A system of practical medicine. By American authors. Vol. 5

by Unknown

CATALEPSY.

BY CHARLES K. MILLS, M.D.

---

DEFINITION.—Catalepsy is a functional nervous disease characterized by conditions of perverted consciousness, diminished sensibility, and especially by muscular rigidity or immobility, which is independent of the will, and in consequence of which the whole body, the limbs, or the parts affected remain in any position or attitude in which they may be placed.

Catalepsy sometimes, but not frequently, occurs as an independent disease; that is, the cataleptic seizure is the only abnormal phenomena exhibited by the patient. It is sometimes present, although also rarely, in organic disease of the nervous system. It has been noted, for instance, as occurring in the course of cases of cerebral hemorrhage, softening of the brain, abscess, tumor, and tubercular meningitis. One case is referred to by C. Handfield Jones in which it seemed to be due to intracranial epithelioma. As commonly seen, it is a complication, or perhaps, more properly speaking, a form of hysteria—hystero-catalepsy.

SYNONYMS.—Some of the many synonyms which have been used for catalepsy are Catochus, Morbus attonitus, Stupor vigilans, Synochus, Eclipsis, and Hysteria cataleptica. Trance and ecstasy are discussed sometimes as synonymous with catalepsy, but they will be considered as separate affections, as they have certain distinctive features. Catalepsy, trance, ecstasy, hystero-epilepsy, and other severe nervous disturbances may, however, all appear in the same patient at different times or at different stages of the same seizure.

With reference to the term catochus (κατοχη, from κατεχω, I take possession of), which has been used as synonymous with catalepsy, Laycock¹ points out what he considers to be the proper use of this word, differentiating two cataleptic conditions, which he designates as the tetanic and the paralytic states. Catochus is the tetanic form, in which the trunk and limbs are rigidly extended and consciousness is abolished. Catalepsy proper is Laycock's paralytic form, although the term paralytic, as here applied, is by no means happy. It is the form characterized by the peculiar and striking symptom known as waxen flexibility (flexibilitas cerea)—a condition in which the limbs or parts are passive and are capable of being moulded like wax or lead pipe. Rosenthal would not consider any case as one of genuine catalepsy if this waxen flexibility was absent. I do not think that this rigorous criterion should always be imposed, although it might perhaps be better to apply the term cataleptoid to all cases which do not present true wax-like flexibility. The distinction sometimes made between catalepsia vera, or true catalepsy, and catalepsia spuria, or false catalepsy, is practically that indicated between Laycock's two forms. According to Charcot and Richer,² the flexibilitas cerea is not present in the cataleptic state of hypnotism.

¹ A Treatise on the Nervous Diseases of Women, by Thomas Laycock, M.D., London, 1840.

² Journal of Mental and Nervous Diseases, Jan., 1883.

HISTORY.—The word catalepsy was used by Greek writers in its etymological signification of a seizure or surprise. Hippocrates described catalepsy; Galen, Aëtius, Rondeletius, and Fernelius have all related cases; Aëtius has left an accurate description of both catochus and catalepsy. In 1683, Laurence Bellini published a quarto volume on various subjects, one of which was catalepsy. From time to time interesting cases of catalepsy have been reported by medical writers. One of the best is that recorded by John Jebb in 1782, and quoted by Chambers in Reynolds's System of Medicine. The researches in hypnotism during the present century, and particularly those of Heidenhain and of Charcot and Richer, have thrown new light on many cataleptic phenomena.

ETIOLOGY.—In catalepsy, as in hysteria, insanity, and many neuroses, inheritance frequently plays a predisposing part. Eulenburg places it in the large group of diseased conditions designated by Griesinger constitutional neuropathies. The cataleptic of one generation may be the descendant of the insane, the epileptic, the syphilitic, or the alcoholized of a former. Catalepsy is particularly likely to occur in families which have a history of insanity or drunkenness. Of the cases detailed or alluded to in this paper, more than a majority had a clear neurotic history. Catalepsy, like hysteria, occurs with some frequency among the tuberculous.

Age plays some part in the development of catalepsy. It is of most frequent occurrence between the ages of fifteen and thirty, but has been observed at all ages. It is of unusual occurrence in very early childhood, but A. Jacoby,³ Clinical Professor of the Diseases of Children in the College of Physicians and Surgeons in New York, reports a case of well-marked catalepsy in a child three years old. This patient, a girl, was admitted to the Mt. Sinai Hospital, New York, in September, 1879. She had whooping cough and some symptoms of typhoid fever. After she had been in the hospital three weeks choreic twitchings of the eyes and eyelids, with divergent strabismus, were observed. Examining her, it was found that she was cataleptic; her arms and legs would remain in any position in which they were placed; she would drop the uplifted arms slowly when commanded; sensibility to contact, pain, and temperature were entirely lost, and the skin and patellar reflexes were diminished. Her appetite was ravenous, and urine was passed in large quantities. Other phenomena and details of cataleptic symptoms, which continued for about a month, are recorded by Jacoby. The child recovered, but remained weak and anæmic for a long time.

³ American Journal of Medical Science, N. S. lxxxix., 1885, p. 450.

Monti⁴ records eleven cases of catalepsy met with in children, male and female in about equal numbers, of from five to fifteen years, the average age being nine years. Eulenburg speaks of catalepsy at five years of age, and quotes Schwartz, who noticed in a boy seven years old, in consequence of rough treatment, first a choreic condition, which later passed into catalepsy. Lloyd's case, to be detailed later, also studied by myself at the University Hospital, was in a boy eight years old. B. L. Hovey⁵ of Rochester, New York, reports an interesting case of catalepsy in a boy eight years old.

⁴ Gerhardt's Handb. d. Kinderk., vol. v., L. P., 186 et seq., quoted by Jacobi.

⁵ The Hospital Gazette, 1879, vi. p. 19.

C. E. de Schweinitz of Philadelphia, Ophthalmic Surgeon to the Children's Hospital and Prosector of Anatomy at the University of Pennsylvania, has kindly put into my hands the unpublished notes of a highly interesting case of catalepsy or automatism at command, or of both, in a child two and a half years old. I will give this case in full, chiefly in the language of De Schweinitz, because it is, so far as I know, the youngest case on record. Some of the tests which were applied in this case are among the most useful which can be resorted to in determining how far the phenomena presented are genuine or induced, simulated, or imitated:

The patient was a girl aged two and a half years, who had recently recovered from an attack of diphtheritic conjunctivitis. During the period of her convalescence the attending nurse called attention to the unusual position assumed by the child while sleeping—viz. a lateral decubitus, the head raised a short distance from the pillow, and the forearm slightly elevated and stretched out from the body, the muscles at the same time exhibiting marked tremulousness. A series of trials readily demonstrated that the child when awake could be placed in any position compatible with her muscular power, and that she could thus remain until released. She was placed, for instance, in the sitting posture, the arm brought at right angles to the body, the forearm at right angles to the arm, and the hand at right angles to the forearm, both legs raised from the bed, and the head bent backward. This position, a most uncomfortable and difficult one to preserve, would be maintained until the little subject dropped from sheer exhaustion. Flexion and extension of each separate finger were easily produced, and the fingers remained until replaced in the positions in which they had been fixed. At the beginning the child's mind was sluggish, although she asked for food and made known her various wants. How far she appreciated surrounding objects could not be accurately ascertained, inasmuch as the previous disease of her eyes had left her with a central corneal macula on each side, rendering her almost sightless in one eye and with but indifferent object-perception in the other. Voluntary motion was preserved, and she sat up, turned, and moved whenever she pleased, but most often when at rest at this stage maintained somewhat of the position before described which during sleep first attracted attention to this condition.

In conjunction with Morris Lewis an examination of the cutaneous sensibility and reflexes was made, which showed diminished sensibility in the legs and thighs, but not higher up, where the pricks of the instrument were quickly appreciated. Her knee-jerk was apparently absent on the right side and present on the left; but this test, always most unsatisfactory in children, yielded no certain evidence and constantly gave contradictory results. Scratching the skin of the soles of the feet, legs, thighs, and abdomen with a pointed instrument was followed by marked reflex movements. Electro-muscular contractility was everywhere preserved. The child at this time was feeble and anæmic, but her appetite was good—not depraved nor voracious; the tongue was clean, the bowels regular. The urine was of a light amber color, specific gravity 1020, free from albumen and sugar.

