The question of oöphorectomy for the relief of hystero-epilepsy is one of increasing importance in these days of major surgery. At the meeting of the American Neurological Association (June, 1884) G. L. Walton read a paper14in which he concludes that hysteria is sometimes set up by ovarian irritation, and can be relieved by removing the offending organ. He cited a single case. Carsten15concludes that it is criminal neglect not to perform Battey's operation in cases which fail to be benefited by other treatment. In the discussion which followed the reading of this paper the subject was well traversed by Spitzka of New York, Putnam of Boston, Putnam-Jacobi of New York, and others. Spitzka referred to one case of Israel's of Breslau, in which a patient was cured of hystero-epilepsy by a sham operation—a superficial incision in the parietes of the abdomen. Under the title of castration in hysteria theLancet16tells of an hysterical patient who had suffered for years from obstinate vomiting and severe ovarian pain. She became extremely weak, and finally consented to spaying as the only hope. The operation—performed under chloroform with antiseptic precautions—was a mockery, the skin only being incised; she was, however, perfectly cured of her hysterical symptoms.
14“A Contribution to the Study of Hysteria as Bearing on the Question of Oöphorectomy.”
15Quoted by Walton fromAmerican Journal of Obstetrics, March, 1883.
16Vol. ii. p. 588.
In two clinical lectures published in thePhiladelphia Medical Times17I have given the histories of two cases of hystero-epilepsy in which oöphorectomy was resorted to for hystero-epilepsy. In the first of these cases, in which clitoridectomy was also performed, nymphomania, which was a distressing symptom, was benefited, but even this was not completely cured. The following is the patient's own statement: “Since the removal of the ovaries I have been able to control the desire when awake, but at times in my sleep I can feel something like an orgasm taking place. My experience leads me to say that my cure (?) is not due to the absence of the ovaries; there is no diminution of the sexual feeling. There would be as much excitement of the parts if the clitoris were still there. If my will gave way, I would be as bad as ever.” Her general mental and nervous condition is much the same as before the operations. She is still dominated by morbid ideas, still unable to take up any vocation which demands persistence, and still the frequent subject of hystero-epileptic seizures.
17April 18 and May 30, 1885.
The second of these cases was a young girl about seventeen years old who had never menstruated. She had had epileptic or hystero-epileptic seizures for several years. An operation was performed in which the ovaries and Fallopian tubes were removed. Twelve days after the operation, from which she made a good recovery, she had four convulsive seizures. She had several attacks subsequently, and then for a considerable period was exempt. She had, however, acute inflammatory rheumatism, with endocarditis and valvular trouble. About seven months after the operation she had several severe convulsions with loss of consciousness, and died about a year after the operation, having had many severe seizures during the last few weeks of her life.
There is no warrant either in experience or in a study of the subject for spaying hysterical girls who have never menstruated. In a casediagnosticated as hysterical rhythmical chorea removal of the ovaries was advised by a distinguished specialist. The girl's trouble came on at about the age of thirteen years. She had never menstruated properly, although on one occasion, after several weeks of electric treatment, she had a slight show for a few days. It was proposed to remove the ovaries in this case on some general principle of given hysterical trouble; the ovaries must go. In this case, as in the last, it would have been far better to have put in a good pair of ovaries, or to have developed these rudimentary organs into health and activity.
With reference to oöphorectomy for hystero-epilepsy or any form of grave hysteria it may be concluded—1, It is only rarely justifiable; 2, it is not justifiable in the case of girls who have not menstruated; 3, when disease of the ovaries can be clearly made out by local objective signs, it is sometimes justifiable; 4, it is justifiable in some cases with violent nymphomania; 5, the operation is frequently performed without due consideration, and the statistics of the operation are peculiarly unreliable.
When we come to consider the treatment of the disease hystero-epilepsy, the practical importance of the distinction between this affection and true epilepsy becomes apparent. Cures of hystero-epilepsy are not rare. The original cases here reported have all apparently recovered. Grave hysteria is sometimes cured spontaneously, either by gradual disappearance with the progress of age, or suddenly because of some violent impression or under the influence of unknown causes. One of the worst cases in the service of Charcot has shown a gradual diminution of the hystero-epileptic manifestations with the advance of age. In another case under the influence of strong moral impressions the disease disappeared at a stroke. The affection, however, should not be abandoned to nature, as treatment is often of value.
The hydrotherapeutic method of treatment has been found of the greatest service. Hydrotherapy must be methodically employed by experienced hands. A number of cases cited by Richer were cured at hydrotherapeutic institutions. Limited success has followed the use of metallo-therapy. Besides metallic plates, the same results may be obtained with other physical agents, to which have been given the name of æsthesiogenic agents. Among these are feeble electric currents, vibrations of a tuning-fork, static electricity, etc.
