclerosis and as he was worried about being unemployed a job was found for him. However, he reported back the following week to say he could not go to work "because whenever I have to cross the road I get so dizzy that I fear I will fall and I feel pins and needles in my fingers and toes".

8. E.D. - 48 years (E. F.)

This woman had been extensively investigated for palpitations. Her story was that suddenly her heart would “race furiously", she would feel slightly nauseous and breathless and her left hand would start tingling. She had been put to bed for months at a time and had had numerous cardiovascular investigations. She was convinced that she had "a bad heart”. All investigations were negative and one day during a ward round attention was directed to her because of loud breathing. On examination, her pulse rate was 134/minute and she gasped “this is one of my attacks". She was quite unaware of the fact that she was overbreathing.

9. M.B. - 29 years. (C.F.)

Her story was that a year before seeking medical advice her daughter had died suddenly in the night “from a tuberculous gland burning in her throat". For 8 months the patient, who was herself under observation at the TB Clinic because of a past pleural effusion, had been getting nocturnal attacks during which she suddenly became very apprehensive, felt "a tight feeling in the throat”, so that she could not breathe properly, but gasped for breath. Associated with this she felt strange and unreal and was so terrified and restless that she would run out into the lonely street at 3 a.m. with her heart racing. The attacks lasted about 30 minutes and afterward she had a feeling of extreme fatigue.

10. Mrs. B. - 45 years. (E.F.)

The patient had had several attacks when bad news had been brought to her. One day while sitting on a bus she felt very short of breath and could not think straight. After a few minutes, she had marked tingling in her extremities and felt very dizzy. She felt she just got out of the bus and asked the conductor to let her off. She spoke thickly because her mouth felt stiff and she was markedly ataxic. He thought she was drunk and refused to stop the bus. In desperation, she jumped off and he threatened to charge her.

She also tended to get attacks when she got very hot, e.g. when cooking over a hot stove. She had several burn marks on her arms from occasions when in a confused state from hyperventilation she has swayed against the hot plates.

To complicate matters she had a congenital heart lesion and was convinced that these attacks were a result of her cardiac lesion especially as she had been made respiration conscious by medical interrogation.

11. Mrs. R. - 38 years. (E.F.)

This woman complained of constant headaches which were considered to be psychogenic. In addition, she was irritable and sensitive to sound. Sometimes when she had a bad headache she got a feeling as though she was suffocating. Then the fingers of her left hand would begin to tingle. She also said her left arm got "lame”. She was greatly relieved when this feeling: was reproduced in the left arm by hyperventilation because she was sure it had meant that she was going to get a "stroke".

12. M.S. - 20 years. (E.F.)

This woman had suffered from dysmenorrhea for several years and from a spastic colon for several months. She said that during the few months before our interview she could get a feeling as though she could not get enough air into her chest. This happened most frequently on retiring for the night. Then she would get a tingling feeling in both hands, especially the left, her legs would feel lame and her mouth so "thick" that she could not speak properly. Attacks lasted about 15 minutes, They also occurred during the day when she got nervous and excited and she occasionally "fainted" with them.

She had a bad work record - due she said to sickness - and her home atmosphere was not good. She was very resentful about her mother's preference for her young sister.

She was sure she had a bad heart because during the attacks her heart beat so fast and "several doctors have told me these attacks are due to a weak heart".

13. T .W. - 17 years. (E.F.)

This girl complained that for two years she had been short of breath on exertion and thought there was something the matter with her chest. Four days before she came to the hospital she had to run for her train. On getting into the train she was short of breath. Alarm about her chest resulted in persistent overbreathing for the next 20 minutes while she sat on the train. As the train drew into the station she felt lightheaded and was so peculiar "that hardly knowing what I was doing I pulled open the door and fell from the moving train". When she arrived at work she was so shaky and tearful that she was sent home. Two minutes of hyperventilation reproduced the same light-headedness and desire for flight.

14. W. K.- 17 years. (E.M.)

This boy said he had been perfectly well until 2 months before our interview. One Saturday night he was sitting on the stoep with a crowd of young people when he suddenly felt dizzy, then became confused and when he came to a few minutes later found his friends holding him down. Six weeks later on a Sunday night under the same circumstances, "I suddenly felt that I must get more fresh air. My right arm began to tingle and as I got up to walk out I collapsed. I could hear everything that went on around me but could not speak or move. They carried me home and I had three more attacks that night. People always knew when I was going to get an attack because my breathing got so deep.”