As the nutrition of the child improved, it was found that the curious positions could be produced by word of command as well as by manipulation. In short, within six weeks after the first manifestations of this disorder, as a usual thing the little patient ate, slept, and played as a normal child should do, but could at any time be thrown into this cataleptoid state. Her one dominant idea apparently was to maintain the position in which she had been placed. She was often turned into some constrained posture, and all attendants absented themselves from the room and left her to her own devices; but no attempt on her part was made to in any way change her attitude. If at dinner-time a bowl of broth was placed before the patient, she would begin to eat with great relish, but if the spoon was taken away and her hands raised over her head, they would so remain, the child making no effort to return to her meal, although the bowl stood before her and all watchers again retired from the room. This experiment was suggested by H. C. Wood, who examined the child with me. To show how completely her consciousness was occupied with one idea of maintaining any position in which she had been placed, the following additional experiments may be quoted: If she was put into a sitting position, as in the act of supplication, with her hands folded and arms extended, and then given a sudden push sufficient to overthrow her equilibrium, the arms would be quickly and intuitively thrown out to protect her from the impending fall, but, the fall accomplished, they would as quickly be returned to their former position. If a heated silver spoon was gradually brought in contact with her extended hand, an expression of pain would pass the child's face, perhaps a cry escape her, and the injured member be rapidly withdrawn, but again almost immediately returned to its original place. It seemed as if the idea of fixity in a certain position which occupied the child's mind was suddenly disturbed by another outside impression, but, being dominant, it quickly drove away the intruder and the former state was restored. At this time the phenomena noted were somewhat in accord with those induced by the mesmeric process, inasmuch as the consciousness seemed largely given up to the one impression operating at that time—i.e. the maintenance of certain fixed positions. Unlike this condition, however, the readiness to receive new impressions, and the complete abeyance of those senses not operating was wanting, for, as seen above, the new impression only for a moment disturbed the child's one idea, to which she quickly returned; nor was there any true absence of sensibility, as was evidenced by the result from touching her with a heated spoon.

As time wore on, a new phase of this condition became evident. The induced manifestations seemed to act the part of some amusement to the child, and the complete absence of volition which had been an early characteristic phenomenon was not now so marked a feature. Thus, if, after the experimenter had for a time moulded and twisted the child into various shapes, he would suddenly leave the room, the little subject would cry lustily, as a child does when suddenly deprived of its playthings, although, curiously enough, no matter how hard she cried, she would not release herself from the last position in which she had been left. Often during any series of observations that were being made it was noted that a faintly-amused look played about her lips, which speedily gave way to a fit of crying when the performance stopped. The hand which, when formerly placed in any position, remained a perfectly motionless and passive object, was now seen slightly to change its place, move the fingers, or the like—an observation first made by A. K. Meigs while examining the patient. The house-physician, Nathan P. Grimm, took great care and interest in observing the case.

De Schweinitz, in reporting the case, briefly discusses the probable cause of the phenomena exhibited. He discards the views that either fear of the experimenter, such as is shown by a trained animal, or the partial blindness of the child, was responsible for the manifestations. He believes that a direct relation existed between the phenomena and the state of the child's nutrition. The more run down her system was, the more nearly did the nervous phenomena resemble those of true catalepsy. Evidently, her symptoms were partly cataleptic and partly phenomena of automatism at command, similar to those which have been observed in hypnotic experiments, and which will be alluded to later.

Catalepsy is of more frequency in the female than in the male sex, but the statistics are not sufficient to give any exact ratio.

The periods of puberty and early menstruation and of pregnancy furnish the most favorable opportunities for the development of cataleptoid seizures in predisposed individuals. In 3 of 10 cases observed by Landouzy catalepsy appeared to be developed in consequence of the sudden suppression of menstruation; in a fourth it occurred in a young girl after a dysmenorrhœa with chronic phlegmasia of the genitals. Masturbation is sometimes mentioned as a cause, particularly in boys.

Reflex irritation undoubtedly often acts as an exciting cause of catalepsy. Preputial irritation, relieved in part by circumcision, was present in the case of Lloyd, and has been noted by others. Handfield Jones mentions a case, recorded by Austen in his work on General Paralysis, in which the cataleptic seizure was, to all appearances, due to fecal accumulations. The attack disappeared promptly after an enema had thoroughly operated.

Briquet believed that catalepsy, when it did not follow upon organic disease, was ordinarily the result of moral causes, such as vivid and strong emotions—fear, chagrin, indigestion, anger, or profound and prolonged meditation. He refers to the able and curious thesis of Favrot,⁶ who states that in twenty cases in which the causes of the malady were indicated it had been always the result of a moral affection. A magistrate insulted at his tribunal, seized with indignation, is suddenly taken with catalepsy, etc. According to Puel, its causes are always depressing moral affections, as chagrin, hatred, jealousy, and terror at bad treatment. Unrequited love is set down as a cause, but what has not unrequited love produced? Jones mentions a case which occurred in a man sixty years old on the sudden death of his wife.

⁶ “De la Catalepsie”—Mémoire couronné par l'Académie de Médecine, Mémoires de l'Académie de Médecine, Paris, 1856, t. xx. p. 409, A. 526.

Cullen believed that catalepsy was always a simulated disease; he preferred, therefore, to place it as a species of apoplexy. Temporary catalepsy may, according to Rosenthal, be produced in hysterical patients by covering their eyes with their hands or a cloth. Malaria has been charged with the production of catalepsy, and apparently properly. Traumatism is another of its well-authenticated causes. Blows upon the head have been particularly recorded as having an etiological relation to this disorder.

Partial catalepsy has been observed after typhoid fever with severe cerebral symptoms, and also associated with meningitis and intermittent fever. Mancini⁷ relates a case of cerebral rheumatism complicated or causing catalepsy. A blacksmith, aged thirty-three, had nearly recovered from a rheumatic attack when he became melancholic, complaining also of severe headache. When admitted to the hospital he was found to be imperfectly nourished. He lay on his back, his face without expression, speechless, motionless, pupils insensible to the light, smell impaired, sensation of heat and pain and reflexes absent, galvanic and faradic contractility increased, the rectum and bladder paralyzed. He presented the phenomena of waxen flexibility, the trunk and limbs remaining in whatever position was given them. Considering the previous attack of articular rheumatism and the sudden appearance of nervous disorder during the convalescence of this disease, Mancini believed that the case was probably one of cerebral rheumatism. The man recovered under diaphoretics and counter-irritation.

⁷ Lo Sperimentale, March, 1878.

Among the important causes of catalepsy bad nutrition may undoubtedly be placed. In the case of De Schweinitz the cataleptoid phenomena rapidly improved, and eventually disappeared as the child's general health was restored by tonics and good diet. Hovey's case was insufficiently clad and badly fed. One of Laségue's cases, quoted by Handfield Jones, died of gradual marasmus, another of pulmonary phthisis. Attacks of catalepsy have sometimes resulted from a combination of excitement, fatigue, and want of food. They occur also in diseases or conditions like phthisis, anæmia, and chlorosis, affections which practically gives us the same cause—namely, bad nutrition. In these cases the nervous system, like other parts of the body, takes part in the general exhaustion.

Rosenthal refers to the production of symptoms of temporary catalepsy by the administration of narcotics and the inhalation of ether and chloroform. In a somewhat ancient American medical periodical⁸ Charles D. Meigs of Philadelphia gives an interesting account of a case of catalepsy produced by opium in a man twenty-seven years of age. The man had taken laudanum. His arms when in a stuporous condition remained in any posture in which they happened to be left; his head was lifted off the pillow, and so remained. “If he were made of wax,” says Meigs, “he could not more steadily preserve any given attitude.” The patient recovered under purging, emetics, and bleeding. Darwin, quoted by Meigs, mentions a case of catalepsy which occurred after the patient had taken mercury. He recovered in a few weeks.

⁸ The North American Medical and Surgical Journal, vol. i. p. 74, 1826.

That imitation is an exciting cause of catalepsy has been shown by the often-told story of epidemic hysteria, but more especially by accounts given of certain peculiar endemics of catalepsy. Handfield Jones⁹ gives an account of an endemic which prevailed at Billinghausen near Wurzburg: “The population consists of peasants who are well off, but who intermarry very much, and are small and deformed. The affected individuals constitute half of the number, males as well as females. They are called there the stiff ones (starren). A chill is commonly said to be the exciting cause of the attacks. The patients are suddenly seized by a peculiar sensation in their limbs, upon which all their muscles become tense, their countenances deadly pale; they retain the posture which they first assume; their fingers are bent and quiver slightly, and the eyeballs in the same way, the visual axis converging; their intellects and senses are normal, but their speech consists only of broken sounds. The attack ceases in from one to five minutes, and the body becomes warm.”

