Chapter M: A. Avery, assistant physician to the insane department of the (1)

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.

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 {333} 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. Hammond[26] 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.

[Footnote 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 {334} which result from control over an easily-moulded will, rather than phenomena due to the fact that the will is entirely in abeyance.

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

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

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

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

It must not be forgotten that genuine catalepsy is very rare. Mitchell at a recent meeting of the Philadelphia Neurological Society said that in his lifetime he had seen but two cases of genuine catalepsy—one for but a few moments before the condition passed off. The other was most extraordinary. Many years ago he saw a young lady from the West, and was told not to mention a particular subject in her presence or very serious results would ensue. He did mention this subject, rather with the desire to see what the result would be. She at once said, “You will see that I am about to die.” The breath began to fail, and grow less and less. The heart beat less rapidly, and finally he could not distinguish the radial pulse, but he could at all times detect the cardiac pulsation with the ear. There was at last no visible breathing, although a little was shown by the mirror. She passed into a condition of true catalepsy, and to his great alarm remained in this state a number of days, something short of a week. Throughout the whole of this time she could not take food by the mouth. Things put in the mouth remained there until she suddenly choked and threw them out. She apparently swallowed very little. She had to be nourished by rectal alimentation. She was so remarkably cataleptic that if the pelvis were raised, so that {335} the head and heels remained in contact with the bed, she would retain this position of opisthotonos for some time. He saw her remain supported on the hands and toes, with feet separated some distance, with the face downward, for upward of half an hour. She remained as rigid as though made of metal. On one occasion while she was lying on her back he raised the arm and disposed of the fingers in various ways. As long as he watched the fingers they remained in the position in which they had been placed. At the close of half an hour the hand began to descend by an excessively slow movement, and finally it suddenly gave way and fell. Not long after this she began to come out of the condition, and quite rapidly passed into hysterical convulsions, out of which she came apparently well. He was not inclined to repeat the experiment.

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

[Footnote 27: _St. Louis Clin. Rec._, iii. 1876, p. 125.]

[Footnote 28: “Case of Natural Catalepsy,” by Thomas H. Streets. M.D., Passed Assistant Surgeon U. S. N., in the _American Journal of Medical Sciences_ for July, 1876.]

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

Dickson[29] reports a very striking case, and in commenting on it holds to the same views. The patient had apparently suffered from some forms of mania with delusions. She was found at times sitting or standing with her body and limbs as rigid as if in rigor mortis, and her face blanched. These spells were preceded by maniacal excitement and followed by violence. On being questioned about the attacks, she said that chloroform had been given her. Numerous experiments were performed {336} with her. Her arms and hands were placed in various positions, in all of which they remained; but it was necessary to hold them for a few moments in order to allow the muscles to become set. She was anæsthetic. After recovering she said that she remembered being on the bed, but did not know how she came there; also, that she had been pricked with a pin, and that her fit had been spoken of as cataleptic. Her mind became more and more affected after each attack, and she finally became more or less imbecile. From the facts observed with reference to this case, Dickson thinks that we may fairly conclude that the mental disturbance in either epilepsy or catalepsy is identical, and results from the same cause—viz. the anæmia and consequent malnutrition of the cerebral lobes; while its termination, dementia, is likely to be the same in either case; also, that catalepsy, instead of being a special and distinct form of nervous disorder, is to be considered as a specific form of epilepsy, and to be regarded as epilepsy, in the same manner as le petit mal is considered epilepsy, and a result of the same proximate cause; the difference in the muscular manifestation bearing comparison with any other specific form of epilepsy, and occurring in consequence of one or other particular cerebral centre becoming more or less affected.

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

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

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

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

It is hardly probable that a cataleptic will often be supposed to be drunk, or a man intoxicated to be a cataleptic; but cases are on record in which doubts have arisen as to whether an individual was dead drunk or in a cataleptic stupor. The labored breathing, the fumes of alcohol, the absence of waxen flexibility, the possibility of being half aroused by {337} strong stimuli, will serve to make the diagnosis from catalepsy. The stupor, the anæsthesia, the partial loss of consciousness, the want of resistance shown by the individual deeply intoxicated, are the reasons why occasionally this mistake may be made.