He had been converted to the Salvation Army at the age of ten and had played in their band on Wednesday and Sunday nights regularly for 6 years. Just before his attacks began he had decided that he must have more “fun" and had driven up his band playing. However, he felt very guilty about it and both attacks had occurred after taking out a girl.

15. G.H. - 28 years. (E.F.)

This woman was interesting in that the pattern of her symptoms varied so much. At one time she would feel that she had to sigh a lot and things went black in front of her eyes, or she would feel that something was pressing on her chest, and her throat would close in spasm. At other times attacks would start with a "pins and needles" sensation in her hands and later her legs felt stiff and her hand would go into spasm. The left hand was always more affected than the right and her left shoulder would also draw up. She felt that her stomach was drawn up into a knot and she would get distended with air and belch a lot. Her hands became cold and were wet with sweat.

She had had a bad time with an unfaithful first husband and imagined that her second husband was too interested in a previous girlfriend. Incidentally, she had spent about £200 on her illness and at one time had been thought to be suffering from Jacksonian epilepsy because of the drawing up of the left shoulder.

However, all her symptoms, including the shoulder movement, were reproduced by overbreathing.

16. W. W. - 45 years. (E. F.)

The patient was quite well until two nights before admission to the hospital. She was sitting reading a book when she suddenly felt faint and began to sweat. She then became unconscious within a few minutes of the onset of her symptoms. She thinks she was completely unconscious for a few minutes. When she came round she noticed that her thumbs were turned into her palms and this happened in spite of herself. Her fingers were blue and she had a sensation of "pins and needles" up both arms. She rubbed her hands together to overcome the abnormal position of her thumbs and remembers that her hands were not weak. She was sweating profusely, her feet were cold and she was breathing rapidly. She could see quite clearly but had no nausea and no palpitations. A friend was present during the attack and told her that her face was blue and her pulse impalpable.

On direct questioning, she remembers that after her evening meal she had a sensation of a lump behind the sternum - like a dull ache which went through to the back and was relieved slightly by breaking wind. Her mother had died of heart trouble a few weeks before this attack. She had had this substernal discomfort on two previous occasions but never so severely.

17. J .K. - 30 years. (Malay woman).

She complained through an interpreter of attacks for one year. They occurred every 5 or 6 days. An attack usually began about 20 minutes after a meal. It would start with a burning feeling under the sternum. She would begin to breathe heavily and would complain of a pricking feeling in the fingers and a stiffness of the legs. After about 20 minutes she would lie down, turn blue, and become unconscious. Simultaneously her abdomen would become enormously distended.

A hyperventilation test carried out for 30 minutes reproduced the picture exactly. The distension of the abdomen was dramatic and she broke a lot of wind at this time. A striking thing was that she yawned uncontrollably during the experiment which she apparently also did spontaneously. While semi-comatose with a distended belly she began a curious grunting noise with an action strongly reminiscent of bearing down in labor. She developed a gross lumbar lordosis during the attack.

Apparently, she had one daughter of 12 years and was desperately anxious to have other children.

18. M.W. - 32 years. (E.M.)

This man stated that 5 weeks before our interview he was driving in Johannesburg at 4.45 a.m. He was on his way to pick up a friend with whom he planned to leave on holiday at 5 a.m. He was worried about being on time, and when a robot flashed against him he became agitated. He felt giddy and everything seemed out of perspective. He began to sweat and his heart was beating like a sledgehammer. He had a feeling of submersion "as though someone was holding my head underwater". Although he would get air into his chest "it was an unsatisfactory breath" and he felt he would die for lack of air. He had a sharp pain over the left breast and a feeling of tension in the muscles of the left forearm.

He immediately thought he had a coronary thrombosis (he had been present at the death of a friend from a coronary thrombosis a few months before) and stopped the car. After a few minutes, he drove on to a telephone booth to which he staggered, but had no change so had to return to the car. He then drove to his friend's flat, holding the door of the car open “so that he could get enough air". He drove through several stop-streets and as he parked out the door of his friend's flat a police car stopped behind him and accused him of being drunk. He excused himself on the grounds of illness and entered the flat.

