Chapter 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Children's Hospital and Prosector of Anatomy at the University of Pennsylvania, has kindly put into my hands the unpublished notes of a highly interesting case of catalepsy or automatism at command, or of both, in a child two and a half years old.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.

[Footnote 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.]

{319} 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. Mancini[7] 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.

[Footnote 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 periodical[8] 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.

[Footnote 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 {320} often-told story of epidemic hysteria, but more especially by accounts given of certain peculiar endemics of catalepsy. Handfield Jones[9] 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.”

[Footnote 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. Flint[10] 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 {321} greater or less depths of unconsciousness, but some degree of unconsciousness or of obtunded consciousness is necessary to the existence of true catalepsy.

[Footnote 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.

[Footnote 11: _Op. cit._]

{322} 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 hypnotism[12] 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 Heidenhain[13] and of Charcot and Richer[14] which relate to the production of a cataleptic or cataleptoid state, and to the phenomena which take place in this state.

[Footnote 12: _Am. Journ. Med. Science_, Jan., 1882.]

[Footnote 13: _Animal Magnetism: Physiological Observations_, by Rudolph Heidenhain, Prof. Physiology in the University of Breslau, London, 1880.]

[Footnote 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. {323} 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.

{324} 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 reported[15] {325} 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.

[Footnote 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.”

[Footnote 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 {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.