⁹ Op. cit., quoted from Schmidt's Jahrbuch.

SYMPTOMATOLOGY.—The cataleptic seizure, when it is not the result of some hypnotizing procedure, usually takes place in the following manner: The patient usually, after some patent exciting cause, suddenly ceases whatever she may chance to be doing, becoming rigid and immobile in the last position which she had been in before the attack ensued. “She remains,” says Rosenthal, “as if petrified by the head of Medusa.” The features are composed, the eyes usually directed forward. She is pale; breathing, pulsation, and temperature are usually somewhat reduced. At first the limbs may be found to offer some resistance; soon, however, and sometimes from the beginning, they can be moulded like wax into any possible position, where they will remain until again changed by external agency.

Attacks of catalepsy, as a rule, come on suddenly, without special warning; sometimes, however, special phenomena, which may be compared to epileptic aura, may precede the attack. Thus, Rosenthal speaks of two cases that were ushered in, and also bowed out, by hiccough. The attacks may terminate as suddenly as they begin, but sometimes the patients come out of the state gradually. They are quite likely to appear dazed and stupid when emerging.

Perverted consciousness is another marked symptom of catalepsy. According to some authors, the loss of consciousness is absolute, and upon this symptom they base their diagnosis from two or three other somewhat similar conditions. As I have already indicated in discussing the general subject of Hysteria, this question of consciousness or unconsciousness is not one to be decided in haste. In catalepsy, as in hystero-epilepsy, the conditions as to consciousness may differ. What might be termed volitional consciousness is in true catalepsy certainly in abeyance. Flint¹⁰ divides catalepsy, according to the condition as to consciousness, into three kinds—namely, complete, incomplete, and complicated. He, however, regards trance and day-mare as instances of incomplete catalepsy, in which the intellectual faculties are not entirely suspended and the senses are not materially affected, the patient being unable to move or speak, but conscious of all that is going on around him. He believes that such cases resemble more closely the cataleptic condition than they do that of ecstasy. In genuine catalepsy with waxen flexibility, analgesia, etc. there may be greater or less depths of unconsciousness, but some degree of unconsciousness or of obtunded consciousness is necessary to the existence of true catalepsy.

¹⁰ Buffalo Medical Journal, xiii., 1857-58, p. 141.

Catalepsy presents well-marked disturbances of sensation, although these, like the conditions as to consciousness, differ somewhat in different cases. Anæsthesia in its different forms, and especially analgesia, are always present in some degree. Experiments without number have been tried on cataleptic patients, showing their insensibility to painful impressions: they have been pinched, pricked, pounded, burned with heated irons, and rubbed down with blocks of ice. Skoda reports a case in which general sensibility was abolished, but a lighted paper rotated rapidly before the eyes gave rise to tremors of the limbs, and strong odors induced slight movement, redness of the cheeks, lachrymation, acceleration of the pulse, and elevation of the temperature.

Hyperæsthesia, although rare, has been noted in a few isolated cases of catalepsy. Puel records a case in which, during the cataleptic paroxysm, the slightest touch or noise caused the patient to grind the teeth and cry out. In some cases sensibility to certain special impressions, as to a strong current of electricity, has been retained, while all others were abolished. In a case of hystero-catalepsy at the Philadelphia Hospital, when all other measures had failed an attack was aborted and evidence of pain produced by the application of a strong faradic current with metallic electrodes.

A marked change in the state of reflex irritability is another of the striking symptoms of true catalepsy. Varying conditions as to reflex irritability have been observed by different authors. So far as I am aware, few special observations have been made upon the tendon reflexes in catalepsy. In the case of De Schweinitz the knee-jerk was apparently absent on one side and present on the other, although the cataleptic symptoms were not unilateral.

The symptom known as flexibilitas cerea, or wax-like flexibility, to which I have referred under Synonyms, is, as has been stated, by some considered pathognomonic of this affection. While I do not hold to this view, I regard the symptom as the most important phenomenon of the disease. It is a symptom which from its very nature can be, up to a certain point, readily shammed, and when considering Diagnosis some methods of determining its genuineness will be given.

Careful observation as to the pulse, respiration, and temperature are lacking in the reported cases of catalepsy. According to Eulenburg,¹¹ “the respiration is generally of normal frequency, sometimes rather slow, more frequently of diminished or irregular intensity, so that lighter and deeper inspirations alternate. The pulse may also be slower, with slight excursion and diminished tension of the arteries. The temperature generally remains normal, but in certain cases is decidedly lowered.” The lowering of temperature, and particularly the presence of extreme coldness of the surface, with exceedingly weak pulse and respiration, have doubtless always been present in the cases—a few, at least, authentic—in which catalepsy has been supposed to be death.

¹¹ Op. cit.

Hypnotic Catalepsy.

The investigations into the subject of hypnotism made in recent years have given to the profession a series of interesting phenomena which should be considered, at least briefly, under the symptomatology of catalepsy. In a general review of the subject of hypnotism¹² by me many of the facts observed and theories advanced by Braid, Heidenhain, Charcot, Richer, and others were examined. I will here recall those observations of Heidenhain¹³ and of Charcot and Richer¹⁴ which relate to the production of a cataleptic or cataleptoid state, and to the phenomena which take place in this state.

¹² Am. Journ. Med. Science, Jan., 1882.

¹³ Animal Magnetism: Physiological Observations, by Rudolph Heidenhain, Prof. Physiology in the University of Breslau, London, 1880.

¹⁴ Etudes cliniques sur l'Hystero-epilepsie, ou Grande Hystérie.

The method of Heidenhain was similar to that employed by Braid. The latter, however, did not make use of passes. In the first place, the individual was made to gaze fixedly at a shining faceted glass button for some six or eight minutes, the visual axes being made to converge as much as possible. Heidenhain, like Braid, found the most advantageous direction of the visual axes to be that of upward convergence. According to Carpenter, in the fixation this upward convergence is very important; it suffices of itself in blind people or in the night to produce hypnosis. After the fixation of gaze had been continued for some six or eight minutes, the operator stroked over the face, without immediately touching the surface, from the forehead to the chest, after each pass bringing the hands, which were warm, around in an arc to the forehead again. He either allowed the eyelids to be closed or gently closed them. After ten or twelve passes he asked the person to open his eyes. When this occurred without hesitation or with only slight difficulty, he again made the person stare at the glass for some six minutes, and then repeated the passes, which often brought about the hypnotic state when the simple fixation did not succeed.

The symptoms of the hypnotic state were in the main those which have just been described as the symptoms of catalepsy—namely, diminution of consciousness, insensibility, increased reflex irritability, and fixity of the body or limbs in any position given.

In the slighter forms of hypnotism the subjects were able to remember what had occurred during their apparent sleep. In more fully-developed forms they had no remembrance of what had taken place, but by giving hints and leading questions of their various actions they were able to call them to mind. In the most complete forms of hypnotism no remembrance whatever was retained. It can nevertheless be proved that even during the most completely developed hypnosis sensory perceptions take place, but they are no longer converted into conscious ideas, and consequently are not retained by the memory; and this is undoubtedly because the hypnotized individuals have lost the power of directing their attention to their sensations.

A symptom of the hypnotic state in its most complete development was highly marked insensibility to pain. A pin could be run right into the hand, and only an indistinct feeling of contact was brought about. Immediately on awaking the full sense of pain was again present. The fact that the tactile sense and the sense of pain are distinct was corroborated.

Increased reflex irritability and tonic spasm of the voluntary muscles accompanied the hypnotic condition. Stroking the flexible right arm of a subject, it at once became stiff, since all the muscles were thrown into a state of reflex spasm. Reflex muscular contraction spread over the body when certain definite cutaneous surfaces were irritated. With slight increase of reflex irritability those muscles alone contracted which lay immediately under the area of the skin which had been stroked. Stroking the ball of the thumb caused adduction of the thumb. Stimulating the skin over the sterno-mastoid caused the head to assume the stiff-neck position. When the irritability was somewhat more increased, by a continuous irritation of a definite spot of skin neighboring and even distant groups of muscles could be set into activity. Heidenhain stroked continuously the ball of the left thumb of his brother, when the following muscle-groups were successively affected with spasm: left thumb, left hand, left forearm, left upper arm and shoulder, right shoulder and arm, right forearm, right hand, left leg, left thigh, right thigh, right leg, muscles of mastication, muscles of the neck.