Static electricity has a position of undoubted importance in the treatment of hystero-epilepsy in some of its phases. Those who have walked in the wards and visited the laboratories of Salpêtrière will recall the enormous insulated stools to which are brought troops of hystero-epileptic patients, who, to save time, are given a vigorous simultaneous charge of electricity. Even this wholesale plan of treatment is sometimes markedly efficacious. Vigoroux recommends static electricity as an æsthesiogenic agent, and regards it as the most valuable of all agents of this character.
Those drugs should be resorted to which have a tonic influence on the nervous system. Potassium bromide, as has already been indicated, is not efficacious. More is to be hoped from tonics and antispasmodics, such as valerian, iron, salts of silver, zinc, copper, sodium, and gold chlorides, etc. Good hygienic influences, moral, mental, and physical, are of the utmost importance.
BYCHARLES K. MILLS, M.D.
BYCHARLES K. MILLS, M.D.
DEFINITION.—Catalepsy is a functional nervous disease characterized by conditions of perverted consciousness, diminished sensibility, and especially by muscular rigidity or immobility, which is independent of the will, and in consequence of which the whole body, the limbs, or the parts affected remain in any position or attitude in which they may be placed.
Catalepsy sometimes, but not frequently, occurs as an independent disease; that is, the cataleptic seizure is the only abnormal phenomena exhibited by the patient. It is sometimes present, although also rarely, in organic disease of the nervous system. It has been noted, for instance, as occurring in the course of cases of cerebral hemorrhage, softening of the brain, abscess, tumor, and tubercular meningitis. One case is referred to by C. Handfield Jones in which it seemed to be due to intracranial epithelioma. As commonly seen, it is a complication, or perhaps, more properly speaking, a form of hysteria—hystero-catalepsy.
SYNONYMS.—Some of the many synonyms which have been used for catalepsy are Catochus, Morbus attonitus, Stupor vigilans, Synochus, Eclipsis, and Hysteria cataleptica. Trance and ecstasy are discussed sometimes as synonymous with catalepsy, but they will be considered as separate affections, as they have certain distinctive features. Catalepsy, trance, ecstasy, hystero-epilepsy, and other severe nervous disturbances may, however, all appear in the same patient at different times or at different stages of the same seizure.
With reference to the term catochus (κατοχη, fromκατεχω, I take possession of), which has been used as synonymous with catalepsy, Laycock1points out what he considers to be the proper use of this word, differentiating two cataleptic conditions, which he designates as the tetanic and the paralytic states. Catochus is the tetanic form, in which the trunk and limbs are rigidly extended and consciousness is abolished. Catalepsy proper is Laycock's paralytic form, although the term paralytic, as here applied, is by no means happy. It is the form characterized by the peculiar and striking symptom known as waxen flexibility (flexibilitas cerea)—a condition in which the limbs or parts are passive and are capable of being moulded like wax or lead pipe. Rosenthal would not consider any case as one of genuine catalepsy if this waxen flexibility was absent. I do not think that this rigorous criterion should always be imposed,although it might perhaps be better to apply the term cataleptoid to all cases which do not present true wax-like flexibility. The distinction sometimes made between catalepsia vera, or true catalepsy, and catalepsia spuria, or false catalepsy, is practically that indicated between Laycock's two forms. According to Charcot and Richer,2the flexibilitas cerea is not present in the cataleptic state of hypnotism.
1A Treatise on the Nervous Diseases of Women, by Thomas Laycock, M.D., London, 1840.
2Journal of Mental and Nervous Diseases, Jan., 1883.
HISTORY.—The word catalepsy was used by Greek writers in its etymological signification of a seizure or surprise. Hippocrates described catalepsy; Galen, Aëtius, Rondeletius, and Fernelius have all related cases; Aëtius has left an accurate description of both catochus and catalepsy. In 1683, Laurence Bellini published a quarto volume on various subjects, one of which was catalepsy. From time to time interesting cases of catalepsy have been reported by medical writers. One of the best is that recorded by John Jebb in 1782, and quoted by Chambers inReynolds's System of Medicine. The researches in hypnotism during the present century, and particularly those of Heidenhain and of Charcot and Richer, have thrown new light on many cataleptic phenomena.
ETIOLOGY.—In catalepsy, as in hysteria, insanity, and many neuroses, inheritance frequently plays a predisposing part. Eulenburg places it in the large group of diseased conditions designated by Griesinger constitutional neuropathies. The cataleptic of one generation may be the descendant of the insane, the epileptic, the syphilitic, or the alcoholized of a former. Catalepsy is particularly likely to occur in families which have a history of insanity or drunkenness. Of the cases detailed or alluded to in this paper, more than a majority had a clear neurotic history. Catalepsy, like hysteria, occurs with some frequency among the tuberculous.
