of the feet or to the spine, are occasionally efficacious. The
galvanic current to the head has been extensively employed in the
service of Charcot to arrest hysterical and hystero-epileptic attacks
of the grave variety. One electrode is applied to the forehead, the
other to any convenient place upon the body, as the leg, the ovarian
region, or the spine. The current is applied continuously for several
minutes, or voltaic alternations are made. This method has been used
with success in a few instances, but should never be resorted to by a
physician uncertain of his diagnosis or one practically unfamiliar
with the powers and properties of the electrical current.
{312} The question of oöphorectomy for the relief of hystero-epilepsy
is one of increasing importance in these days of major surgery. At the
meeting of the American Neurological Association (June, 1884) G. L.
Walton read a paper[14] in which he concludes that hysteria is
sometimes set up by ovarian irritation, and can be relieved by
removing the offending organ. He cited a single case. Carsten[15]
concludes that it is criminal neglect not to perform Battey's
operation in cases which fail to be benefited by other treatment. In
the discussion which followed the reading of this paper the subject
was well traversed by Spitzka of New York, Putnam of Boston,
Putnam-Jacobi of New York, and others. Spitzka referred to one case of
Israel's of Breslau, in which a patient was cured of hystero-epilepsy
by a sham operation—a superficial incision in the parietes of the
abdomen. Under the title of castration in hysteria the _Lancet_[16]
tells of an hysterical patient who had suffered for years from
obstinate vomiting and severe ovarian pain. She became extremely weak,
and finally consented to spaying as the only hope. The
operation—performed under chloroform with antiseptic precautions—was a
mockery, the skin only being incised; she was, however, perfectly
cured of her hysterical symptoms.
[Footnote 14: “A Contribution to the Study of Hysteria as Bearing on
the Question of Oöphorectomy.”]
[Footnote 15: Quoted by Walton from _American Journal of Obstetrics_,
March, 1883.]
[Footnote 16: Vol. ii. p. 588.]
In two clinical lectures published in the _Philadelphia Medical
Times_[17] I have given the histories of two cases of hystero-epilepsy
in which oöphorectomy was resorted to for hystero-epilepsy. In the
first of these cases, in which clitoridectomy was also performed,
nymphomania, which was a distressing symptom, was benefited, but even
this was not completely cured. The following is the patient's own
statement: “Since the removal of the ovaries I have been able to
control the desire when awake, but at times in my sleep I can feel
something like an orgasm taking place. My experience leads me to say
that my cure (?) is not due to the absence of the ovaries; there is no
diminution of the sexual feeling. There would be as much excitement of
the parts if the clitoris were still there. If my will gave way, I
would be as bad as ever.” Her general mental and nervous condition is
much the same as before the operations. She is still dominated by
morbid ideas, still unable to take up any vocation which demands
persistence, and still the frequent subject of hystero-epileptic
seizures.
[Footnote 17: April 18 and May 30, 1885.]
The second of these cases was a young girl about seventeen years old
who had never menstruated. She had had epileptic or hystero-epileptic
seizures for several years. An operation was performed in which the
ovaries and Fallopian tubes were removed. Twelve days after the
operation, from which she made a good recovery, she had four
convulsive seizures. She had several attacks subsequently, and then
for a considerable period was exempt. She had, however, acute
inflammatory rheumatism, with endocarditis and valvular trouble. About
seven months after the operation she had several severe convulsions
with loss of consciousness, and died about a year after the operation,
having had many severe seizures during the last few weeks of her life.
There is no warrant either in experience or in a study of the subject
for spaying hysterical girls who have never menstruated. In a case
{313} diagnosticated as hysterical rhythmical chorea removal of the
ovaries was advised by a distinguished specialist. The girl's trouble
came on at about the age of thirteen years. She had never menstruated
properly, although on one occasion, after several weeks of electric
treatment, she had a slight show for a few days. It was proposed to
remove the ovaries in this case on some general principle of given
hysterical trouble; the ovaries must go. In this case, as in the last,
it would have been far better to have put in a good pair of ovaries,
or to have developed these rudimentary organs into health and
activity.
With reference to oöphorectomy for hystero-epilepsy or any form of
grave hysteria it may be concluded—1, It is only rarely justifiable;
2, it is not justifiable in the case of girls who have not
menstruated; 3, when disease of the ovaries can be clearly made out by
local objective signs, it is sometimes justifiable; 4, it is
justifiable in some cases with violent nymphomania; 5, the operation
is frequently performed without due consideration, and the statistics
of the operation are peculiarly unreliable.
When we come to consider the treatment of the disease
hystero-epilepsy, the practical importance of the distinction between
this affection and true epilepsy becomes apparent. Cures of
hystero-epilepsy are not rare. The original cases here reported have
all apparently recovered. Grave hysteria is sometimes cured
spontaneously, either by gradual disappearance with the progress of
age, or suddenly because of some violent impression or under the
influence of unknown causes. One of the worst cases in the service of
Charcot has shown a gradual diminution of the hystero-epileptic
manifestations with the advance of age. In another case under the
influence of strong moral impressions the disease disappeared at a
stroke. The affection, however, should not be abandoned to nature, as
treatment is often of value.
The hydrotherapeutic method of treatment has been found of the
greatest service. Hydrotherapy must be methodically employed by
experienced hands. A number of cases cited by Richer were cured at
hydrotherapeutic institutions. Limited success has followed the use of
metallo-therapy. Besides metallic plates, the same results may be
obtained with other physical agents, to which have been given the name
of æsthesiogenic agents. Among these are feeble electric currents,
vibrations of a tuning-fork, static electricity, etc.
Static electricity has a position of undoubted importance in the
treatment of hystero-epilepsy in some of its phases. Those who have
walked in the wards and visited the laboratories of Salpêtrière will
recall the enormous insulated stools to which are brought troops of
hystero-epileptic patients, who, to save time, are given a vigorous
simultaneous charge of electricity. Even this wholesale plan of
treatment is sometimes markedly efficacious. Vigoroux recommends
static electricity as an æsthesiogenic agent, and regards it as the
most valuable of all agents of this character.
Those drugs should be resorted to which have a tonic influence on the
nervous system. Potassium bromide, as has already been indicated, is
not efficacious. More is to be hoped from tonics and antispasmodics,
such as valerian, iron, salts of silver, zinc, copper, sodium, and
gold chlorides, etc. Good hygienic influences, moral, mental, and
physical, are of the utmost importance.
{314}
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,
Laycock[1] 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, {315} 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.
[Footnote 1: _A Treatise on the Nervous Diseases of Women_, by Thomas
Laycock, M.D., London, 1840.]
[Footnote 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.
[Footnote 3: _American Journal of Medical Science_, N. S. lxxxix.,
1885, p. 450.]
Monti[4] 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
{316} 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. Hovey[5] of Rochester, New York,
reports an interesting case of catalepsy in a boy eight years old.
[Footnote 4: _Gerhardt's Handb. d. Kinderk._, vol. v., L. P., 186 _et
seq._, quoted by Jacobi.]
[Footnote 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 {317} 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 {318} 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.