From a study of such phenomena Heidenhain was inclined to consider that the hypnotic state was nothing more than artificially produced catalepsy.

The possibility of fixing any part of the body in any given position constituted an essential factor in the exhibition of Hansen. He made one of his subjects, for instance, sit before him in a chair, and adapted the hands to the seat so that his fingers grasped the edges. After hypnotizing him he stroked along his arms, and his fingers took convulsive hold of the edges of the seat. Placing himself in front of the subject, he bent forward; the subject did the same. He then walked noisily backward, and thereupon the subject followed him through the hall, carrying his chair with him like a snail its shell.

One of the observations of Richer was on the influence of light on catalepsy and hysterical lethargy. The patient was placed before a bright focus of light, as a Drummond or electric light, on which she was requested to fix her sight. In a short time, usually a few seconds or several minutes, sometimes instantaneously, she passed into the cataleptic state. She was as one fascinated—immobile, the wide-open eye fixed on the light, the conjunctiva injected and humid. Anæsthesia was complete. If the patient was hemianæsthetic, she became totally anæsthetic. She did not present contractures. Her limbs preserved the suppleness of the normal state or nearly this—sometimes being the seat of a certain stiffness; but they acquired the singular property of preserving the attitude which one gave them. One interesting peculiarity was the influence of gesture on physiognomy. The features reflected the expression of the gesture. A tragic attitude imprinted a severe air on the physiognomy; the brows contracted. If one brought the two hands to the mouth, as in the act of sending a kiss, a smile immediately appeared on the lips. It was an example of what Braid calls the phenomena of suggestion—of Heidenhain's imitation. The state of catalepsy endured as long as the agent which produced it—that is, as long as the light continued to impress the retina.

The characteristics of the two abnormal states—catalepsy and lethargy—into which hystero-epileptics may be thrown were summarized by Richer as follows: (1) Cataleptic state: The eyes wide open; total and absolute anæsthesia; aptitude of the limbs and different parts of the body to preserve the situation in which they are placed; little or no muscular rigidity; impossibility of causing muscular contraction by mechanical excitation. (2) Lethargic state: The eyes wide open or half closed; persistent trembling of the upper eyelids; convulsion of the eyeballs; total and absolute anæsthesia; muscular hyperexcitability; the limbs, in a condition of resolution, do not preserve the situation given to them, except the provoked contracture impressed upon them.

In the experiments at Salpêtrière the hystero-epileptics were sometimes plunged into the states of catalepsy and lethargy under the influence of sonorous vibrations instead of frights.

During the state of provoked hysterical catalepsy it was found that sight and hearing could be affected by various procedures. The eyes were fixed, and seemed not to see anything. If, however, an object was slightly oscillated in the axis of the visual rays at a little distance from the eyes, soon the gaze of the patient followed these movements. The eyes, and sometimes even the head, seemed to turn at the will of the operator. Hallucinations were produced. When the look was directed upward the expression became laughing; when downward, sombre. The cataleptic state might now cease completely. The patient walked, followed the object on which her gaze was fixed, and took attitudes in relation with the hallucination suggested. Music also caused her to assume positions related with the various sentiments suggested to her by the music. Sudden withdrawal of the object from before the eyes or of the sound from the range of hearing caused a return of the catalepsy. The cataleptic patient in whom the eye was in such a state as to perceive the movements of an experimenter placed in front of her reproduced these movements exactly. At the Philadelphia Hospital I have repeated most of the experiments of Heidenhain and of Charcot and Richer.

Unilateral Catalepsy.

Hemi-catalepsy or unilateral catalepsy is sometimes observed, and has been studied both in hypnotic investigations and as a special nervous affection. Charcot and Richer found that hemi-catalepsy or lethargy may be produced on a patient, and that they may both exist simultaneously in the same subject. When, for instance, a patient was plunged into the cataleptic state under the influence of a bright light, shutting with the hand one of the eyes, the patient at once became lethargic on the same side only; the other side remained cataleptic. Heidenhain and Gruetzner studied some remarkable phenomena, which they have recorded under the name of unilateral hypnosis, in which some surprising sensory disturbances occur. They also found, among other things, a striking disturbance in the process of accommodation and in the perception of colors in the eye of the cataleptic side. In a case of hystero-epilepsy upon which I performed numerous hypnotic experiments which have been reported¹⁵ the patient nearly always presented unilateral cataleptic phenomena. These were present on the left side, the patient being subject to convulsions which were more marked on the right side, this being also much wasted.

¹⁵ Philadelphia Med. Times, Nov. 19, 1881.

I witnessed some curious unilateral cataleptoid phenomena in the case of a medical friend, who has made a note of his experience.¹⁶ He says: “In the course of some experiments on table-tipping, which were conducted mainly to satisfy the curiosity of persons who had never seen anything of the kind, I became the subject of a very peculiar and marked hypnotic influence. The ordinary tricks of tipping, answering questions, guessing numbers, etc. had been performed with the table, during the greater part of which I had been one of the circle, when my right hand began to contract so as to form an arch, and was then lifted from the table. These movements were not volitional; I was unable to control them. While my hand was in this position one of the persons sitting at the table suddenly put his hand on my forehead, and I sank back in the chair, passing into a conscious but apparently powerless state, but only for a few moments. Later in the evening the hypnotic influence in the right hand was still more distinctly manifested. If allowed to remain a short time on the table, the fingers began to vibrate vertically and horizontally, the motion finally extending to the forearm and becoming so violent as to throw the hand about in a rapid and forcible manner. While thus affected I found it utterly impossible to sign my name. I would be able to form the first letter or so, and then most extraordinary gyrations would be made. In one instance I wrote very slowly, using all the muscular control at my command, and succeeded in writing the full name, but in a form wholly different from my ordinary signature.”

¹⁶ Polyclinic, Sept. 15, 1883.

My attention was called to these phenomena, and the experiments were repeated the next week in my presence, with like results. In addition, I succeeded in forcibly placing the affected arm in various positions—bent at right angles, the hand resting on the top of the head, etc.—from which positions he was unable to move it. He seemed to have lost the connection between volition and the motor impulse. The experiments were continued for several hours at each sitting, but owing to the depressed mental state which was produced for a short time, apparently by them, they have not been repeated.

Occasionally, cases of unilateral catalepsy associated with rotatory phenomena are met with, especially in hysterical children. In 1882, I studied in the nervous dispensary of the hospital of the University of Pennsylvania an interesting case with rotatory and unilateral cataleptoid symptoms. This case has been reported by James Hendrie Lloyd.¹⁷ The patient was a boy eight years old. His paternal grandfather hanged himself. On the mother's side there was a history of tuberculosis. Two years before coming to the hospital he had had four attacks of spasms. For two weeks he had been having from twelve to twenty similar spasms daily; some of these were observed in the dispensary. “The boy's head was suddenly drawn upward and to the right to its extreme limits by the action chiefly of the sterno-cleido-mastoid muscle. The eyes turned also to the extreme right, with slight convulsive (clonic) action, and became fixed in that position, with very wide dilatation of the pupils. In a second or two he began to rotate his whole body to the right, and turned completely around, perhaps ten or twelve times. On some occasions he had fallen down, his mother said, toward the end of the spell. If taken hold of and steadied—which required but little force by the physician—the rotation could be stopped, though the head and eyes remained drawn, and the boy's arms could be placed in any desired position. If now he was once more let loose, his body again rotated, while his arms were held in true cataleptoid rigidity. The whole duration of the attack was from one half to one minute. The boy was intelligent, and said he knew what was taking place about him while he was in the fit, though he gave no satisfactory evidence of such knowledge at the time. There was no history of headache or any disease. His ears were subsequently examined and found normal. He had taken worm medicine in abundance from the family physician without results. There were no psychical traits of importance to suggest foolish or wilful simulation. The only accident had been a fall from a wagon years previously. As the patient had an adherent prepuce, Wood advised circumcision, and took pains to explain the operation to the mother. This evidently made a great impression on the child's mind, which is worthy of notice in considering the case. The potassium bromide was continued. At the third visit, which had been appointed for the operation of circumcision, the mother reported the patient much better. The boy had been having great fear of the proposed operation, and now said that he thought he could control the spells. A psychical element was thus distinctly indicated, and its likeness to chorea major to some extent increased. It was thought best, however, instead of circumcision, to break up adhesions and retract the foreskin, which was done by J. William White. At the fourth visit, after ten days, a still greater improvement was noted.”

¹⁷ Philada. Med. Times, vol. xii., June 17, 1882.