His friend was horrified by his pallor, so phoned for a doctor. The doctor reassured him and arranged for him to have an electrocardiogram done immediately. It's normal. His blood pressure was normal and his pulse rate 100 beats per minute. He was breathing deeply.

Ha was told that it was an "anxiety attack” and was advised to go on holiday. The whole attack lasted about half an hour.

He left on holiday the following morning and was away for a month. During this period he had attacks very similar to the first only slightly less severe. Attacks occurred at intervals of 2 or 3 days.

All in all, he had a miserable holiday and was still extremely apprehensive about himself when he returned to Johannesburg. He consulted a doctor who told him he was suffering from the "hyperventilation syndrome”, explained the mechanism, and told him to hold his breath if he got symptoms. He was enormously relieved at the logical explanation of his symptoms and felt a lot better. That night he woke up at about 1 a.m. with one of his attacks, and on holding his breath the whole thing passed off and he fell asleep much reassured. Three days later he had a mild attack which was immediately relieved by breath-holding.

The night before our interview he was preparing for bed when he became violently giddy and felt he was going mad. He wondered if he were mad to react to stress by overbreathing. He wanted to scream and took a sedative and after about an hour the attack passed off and he fell asleep. He was not conscious of the old suffocating feeling this time and did not think that breath-holding helped very much.

At the age of 17, he was told when he wanted to take out an insurance policy, that he had nephritis. He was put to bed for a year. Later he was periodically told that he had high blood pressure and albuminuria and got the impression that his days were numbered. He was accepted into the Air Force, however, and served as a pilot throughout the war. He never had any symptoms while flying.

About 11 months ago he began to wake up in the middle of the night with "pins and needles” in the left hand and often had nightmares.

He has had a lot of worry about a brother for the last 11 months. He is unmarried. He says he is ''obsessional" - e.g. smokes only 8 cigarettes a day and then always at the same time; is very punctilious about keeping appointments; does the same set of exercises every day and must eat at regular times. He has a number of medical friends, some of whom are psychiatrists, and has a strong belief in the power of reason and logic.

After three deep breaths, he was violently giddy and afraid to continue. In less than a minute he had "pins and needles" in the left hand and a feeling of tension in the muscles of the left forearm. He then got a sharp precordial pain, a tight feeling around the head, and felt very cold and apprehensive. He said that it was an exact reproduction of his attack.

At his second interview, he demonstrated how practically all day he sucked at his pipe for a few minutes, then took a deep breath as he removed it.

19. G.L. - 52 years. (C. F.)

This woman complained that for 2 years she had noticed that after even very slight exertion she became short of breath and experienced tightness of the chest, sweated profusely, and had tingling in her toes and fingers and round her mouth. For 3 months she had been awakened at night by a feeling of discomfort in the epigastrium, associated with profuse sweating and “pins and needles'' in the extremities. Her abdomen became distended and subsided after about 10 minutes then she had broken a lot of wind. The whole attack lasted about 30 minutes and occurred about twice a week.

Hyperventilation reproduced all her symptoms, including the epigastric sensation, which seemed to be due to spasms of the abdominal muscles. She had no evidence of organic disease. Her husband had left her 2 years previously and she was having a struggle supporting her children.

20. E.M. - 52 years. (E.F.)

This woman had a thyroidectomy 4 years previously. One month after the operation she was recognized as being myxoedematous. During the operation, her recurrent laryngeal nerve had been cut. Eight months after the operation she had her first attack of laryngeal spasm. This was thought to be due to parathyroid removal at the time of the thyroidectomy. The long time interval between the operation and the attack makes this diagnosis improbable. In any case, her serum calcium was normal. She continued to get attacks for years - another unusual feature for the parathyroid type. Her attacks usually occurred at night but occasionally during the day, she felt as though she could not get a deep enough breath and her left hand tingled.

Unfortunately, she was too afraid of the stridor to risk precipitating an attack by overbreathing, but she was undoubtedly a case of hyperventilation.