Age plays some part in the development of catalepsy. It is of most frequent occurrence between the ages of fifteen and thirty, but has been observed at all ages. It is of unusual occurrence in very early childhood, but A. Jacoby,3Clinical Professor of the Diseases of Children in the College of Physicians and Surgeons in New York, reports a case of well-marked catalepsy in a child three years old. This patient, a girl, was admitted to the Mt. Sinai Hospital, New York, in September, 1879. She had whooping cough and some symptoms of typhoid fever. After she had been in the hospital three weeks choreic twitchings of the eyes and eyelids, with divergent strabismus, were observed. Examining her, it was found that she was cataleptic; her arms and legs would remain in any position in which they were placed; she would drop the uplifted arms slowly when commanded; sensibility to contact, pain, and temperature were entirely lost, and the skin and patellar reflexes were diminished. Her appetite was ravenous, and urine was passed in large quantities. Other phenomena and details of cataleptic symptoms, which continued for about a month, are recorded by Jacoby. The child recovered, but remained weak and anæmic for a long time.
3American Journal of Medical Science, N. S. lxxxix., 1885, p. 450.
Monti4records eleven cases of catalepsy met with in children, male and female in about equal numbers, of from five to fifteen years, the average age being nine years. Eulenburg speaks of catalepsy at fiveyears of age, and quotes Schwartz, who noticed in a boy seven years old, in consequence of rough treatment, first a choreic condition, which later passed into catalepsy. Lloyd's case, to be detailed later, also studied by myself at the University Hospital, was in a boy eight years old. B. L. Hovey5of Rochester, New York, reports an interesting case of catalepsy in a boy eight years old.
4Gerhardt's Handb. d. Kinderk., vol. v., L. P., 186et seq., quoted by Jacobi.
5The Hospital Gazette, 1879, vi. p. 19.
C. E. de Schweinitz of Philadelphia, Ophthalmic Surgeon to the Children's Hospital and Prosector of Anatomy at the University of Pennsylvania, has kindly put into my hands the unpublished notes of a highly interesting case of catalepsy or automatism at command, or of both, in a child two and a half years old. I will give this case in full, chiefly in the language of De Schweinitz, because it is, so far as I know, the youngest case on record. Some of the tests which were applied in this case are among the most useful which can be resorted to in determining how far the phenomena presented are genuine or induced, simulated, or imitated:
The patient was a girl aged two and a half years, who had recently recovered from an attack of diphtheritic conjunctivitis. During the period of her convalescence the attending nurse called attention to the unusual position assumed by the child while sleeping—viz. a lateral decubitus, the head raised a short distance from the pillow, and the forearm slightly elevated and stretched out from the body, the muscles at the same time exhibiting marked tremulousness. A series of trials readily demonstrated that the child when awake could be placed in any position compatible with her muscular power, and that she could thus remain until released. She was placed, for instance, in the sitting posture, the arm brought at right angles to the body, the forearm at right angles to the arm, and the hand at right angles to the forearm, both legs raised from the bed, and the head bent backward. This position, a most uncomfortable and difficult one to preserve, would be maintained until the little subject dropped from sheer exhaustion. Flexion and extension of each separate finger were easily produced, and the fingers remained until replaced in the positions in which they had been fixed. At the beginning the child's mind was sluggish, although she asked for food and made known her various wants. How far she appreciated surrounding objects could not be accurately ascertained, inasmuch as the previous disease of her eyes had left her with a central corneal macula on each side, rendering her almost sightless in one eye and with but indifferent object-perception in the other. Voluntary motion was preserved, and she sat up, turned, and moved whenever she pleased, but most often when at rest at this stage maintained somewhat of the position before described which during sleep first attracted attention to this condition.
In conjunction with Morris Lewis an examination of the cutaneous sensibility and reflexes was made, which showed diminished sensibility in the legs and thighs, but not higher up, where the pricks of the instrument were quickly appreciated. Her knee-jerk was apparently absent on the right side and present on the left; but this test, always most unsatisfactory in children, yielded no certain evidence and constantly gave contradictory results. Scratching the skin of the soles of the feet, legs, thighs, and abdomen with a pointed instrument wasfollowed 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 subjectwould 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 onGeneral 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,6who 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.
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.
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. Mancini7relates 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.
7Lo 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 periodical8Charles 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.
8The North American Medical and Surgical Journal, vol. i. p. 74, 1826.
That imitation is an exciting cause of catalepsy has been shown by theoften-told story of epidemic hysteria, but more especially by accounts given of certain peculiar endemics of catalepsy. Handfield Jones9gives 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.”
9Op. cit., quoted fromSchmidt'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. Flint10divides 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 begreater or less depths of unconsciousness, but some degree of unconsciousness or of obtunded consciousness is necessary to the existence of true catalepsy.
10Buffalo 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.
11Op. cit.
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 hypnotism12by 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 Heidenhain13and of Charcot and Richer14which relate to the production of a cataleptic or cataleptoid state, and to the phenomena which take place in this state.
12Am. Journ. Med. Science, Jan., 1882.
13Animal Magnetism: Physiological Observations, by Rudolph Heidenhain, Prof. Physiology in the University of Breslau, London, 1880.
14Etudes 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.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.
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.