Lloyd in reporting this case discusses the physiology of the condition, and refers to other cases in medical literature. According to Brown-Séquard, the great cause of rotation phenomena is a convulsive contraction in some of the muscles on one side of the body. Carpenter believes they are due to weakness of the sensori-motor apparatus of one side. Laycock holds that the cerebellum is involved. Lloyd likens the case to chorea major. He refers to cases reported by Radcliffe¹⁸ and J. Andrew Crawford.¹⁹

¹⁸ Reynolds's System of Medicine, art. “Chorea.”

¹⁹ Cycl. of Pract. Medicine, art. “Chorea.”

At the Pennsylvania Training School for Feeble-minded Children at Elwyn is a little patient familiarly spoken of as the Dervish. I have examined this boy several times, and have frequently watched his performances. I. N. Kerlin, superintendent of the institution, has kindly furnished me with some notes of this case. The antecedents of the patient are unknown. He is about fifteen years of age, is of small stature and weight, a demi-microcephalic, epileptic, and mute idiot. His epilepsy, however, supervened only in 1884, and the seizures continue now at the rate of three or four a month. At all times he is subject to certain automatic tricks with his hands, putting and twisting them into various positions. Periodically almost during every day he gives exhibitions of the habit which has led him to be called the Dervish. He commences by tattooing his chin with his left hand; next he delicately and rapidly touches the fingers of his left hand to the wrist of the right, makes two or three salaams, and then impulsively gyrates the body from left to right. The right heel is pivotal, and the force is maintained by touches of the left toe or heel upon the floor. He will usually take from three to seven turns at a time, with a salaam or two between every series. Fifteen minutes or more will be thus consumed before he darts away toward a window, where he remains a few moments in a dazed state, from which he rouses to recommence his hand tricks. Perhaps he will select a broad belt of light in which to display his hand for visual enjoyment. He has a cataract of the right lens, and possibly partial amaurosis of the left eye. A supplemental performance sometimes indulged in is to stand at one fixed point and throw his head and shoulders from side to side, describing with the former two-thirds of a circle, the occiput being flexed backward as far as the neck will permit. These movements, rapidly made, reach three and four hundred under favorable conditions.

Kerlin regards the displays made by this boy to be the pure automatic phenomena of idiocy which have been developed to an artistic finish, and out of which the patient gets enjoyment. This enjoyment probably exists in some anæsthetic or stuporous condition of certain nerve-centres, something like the sensation of common dizziness. He does not look upon the case, therefore, as one of genuine catalepsy, but I have recorded it here in connection with the case just given because it illustrates a phase of automatism and rotation movements closely allied to cataleptoid conditions.

Catalepsy and Cataleptoid Phenomena among the Insane.

Catalepsy and cataleptoid or cataleptic phenomena are of comparatively frequent occurrence among the insane. Niemeyer says²⁰ that they are especially common among persons suffering from melancholia. Kahlbaum²¹ has described a form of insanity which he names katatonia, from the Greek κατατονος, stretching down. This disease is “characterized by alternate periods, supervening with more or less regularity, of acute mania, melancholia, and epileptoid and cataleptoid states, with delusions of an exalted character and a tendency to dramatism.”²²

²⁰ Textbook of Practical Medicine, Felix von Niemeyer, American trans., 1876, vol. ii. p. 387.

²¹ Klinische Abhandlungen über psychische Krankheiten, 1 Heft, “Die Katatonie,” Berlin, 1874.

²² A Treatise on Insanity in its Medical Relations, by William A. Hammond, M.D., New York, 1883, p. 576.

Kiernan²³ has written a valuable memoir on this affection. He has collected fifty cases, a few of which he gives in detail. Hammond and Spitzka discuss the disorder, giving new cases, in their treatises on insanity.

²³ American Journal of Insanity, July, 1877, and Alienist and Neurologist, October, 1882.

Katatonia may begin in various ways, but it usually pursues a certain cycle. First appears stuporous melancholia, accompanied or followed by cataleptoid manifestations; then a period of mania with illusions, hallucinations, and delusions. Melancholia reappears in some form, with cataleptoid, waxy condition of the muscles, and a disposition to talk in a pompous or dramatic manner; convulsions or choreic movements may be present.²⁴ Sometimes some phase of the cycle is absent.

²⁴ Hammond.

In some cases in which the peculiar cycle and special phenomena which characterize katatonia are not present marked cataleptic or cataleptoid states may be observed among the insane, either as episodes or as long-continuing conditions.

As cases illustrating cataleptoid phenomena among the insane have not yet been published in large number, and are not well understood, I will record here, under the Symptomatology of Catalepsy, some illustrative cases which have either fallen under my own observation or have been supplied to me directly by medical friends.

M. A. Avery, assistant physician to the insane department of the Philadelphia Hospital, has kindly furnished notes of the following interesting case:

T——, aged twenty, single, dressmaker. The patient was somewhat below medium height, slender and emaciated, of nervous temperament, expression melancholy. The attack of insanity for which she was admitted was her first. It began four months before admission. No satisfactory history of the attack could be obtained; she was said to have been depressed in spirits and to have delusions of poisoning. She had attempted suicide by throwing herself from the window.

Upon admission, Sept. 20, 1883, she was quiet and gentle in her manner, but much depressed; she answered questions rationally. No delusions were detected. Sept. 21st she sat quiet and motionless. Her eyes were fixed, with marked double, inward squint. She was apparently insensible to external impressions. This condition lasted about three hours, when she suddenly sprang up, rushed through the ward, and made vigorous efforts to escape. On the 22d she lay in bed in a perfectly passive state, with eyes open and fixed, but the squint had disappeared. There was a constant slight tremor of the lids. The conjunctiva was apparently insensible to touch. She seemed to be unconscious of what was going on around her. Her arms remained raised in any position in which they were placed. About three o'clock in the afternoon this condition passed away, and from that time until she went to bed at eight o'clock she was bright and cheerful and talked in a rational and intelligent manner. For five days she was quiet and melancholy, with one spell of a few hours in which she was in a passive and cataleptic state, as on the 22d.

On the 28th she stood erect with arms extended, whirling rapidly. She continued this for about half an hour, and then, after a short rest, began again. She paid no attention to what was said to her, and seemed unconscious of what took place around her. The next day she remained in a stupid condition most of the time, but occasionally sprang up and danced violently or spun round rapidly with arms extended for a few moments at a time. On the 30th her cataleptic condition was uninterrupted. She lay motionless, with pulse slow and feeble, extremities cold; her limbs were easily placed in any desired position, and remained so for about twenty minutes; then they returned slowly to a more natural and comfortable position. She continued for several days in this condition, then aroused and ate heartily. She seemed brighter and more cheerful, and talked rationally. She said that she knew all that was said and done when she seemed unconscious, and that she wanted to speak, but could not. For several weeks cataleptic symptoms prevailed, with occasional lucid intervals of a few hours. She eventually settled into a childish, demented condition.

In the insane department of the Philadelphia Hospital was a middle-aged man who remained for several years in a stuporous and cataleptoid state. On several occasions he was before the class in the clinic-room. He could not be made to speak, but remained perfectly silent in any condition in which he was placed. His head and trunk could be bowed forward, sideway, or backward; one foot could be elevated while he stood; his arms could be placed in grotesque positions. In whatever attitude he was placed he would remain for a long time. The only history that could be obtained of this man was that he had for several months been in a state of melancholia, after which he was maniacal for three or four months. He escaped from the hospital, and was brought back in the stuporous and cataleptoid condition in which he continued. He had been a masturbator.

A Dane, while on a voyage from Copenhagen, fell and broke his leg, for which he was treated in a hospital. He recovered and became a nurse in the institution. He fell in love with a female nurse, and was to be married, but the lady suddenly fell dead. He became melancholic, and three weeks afterward tried to hang himself. He also had hystero-epileptic seizures, and was for a long time in a condition of extreme stupor with cataleptoid phenomena, from which he passed into a rather excited condition. He had no special delusions, but there was a tendency to dramatism.

Another case came into the nervous wards of the Philadelphia Hospital. No history could be obtained from the patient. Whether or not he had previously suffered from melancholia could not be learned. He would retain for a long time any position in which he was placed. He also had hystero-cataleptic spells, and a peculiarity of enunciation with a tendency to pose. When asked, “How are you to-day?” he would reply, “I pre-sume-that-I-am-a-bout-the-same—that-it-is-likely-that-some-thing-has-dis-ap-peared-in-the-mind.” When asked, “How long have you been sick?” he would begin in the same way: “I-pre-sume-that-I-will-have-to-say-that-at-a-time-re-mote-ly-dis-tant;” and then he would branch off into something else.