Catalepsy is simulated not infrequently by hysterical patients. Charcot and Richer[30] give certain tests to which they put their cataleptic subjects with the view of determining as to the reality or simulation of the cataleptic state. They say that it is not exactly true that if in a cataleptic subject the arm is extended horizontally it will maintain its position during a time sufficiently long to preclude all supposition of simulation. “At the end of from ten to fifteen minutes the member begins to descend, and at the end of from twenty to twenty-five minutes at the most it resumes the vertical position.” These also are the limits of endurance to which a vigorous man endeavoring to preserve the same position will attain. They have therefore resorted to certain experimental tests. The extremity of the extended limb is attached to a tambour which registers the smallest oscillations of the member, while at the same time a pneumograph applied to the chest gives the curve of respiratory movements. In the case of the cataleptic the lever traces a straight and perfectly regular line. In the case of the simulator the tracings at first resemble those of the cataleptic, but in a few minutes the straight line changes into a line sharply broken, characterized by instants of large oscillations arranged in series. The pneumograph in the case of the cataleptic shows that the respirations are frequent and superficial, the end of the tracings resembling the beginning. In the case of the simulator, in the beginning the respiration is regular and normal, but later there may be observed irregularity in the rhythm and amplitude of the respiratory movements—deep and rapid depressions, indicative of the disturbance of respiration that accompanies the phenomena of effort. “In short, the cataleptic gives no evidence of fatigue; the muscles yield, but without effort, and without the concurrence of the volition. The simulator, on the contrary, committed to this double test, finds himself captured from two sides at the same moment.”

[Footnote 30: _Journal of Nervous and Mental Diseases_, vol. x., No. 1, January, 1883.]

Chambers[31] says that no malingerer could successfully feign the peculiar wax-like yielding resistance of a cataleptic muscle. He speaks of using an expedient like that of Mark's. Observing that really cataleptic limbs finally, though slowly, yield to the force of gravity and fall by their own weight, he attached a heavy body to the extended hand of a suspected impostor, who by an effort of will bore it up without moving. The intention of the experiment was explained, and she confessed her fraud. This rough test, although apparently different, is in reality similar to that of Charcot and Richer. In both proof of willed effort is shown.

[Footnote 31: _Reynolds's System of Medicine_, vol. ii., No. 108.]

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

PROGNOSIS.—The prognosis of catalepsy is on the whole favorable. It must be admitted, however, that owing to the presence of neurotic or neuropathic constitution a tendency to relapse is present. {338} Hystero-catalepsy tends to recover with about the same frequency as any of the other forms of grave hysteria. Those cases which can be traced to some special reflex or infectious cause, as worms, adherent prepuce, fecal accumulations, scars, malaria, etc., give relatively a more favorable prognosis. Cases complicated with phthisis, marasmus, cancer, insanity, etc. are of course relatively unfavorable.

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

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

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

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

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

{339}

ECSTASY.

BY CHARLES K. MILLS, M.D.

DEFINITION.—Ecstasy is a derangement of the nervous system characterized by an exalted visionary state, absence of volition, insensibility to surroundings, a radiant expression, and immobility in statuesque positions. The term ecstasy is derived from two Greek words, _ἐκ_ and _στάσις_, which means to be out of one's senses or to be beside one's self. Commonly, ecstasy and catalepsy, or ecstasy and hystero-epilepsy, or all three of these disorders, alternate, coexist, or occur at intervals in the same individual. Occasionally, however, the ecstatic seizure is the only disorder which attracts attention. Usually, in ecstasy the concentration of mind and the visionary appearance have reference to religious or spiritual objects.

SYNONYMS.—Trance is sometimes used as synonymous with ecstasy. While, however, ecstasy is a trance-like condition, conditions of trance occur which are not forms of ecstasy. Other synonyms are Carus-extasis, Catochus, Catalepsia spuria.