21. P.L. - 19 years. (E.M.)

This was a second-year medical student who complained of a subjective and objective coldness of the extremities coming on during lectures about 4 times a week and lasting several hours. He had had this symptom for a year and on questioning said that for the same period he had had a feeling of not being able to take a deep enough breath so that he had to breathe through his mouth. During these attacks, he sweated excessively and said he got the sensation "as if someone was putting dry ice on his toes and fingers". He thought he had some peripheral vascular disease. He was going through an unsettling time because he had had a strict religious upbringing and was bewildered by his zoological studies, as they seemed to fit the theory of evolution which his parents said was arrant nonsense. His mother had recently developed peripheral vascular trouble. After the mechanism of his attacks had been explained and demonstrated to him by a hyperventilation test he made an immediate recovery.

22. P.L. - 19 years (E.F.)

Her story extended over 3 months. Her first attack occurred just after her pet dog had been killed. It started with a peculiar feeling in the epigastrium "as though her stomach had turned to jelly". She felt she could not get a deep enough breath, felt giddy and her fingers and toes began to tingle. She sweated profusely. The attack lasted 5 to 10 minutes. Two months later when working under stress she had a series of similar attacks. She always had attacks when she was lying on her bed alone thinking about something miserable. She was a conscientious girl and could not cope with work in an understaffed office.

She was referred to as a case of hypoglycemia.

23. Mrs. R.J.- 49 years (E.F.)

This woman complained that for about two years she had suffered from a tight feeling across the upper sternum associated with a tingling feeling in the left hand and a feeling as though she could not get a deep enough breath. The attacks lasted for about 20 minutes and were not necessarily associated with exertion, emotional stress being often the precipitating factor. On several occasions, she had felt faint. She was not hypertensive or diabetic and hyperventilation reproduced all the symptoms, including the substernal pain.

24. R.K. - 18 years (E.F.)

This girl was referred to the Neurology outpatients department as an epileptic. Her story was that 5 days previously she had just returned from church and saw her mother scolding her sister-in-law for some minor misdemeanor when she "suddenly dropped to the ground". Although unable to speak she could hear everything. Since that time she had had several attacks every day - sometimes a bitter taste in her mouth preceded an attack. She had never bitten her tongue or wet herself during an attack. On one occasion she had had some tingling in her hands-on "coming to".

She was told to overbreathe, which she did recumbent for 4 minutes without developing any striking symptoms. She was then told to sit up and immediately there was a marked increase in rate and depth of breathing and she fell back semi-conscious with her bends in the tetanic posture. Her mother, watching this, said "But this is exactly what happens when one gets a fit; she always breathes like that but we did not think it important."

The girl had been converted to some religious group and spent all her spare time doing religious work. Her boyfriend, who had been converted with her, had recently deserted both the religious movement and the patient.

25. B.B. - 45 years. (E.M.)

For about a year he had had repeated episodes of inability to get “a proper breath". He would writhe and struggle at these times, breathing fast and irregularly. About 3 or 4 times a week he would be awakened at night and forced to jump out of bed and contort his body to get some respiratory satisfaction. Sweat poured off him and his abdomen became distended. He felt light-headed.

When his attacks started he had just remarried a woman he had previously divorced. She was extravagant and was making the lives of his children a misery by her scolding and irritability.

26. Mrs. S.T. - 40 years. (E.F.)

This woman was admitted with a sciatic syndrome. She had no other complaints except that on direct questioning she admitted that periodically in the last 3 years she had had a feeling as though she could not get a deep enough breath. This usually occurred when she was upset about her domestic troubles.

On the third day of admission, she was lying in bed when she suddenly developed this respiratory difficulty. A few minutes later she felt cold and hot by turn and simultaneously a tingling sensation crept up her legs and arms until her face and trunk were involved. Then her hands went into tetanic spasm.

The nursing staff was alarmed and called the houseman. When he arrived she was over- breathing vigorously, had a positive Chvostek and Trousseau sign, and her neck was stiff. He thought it might be a result of the lumbar puncture which he had done that morning but with reassurance, all the patient's symptoms disappeared in about 20 minutes.

The picture was reproduced the following day by overbreathing her for 6 minutes.

On inquiry it was found that her husband was unreliable and unfaithful and she was worried about the care of her children because she had not been visited at all since admission.

27. O.W. - 30 years. (E.F.)

This woman had had a splenectomy 10 days before she began overbreathing. Her story was that after the operation she felt fine for 5 days. Then she developed watery diarrhea about 3 or 4 times daily. One night she developed a severe paroxysmal cramp-like pain across the epigastrium. The pain waxed and waned but was present throughout the night. She also vomited repeatedly during the night. The following morning during a bout of pain she became very alarmed about herself and noticed that her hands and face were tingling.