Wilks²⁵ speaks of a man whom he saw in the asylum at Morningside who could be moulded into any position. While in bed on his back his arms and legs could be arranged in any position, and there they would remain. He also speaks of a case seen by Savage in Bethlem—a young man who kept his arms stretched out for two hours, and stood on one leg for a very long time or until he fell.

²⁵ Lectures on Diseases of the Nervous System, delivered at Guy's Hospital.

William Barton Hopkins of Philadelphia has given me brief details of a case observed by him at the Pennsylvania Hospital, which would seem to have been either one of katatonia or one of cataleptoid attacks occurring in an inebriate. The patient was an habitual moderate drinker. For three weeks before he was admitted to the hospital he had been drinking heavily. His family history showed a tendency to insanity. He showed great mental anxiety; his face was pale and had a very troubled aspect. He had no hallucinations. Two days after admission a sudden outbreak of mania occurred, in which he showed destructive and dangerous tendencies, and mechanical restraint had to be employed. Under treatment he became quiet, and was removed by his friends, having been altogether five days in the hospital. On the day of his departure, while awaiting some of his friends in the main hall, he suddenly ran up stairs, and was quickly followed by a nurse, who found him raising a window with the apparent intention of jumping out. His face at this time had lost its troubled look, and had rather a pleased but vacant appearance. While in this condition his limbs were placed in various positions, and there remained. On another occasion, while lying on the bed, his limbs and trunk were placed in various grotesque positions, and there remained. The condition of waxen flexibility was well marked; many tests were made.

To Wharton Sinkler I am indebted for the unpublished notes of the case of a woman twenty-seven years of age, who had no family history of insanity, but whose father was a highly nervous man. She had always had good health, and was of good physique. Seven years ago she had an attack of melancholia lasting four or five months; since then she had no trouble until six months since. At this time she began to be low-spirited. Then delusions came on—that she was unworthy to live; that it was wicked for her to eat, because no one else had food; that those about her were in ill-health. She refused to eat, and would not talk, and slept badly. When first seen by Sinkler she was stout and with apparently good nutrition, but was said to have lost flesh. Her face was expressionless, and she was unwilling to converse, but said she was quite well, and that her stepmother was ill and needed treatment. She was undecided in all her movements, and would stand in one spot until led to a chair, where she would remain if seated.

The patient was placed under the care of two nurses, and for a week improved daily—ate food, conversed, read aloud, and sewed. At the end of this time she was left with one nurse, but became obstinate about eating, and had an altercation with the nurse, in which she became violent. After this she gradually got into a cataleptoid state. At first she would stand for a long time in one place, and if seated in a chair would remain in any position in which she was placed. She began to have attacks in which she would lie on the floor motionless for hours. A sharp faradic current was applied to the forearms on one occasion, and she soon became relaxed. In the attacks the eyes were closed or rolled upward and fixed on the ceiling. The muscles were rigid. The arms and legs could be placed in any attitude, and would there remain. There was no analgesia: she had decided objection to pin-pricks. For two or three days she was readily aroused from the cataleptic state by electricity, but it lost its effect, and etherization was resorted to. The first time a few whiffs of ether relaxed the rigid limbs. The next day the rigidity continued until complete etherization was effected. In fact, when the breathing was loudly stertorous and the conjunctiva insensible to touch, the rigidity was complete, and it was not until a large amount of ether had been inhaled that the limbs relaxed. While under the effects of the ether a vaginal examination was made, and the uterus found normal in position and size. No evidences of self-abuse were found, nor had there been any reason for suspecting this. She continued in the condition described for many days. She was filthy in her habits, and would not use the commode, although she was made to sit on it for hours. She would have a stool on the floor or in bed immediately after rising from the commode. She seemed imbecile, and scarcely spoke, or, if she did, would say she was dead or was a baby. She would eat nothing voluntarily: food was put into her mouth, and she would swallow it, but made no effort to close the lips herself. She was fed in this way for four or five weeks. If taken up to be dressed, she would make the procedure as difficult as possible, and when dressed would not let her clothing remain buttoned, so that her clothes had to be sewed on her.

After about ten weeks a slight improvement showed itself, first in her taking food voluntarily, then in speaking. By degrees she became reasonable, and in about four months from the time she was first seen was perfectly well. The medication used was very slight, but she was thoroughly fed, took bromide of sodium and ergot for a time, and occasionally a dose of paraldehyde to produce sleep. She had two efficient nurses, who carefully carried out all directions, and who never yielded a point, but tried to be always as kind as firm. This case is instructive, not only because of its phenomena, but also because of the method of feeding and managing the patient and the result of treatment.

At a meeting of the Philadelphia Neurological Society held February 22, 1886, I exhibited, at the request of Dr. C. P. Henry, of the Insane Department of the Philadelphia Hospital, a case presenting cataleptoid symptoms, the phenomena of automatism at command, and of imitation automatism.

This patient had been recently admitted to the hospital, and no previous history had been obtained. He was a middle-aged man, not unintelligent-looking, and in fair physical condition. His condition and his symptoms had remained practically the same during the short time that had elapsed since admission. He remained constantly speechless, almost continually in one position; would not open his eyes, or at least not widely; would not take food unless forced; and his countenance presented a placid but not stupid or melancholy appearance. He had on several occasions assumed dramatic positions, posing and gesticulating. It had been discovered by Henry that the patient's limbs would remain where they were placed, and that he would obey orders automatically. The case had been regarded as probably one of katatonia, but in the absence of previous history it was not known whether or not he had passed through the cycle of mania, melancholia, etc. which constitutes this fully-developed disease. He had had since admission attacks of some severity, probably, from description, hystero-epileptic in character.

In exhibiting the patient I first placed his arms and legs and body and head in various positions, where they remained until he was commanded to place them in other positions. His mouth was opened, one eye was opened and the other was shut, and he so remained until ordered to close his mouth and eyes. In most of these experiments the acts performed were accompanied by remarks that the patient would do thus and so as he was directed.

Various experiments to show automatism at command were performed. I remarked, for instance, that the gentleman was a good violin-player, when he immediately proceeded to imitate a violin-player. In a similar way he took a lead-pencil which was handed to him and performed upon it as if it were a flute. He danced when it was asserted that he was an excellent dancer; placed his arms in a sparring position and struck out and countered on telling him that he was a prize-fighter; went through many of the movements of drilling as a soldier, such as attention, facing, marking time, and marching. He was told that he was a preacher and must preach, and immediately began to gesticulate very energetically, as if delivering an earnest exhortation. He posed and performed histrionically when told that he was an actor. He was given a glass of water and told that it was good wine, but refused to drink it, motioning it away from him. He was then told that it was very good tea, when he tasted it, evincing signs of pleasure. During all these performances he could not be induced to speak; his eyes remained closed, or at least the eyelids drooped so that they were almost entirely closed. He showed a few phenomena of imitation, as keeping time and marching to the sound of the feet of the operator.

In the nervous wards of the Philadelphia Hospital there is now an interesting case of melancholia with catalepsy and the phenomena of automatism at command—a man aged twenty-five, white, single, who for thirteen years had worked in a type-foundry. Three years before coming to the hospital he had an attack of acute lead-poisoning with wrist-drop. Two years later he had an attack of mental excitement with other evidences of insanity. He had hallucinations of sight and hearing, and thought that he heard voices accusing his sister of immorality. He at times accused this sister of trying to poison him. He believed that his fellow-workmen were trying to have him discharged. This condition lasted for six weeks, when he became gloomy and stuporous, and would make no effort to do anything for himself. His friends had to feed him. When first admitted to the nervous wards he sat in the same position all day long, with his head almost touching his knees, his arms fully extended by his sides. He would not help himself in any way. His eyes were always open, and he never winked. He never slept any during the day, but was perfectly oblivious to all surroundings. He did not speak or move out of any position in which he was placed. He could be placed in all sorts of uncomfortable positions, and would remain in them. After treatment with strong electrical currents and forced exercise he brightened considerably, and would walk, after being started, without urging. When treatment was discontinued, he relapsed into his former state. Frequent experiments have been performed with this man. Placing his limbs in any position, they will remain if a command is given to retain them. He marches, makes movements as if boxing, etc. at command.