HISTORY AND LITERATURE.—Accounts of cases of ecstasy abound in both ancient and modern medical and religious literature. The epidemics of the Middle Ages, the days of the New England witchcraft, the revivals in England and America, have afforded many striking illustrations. Not a few special cases of ecstasy have become historical. Elizabeth of Hungary and Joan of Arc were both cataleptics and ecstatics. Saint Gertrude, Saint Bridget, Saint Theresa, Saint Catharine, and many other saintly individuals of minor importance have owed their canonization and their fame to the facility with which they could pass into states of ecstasy, catalepsy, or hystero-epilepsy.

Gibbon[1] has well described the occurrence of ecstasy in the monks of the Oriental Church in the following passage: “The fakirs of India and the monks of the Oriental Church were alike persuaded that in total abstraction of the faculties of the mind and body the purer spirit may ascend to the enjoyment and vision of the Deity. The opinions and practices of the monasteries of Mount Athos will be best represented in the words of an abbot who flourished in the eleventh century. ‘When thou art alone in thy cell,’ says the ascetic teacher, ‘shut thy door and seat thyself in a corner; raise thy mind above all things vain and transitory; recline thy beard and thy chin on thy breast; turn thine eyes and thy thoughts toward the middle of thy belly, the region of the navel; {340} and search the place of the heart, the seat of the soul. At first all will be dark and comfortless; but if you persevere day and night you will feel an ineffable joy; and no sooner has the soul discovered the place of the heart than it is involved in a mystic and ethereal light.’ This light, the production of a distempered fancy, the creature of an empty stomach and an empty brain, was adored by the Quietists as the pure and perfect essence of God himself; and as long as the folly was confined to Mount Athos the simple solitaries were not inquisitive how the divine essence could be a material substance, or how an immaterial substance could be perceived by the eyes of the body. But in the reign of the younger Andronicus the monasteries were visited by Barlaam, a Calabrian monk, who was equally skilled in philosophy and theology, who possessed the languages of the Greeks and Latins, and whose versatile genius could maintain their opposite creeds according to the interest of the moment. The indiscretion of an ascetic revealed to the curious traveller the secrets of mental prayer, and Barlaam embraced the opportunity of ridiculing the Quietists, who placed the soul in the navel—of accusing the monks of Mount Athos of heresy and blasphemy.”

[Footnote 1: _Decline and Fall of the Roman Empire_, by Edward Gibbon, Esq., in 8 vols., vol. viii. p. 64, London, 1838.]

Some of Swedenborg's supernatural visions were, so far as can be judged, simply accounts of attacks of ecstasy; and of like character were the visions of John Engelbrecht as related by Arnold.[2]

[Footnote 2: _Observations_, etc., London, 1806.]

In a very curious American book[3] published in 1815 a history is given of the wonderful performances of a woman named Rachel Baker, who was undoubtedly in the habit of passing into conditions of religious ecstasy, during which were present many of the phenomena which occur in ecstatics, Catholic or Protestant, religious or otherwise. When seventeen years old she witnessed the baptism of a young lady, which impressed her strongly and caused her to become much dejected and affected about her religious state. She began to have evening reveries or night talks which soon attracted attention. She united with the Presbyterian Church. These reveries after a while expanded into evening exercises which began with prayer, after which she exhorted and made a closing prayer. She removed from Marcellus to Scipio, New York, in 1813, and shortly afterward, in the same year, she went to New York City for medical advice. While there she gave many opportunities to witness her powers when in what her editors quaintly call her somnial paroxysms. Her discourses were good illustrations of what is sometimes termed trance-preaching.

[Footnote 3: _Devotional Somnium; or, A Collection of Prayers and Exhortations Uttered by Miss Rachel Baker_, by Several Medical Gentlemen, New York, 1815.]

One of the most interesting parts of this curious book is a dissertation by Samuel L. Mitchill, M.D., on the function of somnium. He says there are three states of animal existence—wakefulness, sleep, and vision or dream. The definition of somnium, which he quotes from Cicero, is a very fair one to be applied to some of the conditions which we now speak of under such heads as lethargy, trance, ecstasy, etc. “By somnium,” he says, “may be understood the performance of certain mental and bodily actions, which are usually voluntary, without the direction or government of the will or without the recollection afterward that such volition existed.” He divides somnium into symptomatic and {341} idiopathic. The symptomatic somnium occurs from indigestion, the nightmare, from affusions of water into the chest, from a feverish state of the body, from debility with fasting, from fresh and vivid occurrences, etc. The idiopathic somnium is divided into somnium from abstraction, somnium with partial or universal lunacy, with walking, with talking, with invention, with mistaken impressions of sight and of hearing, with singing, with ability to pray and preach or to address the Supreme Being and human auditors in an instructive and eloquent manner, without any recollection of having been so employed, and with utter incompetency to perform such exercises of devotion and instruction when awake. To the last of these affections he refers the case of Rachel Baker, whose devotional somnium he describes.