A little later the houseman put on a tourniquet to take blood and missed the vein several times. She again began tingling and the obstructed hand went into typical tetanic spasm. At this time although she herself was unaware of it, it was observed that she was overbreathing. In this case, the patient was peculiarly susceptible to the effects of overbreathing because she was already alkalotic from the vomiting.

28. W. T. - 19 years. (E.M.)

This patient developed severe abdominal pain and vomiting which subsequently was found to be due to acute appendicitis. Two days after the onset of the pain he suddenly got "a peculiar attack", which consisted of tingling or his face with a "stiff" feeling around his mouth; a few minutes later his body became stiff and his hands assumed the tetanic posture. He said the spasm was acutely painful. A doctor was hastily called and relieved the condition by an injection of calcium gluconate.

For the next 2 days, he was free of attacks but still had abdominal pain. On the third day, he was sent to the hospital for an operation. On the day of admission, he had a similar attack although this time his face was spared. He was not aware of any respiratory abnormality though the attack in the hospital was ushered in by obvious overbreathing. Alkalosis due to vomiting made him vulnerable in the first attack and emotional stress due to an impending operation was the factor precipitating the second attack when he was not alkalotic.

29. G.M. - 17 years. (E.F. )

This nurse said that for about a year she had tended to laugh and cry very easily. Four months before seeking medical advice she had an attack with the following symptoms: she was laughing a lot then suddenly began to cry. She felt she could not get a deep enough breath and began to pant. After a few minutes, her hands and feet became numb and "dead" up to the middle of the forearms. The attack lasted for 50 minutes and was terminated by a doctor giving her a sedative. Three and a half months later she had a similar attack.

On questioning, she admitted that she hated nursing but felt that her parents would be angry if she proposed a change of occupation.

30. E. . - 38 years. (E.F.)

This woman was referred from a country town with a diagnosis of thyrotoxicosis. She said that she periodically got attacks when she had difficulty in breathing, developed "pins and needles" in the fingertips, sweated profusely, and got palpitations.

She was going through a period of domestic tension.

31. F.J. - 39 years. (E.M.)

For 6 months before admission, the patient had experienced attacks of coldness, pallor, and sweating of the hands. Sometimes the hands felt “dead" and he had a tingling feeling in his face. Associated with this he often experienced a feeling of discomfort in the left hypochondrium which extended up to his chest "as though something was pressing on my heart". Attacks lasted 10 to 30 minutes and he felt blown up and broke a lot of wind, which relieved the discomfort in the left side. He felt a bit short of breath with the attacks. Attacks usually occurred about midnight waking him from sleep. He had been told that his heart was diseased and had been put to bed for 5 weeks.

One month before his symptoms began his sister-in-law, who was asthmatic, died. Throughout her distressing and dyspnoeic final agonies, the patient was present and says it made a deep impression on him.

32. C.K. - 26 years. (E.F.)

This woman had been getting attacks for about 2 months before she came to the hospital.

She said: "When I get the attacks they start with a feeling as though my nose is blocked, so I breathe through my mouth. I feel smothered and I can't get enough air. I feel as though I am going to faint, so go and lie down. All the blood seems to leave my hands. The saliva dries up in my mouth. I get a "pins and needles" feeling in my arms as far as the elbows and in both feet. I get a stabbing pain over my heart and break a lot of wind. I water a lot during the attack and my water is very pale. An attack lasts about 20 to 30 minutes”.

She had married her husband when their child was about 2 years old and had been treated unkindly by his family, who did not think she was good enough for him and were constantly interfering in their marriage.

33. E.M. - 19 years. (C.F.)

This girl said that she had been well until 10 days before she came to the hospital. Then one night as she lay in bed reading she felt she could not get a deep enough breath. She felt giddy and had "pins and needles" in her hands and feet. She had cold shivers and trembled violently. She walked up and down for about 2 hours before the attack finally wore off. Seven days later she had a similar attack at about midnight and was wakened every 1 or 2 hours throughout the night by a recurrence of the symptoms.

She denied all worries but said, weeping, that a favorite aunt of hers had died 3 weeks before.