The phenomena shown by both of these patients are those which have for many years been known and described under various names. I well remember when a boy attending a series of exhibitions given by two travelling apostles of animal magnetism, in which many similar phenomena were shown by individuals, selected apparently at haphazard from a promiscuous audience, these persons having first undergone a process of magnetizing or mesmerizing. In experiments of Heidenhain of Breslau upon hypnotized individuals many similar phenomena were investigated, and described and discussed by this physiologist under the names of automatism at command and imitation automatism. The hypnotized subjects, for instance, were made to drink ink, supposing it to be wine, to eat potatoes for pears, to thrust the hand into burning lights, etc. They also imitated movements possible for them to see or to gain knowledge of by means of hearing or in any other way. They behaved like imitating automatons, who repeated movements linked with unconscious impressions of sight or hearing or with other sensory impressions. It was noted in the experiments of Heidenhain that the subjects improved with repetition. The manifestations of my patients, although not simulated, improved somewhat by practice. Charcot, Richer, and their confrères have made similar observations on hysterical and hypnotized patients, which they discuss under the name of suggestion. Hammond²⁶ suggested the term suggignoskism, from a Greek word which means to agree with another person's mind, as a proper descriptive designation for these phenomena. In referring to persons said to be in one of the states of hypnosis, he says that he does not believe that the terms hypnotism and hypnosis are correct, as, according to his view, the hypnotic state is not a condition of artificial somnambulism; the subject, he believes, is in a condition where the mind is capable of being affected by another person through words or other means of suggesting anything. In the clinical lecture during which these opinions were expressed he is reported to have performed on four hypnotized young men experiments similar to those which were exhibited by my insane patients. His subjects, however, were not insane. A bottle was transformed by suggestion into a young lady; sulphur was transmuted into cologne; one of the subjects was bent into all sorts of shapes by a magnet; another was first turned into Col. Ingersoll and then into an orthodox clergyman, etc. In reading such reports, and in witnessing public exhibitions of the kind here alluded to, one often cannot help believing that collusion and simulation enter. Without doubt, this is sometimes the case, particularly in public exhibitions for a price; but what has been observed in the mentally afflicted, what has been shown again and again by honest and capable investigators of hypnotism, prove, however, not only the possibility, but the certainty, of the genuineness of these phenomena in some cases.

²⁶ Med. and Surg. Reporter, vol. xlv., Dec. 10, 1881.

Catalepsy and this automatism at command are sometimes confused, or they may both be present in the same case; indeed, they are probably merely gradations of the same condition, although it is well to be able to differentiate them for the purposes of more careful and accurate investigation. In automatism at command the individual does what he is directed as long as he remains in this peculiar mental condition. In experimenting upon him, his arms or legs, his trunk or head, may be put in various positions, and if commanded to retain them in these positions he will do so, or he will, at command, put them in various positions, there to stay until a new order is given. Imitation automatism occurs also in such cases; patients will imitate what they see or hear. These cases differ only from those of genuine catalepsy in that they do not seem to present true waxen flexibility. The phenomena presented are those which result from control over an easily-moulded will, rather than phenomena due to the fact that the will is entirely in abeyance.

PATHOLOGY—Attempts to explain the nature of catalepsy leave one in a very uncertain and irritable frame of mind. Thus, we are told very lucidly that most authors are inclined to the opinion that the cataleptic rigidity is only an increase of the normal tonus of the voluntary muscles occurring occasionally in the attacks. What appears to be present in all genuine cases of catalepsy is some absence or abeyance of volition or some concentration and circumscription of cerebral activity. The study of the phenomena of catalepsy during hypnosis throws some light upon the nature of catalepsy. Heidenhain's theory of hypnotism is that in the state of hypnosis, whether with or without cataleptic manifestations, we have inhibition of the activity of the ganglion-cells of the cerebral cortex. Herein is the explanation of many cataleptic phenomena even in complicated cases. In hysteria and in catalepsy the patient, dominated by an idea or depressed in the volitional sphere by emotional or exhausting causes, no longer uses to their full value the inhibitory centres. When organic disease complicates catalepsy, it probably acts to inhibit volition by sending out irritative impulses from the seat of lesion.

DURATION.—Usually, attacks of catalepsy recur over a number of years; but even when this is the case the seizures are not as frequent, as a rule, as those of hystero-epileptic paroxysms. Uncomplicated cases of catalepsy, or those cases which occur in the course of hystero-epilepsy, usually preserve good general health.

Of the duration of attacks of catalepsy it need only be said that they may last from a few seconds or minutes to hours, days, weeks, or even months. The liability to the recurrence of cataleptic attacks may last for years, and then disappear.

DIAGNOSIS.—In the first place, the functional nervous disorder described as catalepsy must be separated from catalepsy which occurs as a symptom in certain organic diseases. It is also necessary to be able to determine that a patient is or is not a true katatonic.

It must not be forgotten that genuine catalepsy is very rare. Mitchell at a recent meeting of the Philadelphia Neurological Society said that in his lifetime he had seen but two cases of genuine catalepsy—one for but a few moments before the condition passed off. The other was most extraordinary. Many years ago he saw a young lady from the West, and was told not to mention a particular subject in her presence or very serious results would ensue. He did mention this subject, rather with the desire to see what the result would be. She at once said, “You will see that I am about to die.” The breath began to fail, and grow less and less. The heart beat less rapidly, and finally he could not distinguish the radial pulse, but he could at all times detect the cardiac pulsation with the ear. There was at last no visible breathing, although a little was shown by the mirror. She passed into a condition of true catalepsy, and to his great alarm remained in this state a number of days, something short of a week. Throughout the whole of this time she could not take food by the mouth. Things put in the mouth remained there until she suddenly choked and threw them out. She apparently swallowed very little. She had to be nourished by rectal alimentation. She was so remarkably cataleptic that if the pelvis were raised, so that the head and heels remained in contact with the bed, she would retain this position of opisthotonos for some time. He saw her remain supported on the hands and toes, with feet separated some distance, with the face downward, for upward of half an hour. She remained as rigid as though made of metal. On one occasion while she was lying on her back he raised the arm and disposed of the fingers in various ways. As long as he watched the fingers they remained in the position in which they had been placed. At the close of half an hour the hand began to descend by an excessively slow movement, and finally it suddenly gave way and fell. Not long after this she began to come out of the condition, and quite rapidly passed into hysterical convulsions, out of which she came apparently well. He was not inclined to repeat the experiment.

Catalepsy is to be diagnosticated from epilepsy. It is not likely that a grave epileptic seizure of the ordinary type will be mistaken by an observer of even slight experience for a cataleptic attack. It is some of the aberrant or unusual types of epilepsy that are most closely allied to or simulate catalepsy. Cataleptic or cataleptoid conditions undoubtedly occur regularly or irregularly in the course of a case of epilepsy, but I do believe that it is true, as some observers contend, that between catalepsy and some types of true epilepsy no real distinction can be made. Hazard,²⁷ in commenting on a case reported by Streets,²⁸ holds that no difference can be made between the attacks detailed and those forms of epilepsy described as petit mal.

²⁷ St. Louis Clin. Rec., iii. 1876, p. 125.

²⁸ “Case of Natural Catalepsy,” by Thomas H. Streets. M.D., Passed Assistant Surgeon U. S. N., in the American Journal of Medical Sciences for July, 1876.

The case was that of a sailor aged forty-two years, of previous good health. The attacks to be described followed a boiler explosion, by which he was projected with great force into the water, but from which he received no contusion nor other appreciable injury. There was no history of any nervous trouble in his family. It was the patient's duty to heave the lead. The officer noticed that he was neglecting his business, and spoke to him in consequence, but he paid no attention to what was said to him. “He was in the attitude he had assumed in the act of heaving the lead, the left foot planted in advance, the body leaning slightly forward, the right arm extended, and the line held in the left hand. The fingers were partially flexed, and the sounding-line was paying out through them in this half-closed condition. The eyes were not set and staring, as is the case in epilepsy, but they were moving about in a kind of wandering gaze, as in one lost in thought with the mind away off. The whole duration of the trance was about five minutes.”

