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 {326} 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.”
[Footnote 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
Radcliffe[18] and J. Andrew Crawford.[19]
[Footnote 18: _Reynolds's System of Medicine_, art. “Chorea.”]
[Footnote 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 {327} 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 says[20] that they are
especially common among persons suffering from melancholia.
Kahlbaum[21] 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]
[Footnote 20: _Textbook of Practical Medicine_, Felix von Niemeyer,
American trans., 1876, vol. ii. p. 387.]
[Footnote 21: _Klinische Abhandlungen über psychische Krankheiten_, 1
Heft, “Die Katatonie,” Berlin, 1874.]
[Footnote 22: _A Treatise on Insanity in its Medical Relations_, by
William A. Hammond, M.D., New York, 1883, p. 576.]
Kiernan[23] 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.
[Footnote 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 {328} 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.
[Footnote 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, {329} 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.
Wilks[25] 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.
[Footnote 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 {330} 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 {331} 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.
{332} 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.