During 2 minutes of hyperventilation, she got exactly the same symptoms and wept profusely.

34. H.A. - 44 years. (E.M.)

This man stated that for 3 months before coming to the hospital he had been getting attacks when he felt anxious. His breathing became stertorous. He felt a "pins and needles" sensation in his hands and then his hands "drew up" so that he was unable to use them. At the same time he felt faint and unreal “as though mesmerized" and on one occasion actually fell over because of the faintness. His speech became thick and he couldn't articulate properly. Attacks lasted about an hour and were relieved by neat brandy.

He had always sighed a lot and for several years had been unable to write while observed because of a violent tremor of the hands and a feeling as though he was suffocating; if he was asked to sign a hotel register he felt incapable of doing so and made some excuse about putting the car away so that his wife could do the signing.

A hyperventilation test resulted in marked giddiness and paresthesia in both hands with a marked tremors of the hands. He refused to continue beyond 2 minutes as he felt so ill.

35. C.B. - 33 years. (E.M.)

This man was an immigrant who was "having a hard and bitter fight" to make a living in this country. In addition, his wife had severe asthma; "hearing her struggle for breath at night makes me breathe faster". He sometimes had dizzy spells which were so disturbing when driving that he had to park his ear and wait until the attack had passed. His main complaint, however, was of a tight feeling across the upper abdomen, "gripping like a vice", which made him feel that he could not breathe properly. When he had this feeling he was extremely restless and if an attack occurred near meal time he was forced to eat standing up.

Experimental hyperventilation reproduced the vice-like feeling "exactly".

36. P.C. - 36 years. (E.F.)

This woman was very preoccupied with a pain in her back which had been extensively investigated on many occasions in hospital. She had had a Halsted operation some years before for a suspected mammary carcinoma and was convinced that the pain was due to a secondary deposit. She eventually became a chronic hospital inmate and if discharged would hyperventilate herself into a state of semi-coma and have herself re-admitted as a "coma of unknown origin".

37. M.B. - 18 years. (E.F.)

This girl was a nurse who was sitting talking to her friends around the fire one evening when she became aware of a feeling of numbness in her hands and feet. She got up to leave the room and while walking across the room got "lame" in her legs and collapsed. She was carried to bed and after a few minutes, her hands and feet assumed the tetanic posture. She was not conscious of overbreathing but said a friend of hers was alarmed when they were sitting in front of the fire "because her breathing was so deep". She continued to have tetanic spasms throughout the night. The next morning she had marked muscle tenderness and a "feeling of lameness in her legs. "

She was admitted to the City Hospital as suspected of poliomyelitis.

She denied any worries, but the fact that she was due to go home on leave the next day was thought to be of some significance.

38. A.M. - 38 years. (E.M.)

This patient developed left-sided hemiplegia - due to a vascular accident. One month after this he experienced an attack which he described thus: "I woke up one morning and found my left hand in spasm. I had a tingling feeling on the left side of my mouth. Then my left leg got stiff. My wife had to massage me for about 15 minutes before the spasm passed off. I don't think I was breathing fast, but my wife says I always breathe too deep".

He hyperventilated experimentally for about 30 minutes and then developed well-marked tetany in the left hand which was present for a good 20 minutes before there was any sign of tetany on the other side. Incidentally apart from slight weakness on the left side and positive finger flexion and Hoffman he had very little evidence of hemiplegia. Hyperventilation did not bring out any additional pyramidal signs.

39. J.D. - 34 years. (E.M.)

This man was in the hospital with a proven duodenal ulcer. One morning he developed a sharp pain "like a knife" in the left precordium. He asked for the houseman who was busy and was fairly casual about the pain. About 30 minutes later the patient developed tingling in the left ulnar distribution and "broke out in a cold sweat". His feet and hands then became "dead" and he could not move his limbs or open his eyes. He could hear the medical staff talking around his bed but could not speak. Witnesses say he was breathing heavily at the time though he was quite unaware of this.

40. E.F. - 18 years. (C.F.)

This girl came to the hospital complaining of "blackouts" which occurred about 3 times a week, especially when she was in crowds. She never became unconscious but during the attack, she had difficulty in seeing properly and sounds seemed far away. In addition, she breathed fast and her hands were wet with sweat.

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