Dickson²⁹ reports a very striking case, and in commenting on it holds to the same views. The patient had apparently suffered from some forms of mania with delusions. She was found at times sitting or standing with her body and limbs as rigid as if in rigor mortis, and her face blanched. These spells were preceded by maniacal excitement and followed by violence. On being questioned about the attacks, she said that chloroform had been given her. Numerous experiments were performed with her. Her arms and hands were placed in various positions, in all of which they remained; but it was necessary to hold them for a few moments in order to allow the muscles to become set. She was anæsthetic. After recovering she said that she remembered being on the bed, but did not know how she came there; also, that she had been pricked with a pin, and that her fit had been spoken of as cataleptic. Her mind became more and more affected after each attack, and she finally became more or less imbecile. From the facts observed with reference to this case, Dickson thinks that we may fairly conclude that the mental disturbance in either epilepsy or catalepsy is identical, and results from the same cause—viz. the anæmia and consequent malnutrition of the cerebral lobes; while its termination, dementia, is likely to be the same in either case; also, that catalepsy, instead of being a special and distinct form of nervous disorder, is to be considered as a specific form of epilepsy, and to be regarded as epilepsy, in the same manner as le petit mal is considered epilepsy, and a result of the same proximate cause; the difference in the muscular manifestation bearing comparison with any other specific form of epilepsy, and occurring in consequence of one or other particular cerebral centre becoming more or less affected.

²⁹ “On the Nature of the Condition known as Catalepsy.” by J. Thompson Dickson, M.A., M.B. (Cantab., etc.), British Med. Journ., vol. ii., Dec. 25, 1869.

I do not believe that this ground is well taken. The conditions present in petit mal are sometimes somewhat similar to, but not identical with, those of genuine catalepsy. In the first place, the loss of consciousness, although more complete and more absolute—or rather, strictly speaking, more profound—than in genuine catalepsy, is of much briefer duration. The vertigo or vertiginous phenomena which always accompany genuine petit mal are rarely if ever present in catalepsy. To say that the mental disturbance in catalepsy and in epilepsy is identical is to admit an imperfect acquaintanceship with both disorders. The mental state during the attack of either disorder it is only possible to study by general inspection or by certain test-experiments.

Tetanus is not likely, of course, to be mistaken for catalepsy, but there is a possibility of such an occurrence. The differential diagnosis already given between hystero-epilepsy and tetanus will, however, furnish sufficient points of separation between catalepsy and tetanus.

Catalepsy has been supposed to be apoplexy, or apoplexy catalepsy. The former mistake is, of course, more likely to be made than the latter. A careful study of a few points should, however, be sufficient for the purposes of clear differentiation. The points of distinction given when discussing the diagnosis of hysterical and organic palsies of cerebral origin will here apply. In true apoplexy certain peculiar changes in pulse, respiration, and temperature can always be expected, and these differ from those noted in catalepsy. The stertorous breathing, the one-sided helplessness, the usually flushed face, the conjugate deviation of the eyes and head, the loss of control over bowels and bladder, are among the phenomena which can be looked for in most cases of apoplexy, and are not present in catalepsy.

It is hardly probable that a cataleptic will often be supposed to be drunk, or a man intoxicated to be a cataleptic; but cases are on record in which doubts have arisen as to whether an individual was dead drunk or in a cataleptic stupor. The labored breathing, the fumes of alcohol, the absence of waxen flexibility, the possibility of being half aroused by strong stimuli, will serve to make the diagnosis from catalepsy. The stupor, the anæsthesia, the partial loss of consciousness, the want of resistance shown by the individual deeply intoxicated, are the reasons why occasionally this mistake may be made.

Catalepsy is simulated not infrequently by hysterical patients. Charcot and Richer³⁰ give certain tests to which they put their cataleptic subjects with the view of determining as to the reality or simulation of the cataleptic state. They say that it is not exactly true that if in a cataleptic subject the arm is extended horizontally it will maintain its position during a time sufficiently long to preclude all supposition of simulation. “At the end of from ten to fifteen minutes the member begins to descend, and at the end of from twenty to twenty-five minutes at the most it resumes the vertical position.” These also are the limits of endurance to which a vigorous man endeavoring to preserve the same position will attain. They have therefore resorted to certain experimental tests. The extremity of the extended limb is attached to a tambour which registers the smallest oscillations of the member, while at the same time a pneumograph applied to the chest gives the curve of respiratory movements. In the case of the cataleptic the lever traces a straight and perfectly regular line. In the case of the simulator the tracings at first resemble those of the cataleptic, but in a few minutes the straight line changes into a line sharply broken, characterized by instants of large oscillations arranged in series. The pneumograph in the case of the cataleptic shows that the respirations are frequent and superficial, the end of the tracings resembling the beginning. In the case of the simulator, in the beginning the respiration is regular and normal, but later there may be observed irregularity in the rhythm and amplitude of the respiratory movements—deep and rapid depressions, indicative of the disturbance of respiration that accompanies the phenomena of effort. “In short, the cataleptic gives no evidence of fatigue; the muscles yield, but without effort, and without the concurrence of the volition. The simulator, on the contrary, committed to this double test, finds himself captured from two sides at the same moment.”

³⁰ Journal of Nervous and Mental Diseases, vol. x., No. 1, January, 1883.

Chambers³¹ says that no malingerer could successfully feign the peculiar wax-like yielding resistance of a cataleptic muscle. He speaks of using an expedient like that of Mark's. Observing that really cataleptic limbs finally, though slowly, yield to the force of gravity and fall by their own weight, he attached a heavy body to the extended hand of a suspected impostor, who by an effort of will bore it up without moving. The intention of the experiment was explained, and she confessed her fraud. This rough test, although apparently different, is in reality similar to that of Charcot and Richer. In both proof of willed effort is shown.

³¹ Reynolds's System of Medicine, vol. ii., No. 108.

It must not be forgotten that in catalepsy, as has been already noted in hysteria, real and simulated phenomena may commingle in the same case; also, that upon a slight foundation of genuine conditions a large superstructure of simulated or half-simulated phenomena may be reared.

PROGNOSIS.—The prognosis of catalepsy is on the whole favorable. It must be admitted, however, that owing to the presence of neurotic or neuropathic constitution a tendency to relapse is present. Hystero-catalepsy tends to recover with about the same frequency as any of the other forms of grave hysteria. Those cases which can be traced to some special reflex or infectious cause, as worms, adherent prepuce, fecal accumulations, scars, malaria, etc., give relatively a more favorable prognosis. Cases complicated with phthisis, marasmus, cancer, insanity, etc. are of course relatively unfavorable.

TREATMENT.—The treatment of the cataleptic seizure is not always satisfactory, a remedy that will succeed in one case failing in another. Niemeyer says that in case of a cataleptic fit he should not hesitate to resort to affusion of cold water or to apply a strong electrical current, and, unless the respiration and pulse should seem too feeble, to give an emetic. The cold douche to the head or spine will sometimes be efficacious. In conditions of great rigidity and coldness of surface Handfield Jones recommends a warm bath, or, still better, wet packing. Chambers quotes the account of a French patient who without success was thrown naked into cold water to surprise him, after having been puked, purged, blistered, leeched, and bled. This treatment is not to be recommended unless in cases of certain simulation, and even here it is of doubtful propriety and utility. If electricity is used, it should be by one who thoroughly understands the agent. A galvanic current of from fifteen to thirty cells has been applied to the head with instantaneous success in hystero-epileptic and hystero-cataleptic seizures. A strong, rapidly-interrupted faradic current, or a galvanic current to the spine and extremities, sometimes succeeds and sometimes fails. Rosenthal reports that Calvi succeeded in relieving cataleptic stiffness in one case by an injection of tartar emetic into the brachial vein—a procedure, however, not to be recommended for general use. Inhalations of a few drops of nitrate of amyl is a remedy that should not be passed by without a trial; it is of great efficacy in the hysteroidal varieties. Inhalation of ammonia may also be tried. A hypodermic injection of three minims of a 1 per cent. solution of nitroglycerin, as recommended for severe hystero-epileptic seizures, would doubtless be equally efficient in catalepsy.

Music has been used to control hysterical, hystero-epileptic, and cataleptic seizures. The French cases reported have all been of the convulsive types without loss of consciousness and those varieties in which the special sensibility sometimes persists, as in hystero-catalepsy, lethargy, and somnambulism. Music has been used as medicine from the times of Pythagoras to the present, although it can hardly be claimed to have attained a position of much prominence as a therapeutic agent.

In one case a vigorous application of fomentations of turpentine to the abdomen was promptly efficacious in bringing a female patient out of a cataleptic seizure.

Meigs, whose case of catalepsy produced by opium has been reported under Etiology, suggests that purgative medicines, used freely in the treatment of his case, might be advantageously resorted to in any case of catalepsy.

Powerful tonics, such as quinine, iron, salts of zinc and silver, should be used in connection with nutrients, such as cod-liver oil, peptonized beef preparations, milk, and cream, to build up cataleptic cases in the intervals between the attacks.