A number of other curious cases are recorded in this book: that of Job Cooper, a weaver who flourished in Pennsylvania about the year 1774; that of the Rev. Dr. Tennent, who came near having a funeral in one of his states of trance, who has related his own views, apprehensions, and observations while in a state of suspended animation. He saw hosts of happy beings; he heard songs and hallelujahs; he felt joy unutterable and full of glory: he was, in short, in a state of ecstatic trance. Goldsmith's history of Cyrillo Padovando, a noted sleep-walker, who was a very moral man while awake, but when sleep-walking a first-class thief, robber, and plunderer of the dead, is also given.

One of the most remarkable instances of ecstasy is that of the girl Bernadette Soubirons, whose wonderful visions led to the establishment of the now famous shrine of Our Lady of Lourdes in the south of France. It is related of this young girl by her historian Lasserre[4] that when about to cross the Gave, a mountain-stream of the Pyrenees, she suddenly saw in a niche of a rock a female figure of incomparable splendor, which she described as a real woman with an aureola about her head and her whole body of surprising brightness. The child afterward described in detail the vision she had seen. Later, on a number of occasions at the same spot, she saw the same vision, described as appearing transfigured. The child believed that she saw the Immaculate Virgin. The Virgin told her that she wished a church to be built on the spot. The place has since become a shrine for Catholics of all nations.

[Footnote 4: _Our Lady of Lourdes_, by Henri Lasserre, translated from the French, 7th ed., New York, 1875.]

Meredith Clymer[5] has written an elaborate communication on ecstasy. Ambrose Paré, quoted by Clymer, defines ecstasy as a reverie with rapture of the mind, as if the soul was parted from the body. Briquet describes it as a state of cerebral exaltation carried to such a degree that the attention, concentrated on a single object, produces the temporary abolishment of the other senses and of voluntary movements.

[Footnote 5: “Notes on Ecstasy and other Dramatic Disorders of the Nervous System,” _Journal of Psychological Medicine_, vol. iv., No. 4, October 1870.]

ETIOLOGY.—Under the predisposing causes of ecstasy may be comprised almost all of those described under hysteria. The predisposition to the development of ecstasy will be governed in great measure by peculiarities of religious education and of domestic and social environment.

Extreme religious feeling is undoubtedly among the most frequent of {342} the exciting causes of ecstasy. The accidents and incidents of love have also had a place. Sexual excitement is sometimes associated with the production of ecstasy. “In pre-Christian times,” says Chambers, “when, in default of revelation, men worshipped their incarnate passions, we have from the pen of Sappho a description of a purely erotic ecstasy which can never be produced again.” Fear or fright has been known to throw a predisposed individual into an attack of ecstasy. Severe threats have occasionally had the same influence.

SYMPTOMATOLOGY.—In considering the symptomatology of ecstasy it will only be necessary to call attention to the ecstatic attack. The accompanying phenomena are those of hysteria, hystero-epilepsy, etc., already fully described. I cannot do better than quote from Lasserre the account of one of the ecstatic seizures of Bernadette Soubirons. Although given in turgid language and from the religious point of view, the description is a good one of the objective phenomena of ecstasy:

“A few moments afterward you might have seen her brow light up and become radiant. The blood, however, did not mantle her visage; on the contrary, she grew slightly pale, as if Nature somewhat succumbed in the presence of the apparition which manifested itself to her. All her features assumed a lofty and still more lofty expression, and entered, as it were, a superior region, a country of glory, significant of sentiments and things which are not found below. Her mouth, half open, was gasping with admiration and seemed to aspire to heaven. Her eyes, fixed and blissful, contemplated an invisible beauty, which no one else perceived, but whose presence was felt by all, seen by all, so to say, by reverberation on the countenance of the child. This poor little peasant-girl, so ordinary in her habitual state, seemed to have ceased to belong to this earth.

