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

by Unknown

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.