“It was the Angel of Innocence, leaving the world for a moment behind and falling in adoration at the moment the eternal gates are opened and the first view of paradise flashes on the sight.

“All those who have seen Bernadette in this state of ecstasy speak of the sight as of something entirely unparalleled on earth. The impression made upon them is as strong now, after the lapse of ten years, as on the first day.

“What is also remarkable, although her attention was entirely absorbed by the contemplation of the Virgin full of grace, she was, to a certain degree, conscious of what was passing around her.

“At a certain moment her taper went out; she stretched out her hand that the person nearest to her might relight it.

“Some one having wished to touch the wild rose with a stick, she eagerly made him a sign to desist, and an expression of fear passed over her countenance. ‘I was afraid,’ she said afterward with simplicity, ‘that he might have touched the Lady and done her harm.’”

Side by side with this description by the devout Lasserre of the appearance presented by Bernadette when in a state of ecstasy, I will quote the often-recorded account which Saint Theresa has given in her _Memoirs_ of her subjective condition while in a similar state:

“There is a sort of sleep of the faculties of the soul, understanding, memory, and will, during which one is, as it were, unconscious of their working. A sort of voluptuousness is experienced, akin to what might {343} be felt by a dying person happy to expire on the bosom of God. The mind takes no heed of what is doing; it knows not whether one is speaking or is silent or weeping; it is a sweet delusion, a celestial frenzy, in which one is taught true wisdom in a way which fills us with inconceivable joy. We feel as about to faint or as just fallen into a swoon; we can hardly breathe; and bodily strength is so feeble that it requires a great effort to raise even the hands. The eyes are shut, or if they remain open they see nothing; we could not read if we would, for, though we know that they are letters, we can neither tell them apart nor put them together, for the mind does not act. If any one in this state is spoken to, he does not hear; he tries in vain to speak, but he is unable to form or utter a single word. Though all external forces abandon you, those of the soul increase, so as to enable you the better to possess the glory you are enjoying.”

Occasionally striking illustrations of ecstasy are to be found among hysterical and hystero-epileptic patients in whom religious faith has no place. In these cases usually other special phases of grave hysteria are present. In some of the descriptions given by Charcot and Richer of hystero-epileptics in the stage of emotional attitudes or statuesque positions the patients are, for a time at least, in an ecstatic condition in which the hallucinations may be connected with sentiments of religion, love, fear, or other emotions. One shows an attitude of menace or an expression of fear; in another the expression is of beatitude or saintly happiness: to this expression perhaps succeeds one of intense joy; to this, one of passion and lubricity. Throughout all the changing phases of attitude and expression the patient has the other concomitants of the true ecstatic state, such as want of volition and insensibility.

DIAGNOSIS.—A cataleptic may also be an ecstatic or the reverse; but not a few cases are on record in the history of which, on the one hand, an individual has been subject over a long period to cataleptic seizures without the recurrence of ecstasy, or, on the other hand, to fits of ecstasy without a single attack of true catalepsy. Cataleptic attacks usually occur with more suddenness than ecstasy; the cataleptic may suddenly become rigid and statuesque—the ecstatic gradually, although it may be somewhat rapidly, passes step by step into a visionary state. In catalepsy and ecstasy the expression of the patient differs. One of the striking features of ecstasy is not simply the absorbed and abstracted, but also the radiant, expression of countenance. In catalepsy the expression is more likely to be vacant or at least negative. In ecstasy waxen flexibility is not present. The muscles can act in obedience to the will, and the trunk and limbs do not maintain the positions in which they are placed for any unusual time. In genuine catalepsy the consciousness is so suspended or altered that the period of the seizure afterward remains a blank in the memory of the patient. In ecstasy, however, the visions and fancies present during the fit can afterward be recalled, and are frequently recounted by the individual.

DURATION, COURSE, PROGNOSIS.—Nothing need be said as to duration, course, prognosis, etc. of ecstasy. The remarks made in considering hysteria, hystero-epilepsy, etc. fully cover these matters.