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 Contents vii

  7.4 Current strategies of competitors 181

  7.5 Factors that determine success and strengths and weaknesses
of competitors 182
  7.6 Expected strategies of competitors 186
  7.7 Data sources 187
Summary 189
Case McDonald’s versus Burger King: concept or taste 190

8 Analysis of distribution and suppliers 196

Introduction 197
  8.1 Goal and structure of a distribution analysis 197
  8.2 Distribution analysis at the macro level 198
  8.3 Distribution analysis at the meso level 200
  8.4 Distribution analysis at the micro level: retail analysis 203
  8.5 Analysis of suppliers 207
Summary 209
Case challenges in food distribution: the Barika story 210

9 SWOT analysis  216

Introduction 217
  9.1 Definitions and forecasting 217
  9.2 Summary of the situation analysis 220
  9.3 Vision on the environment 221
  9.4 Problem conclusion and unrevised policy 222
  9.5 Choice of a value strategy 223
  9.6 Marketing strategic options 224
  9.7 Choosing a marketing strategic option 230
Summary 234
Case Pepsi Cola in the USA: strategic choices 235

Part III: Corporate decisions and marketing decisions

10 Corporate objectives and corporate strategies 243
Introduction 244
10.1 Corporate vision and corporate objectives 244
10.2 Portfolio analysis 245
10.3 Corporate strategy: where to compete 257
10.4 Corporate strategy: with whom to compete 262
Summary 267
Case chocolate of Barry Callebaut 268
viii CONTENTS

11 Marketing objectives and marketing strategies 277

Introduction 278
11.1 Marketing objectives 279
11.2 Segmentation and choice of a target group 280
11.3 Brand positioning 287
11.4 Brand architecture 298
11.5 Brand names 299
11.6 Design and logo 306
11.7 Managing brands 308
Summary 317
Case Audi: Vorsprung durch Technik 319

Part IV: Implementation

12 Product, price, place 325
Introduction 326
12.1 Guidelines for the marketing mix 327
12.2 Product 329
12.3 Pricing 332
12.4 Distribution 337
Summary 342
Case Nespresso: exclusive coffee 343

13 Marketing communication 347

Introduction 348
13.1 Steps in communication planning 348
13.2 Determination of the target audience 349
13.3 Selecting a proposition 351
13.4 Communication objectives and communication budget 352
13.5 Briefing and requirements for communication 357
13.6 Creation and execution 359
13.7 Pretesting 364
13.8 Communication tools and media 366
13.9 Online communication 372
13.10 Brand and advertising tracking and effect research  375
Summary 380
Case Ikea moves online 381

14 Organization and implementation of marketing 386

Introduction 387
14.1 Marketing and personnel 387
14.2 Organization of marketing and communication 395
 Contents ix

14.3 Performance projection and selling the plan 400

14.4 Planning guidelines 403
Summary 405
Case personal care more important for Unilever  407

Bibliography411
Index417
Taylor & Francis
Taylor & Francis Group
http:/taylorandfrancis.com
 Preface

This book describes the current thinking on strategic marketing from a how-to perspec-
tive. The theory of strategic marketing is presented in steps. Those steps can be followed
to arrive at a strategic marketing plan. This book features a combination of five attributes
that make it different from other marketing strategy books. First, it deals only with strate-
gic marketing. Therefore, there are no separate chapters devoted to consumer behaviour,
market research, or marketing instruments (the four Ps are included in two chapters). The
second attribute is the process approach. The third attribute relates to what the author
feels is important in marketing: customers and brands. A customer and brand orientation
is followed throughout the book: in the analysis, in choosing options, in developing mar-
keting strategy, and in implementation. The fourth attribute is that in many places in the
book strategic guidelines are given: what to do and what not to do in marketing practice.
Finally, there is much attention focused on tools and techniques that may be helpful in
the planning process. In summary, this book combines an academic and applied approach
of strategic marketing planning.
The book is primarily targeted at students with a basic knowledge of marketing. Thus,
the relevant target groups are undergraduates in the third or fourth year and some MBAs.
The book may be used in, for example, courses in marketing strategy or marketing man-
agement. The book may also be used in executive teaching, and by marketing practition-
ers who are looking for academic support for their daily decision making.
The book consists of four parts comprising 14 chapters, with each chapter being a step
in the strategic marketing planning process.
Part I Introduction and marketing planning
1. The essence of marketing
2. The strategic marketing planning process
Part II Situation analysis
3. Mission, value strategies, and market definition
4. Internal analysis
5. Customer analysis
xii Preface

6. Industry analysis
7. Competitor analysis
8. Analysis of distributors and suppliers
9. SWOT analysis
Part III Corporate decisions and marketing decisions
10. Corporate objectives and corporate strategies
11. Marketing objectives and marketing strategies
Part IV Implementation
12. Product, price, place
13. Marketing communication
14. Organization and implementation of marketing

Throughout the text many examples are included, most of them in separate boxes,
enabling readers to concentrate on the theory or the examples, or both. Each chapter ends
with a summary and an illustrative international case with questions.
This book tries to reduce the gap between strategic marketing theory and marketing
practice. The main message is that you should ask yourself continuously what effect your
company’s behaviour has on potential customers. For example, you might ask: How does
my amusing commercial score on brand recall? Or: Do more brand extensions reduce
or increase customers’ confusion? Things like this have to do with the attitude of the
manager and also with the way the planning process is done. Both aspects receive atten-
tion in this book. The content of the book is the result of continuously wondering whether
strategic marketing issues are and should be applicable in marketing practice. However,
there is no ‘truth’. Science by definition is a matter of ‘asking questions’, and a field as
young as marketing science is only at the beginning of the process of finding the ‘truth’.
It is my hope that the ideas in this book not only lead to better marketing decision making
but also lead to the asking of better marketing questions.
I would greatly appreciate it if you, as my customer, make me part of your ongoing
needs and perceptions with regard to this book.

Karel Jan Alsem

Hanze University of Applied Sciences, Groningen
July 2018
 Acknowledgements

This book is an updated and revised version of its Dutch counterpart, which is now in
its seventh edition. First, I thank my Dutch publisher Noordhoff for permitting me to
undertake this international version.
Second, I owe many thanks to Erik Kostelijk for preparing the cases and questions. He
has been my ‘case partner’ for many years, and I hope this will continue in the future. I
thank my publisher Routledge for publishing the book. Finally, I thank my main co-brand
Cato, and my sub-brands Tom, Sophie, Anne, and Floor for being inspiring and down-to-
earth sparring partners in this current dynamic life.
Taylor & Francis
Taylor & Francis Group
http:/taylorandfrancis.com
 Part I

Introduction
and marketing
planning

1. The essence of marketing

2. The strategic marketing planning process

This book was written to bridge the gap between the theory and practice of strategic
marketing. Current marketing theory describes how a company (or a brand) can imple-
ment the strategic marketing planning process, and how strategic marketing decisions
can be based on an analysis of the brand and the environment. Therefore, we will focus
on the activities that must be carried out by a company within the framework of strategic
marketing. These activities may be categorized as evaluation/retrospective, analysis,
planning (strategy development), and implementation (execution).
The book is divided into four parts. Part I describes the basic assumptions of
the book and the marketing planning process. Then, each step of this process will
be described. Part II is dedicated to evaluation and situation analysis. The basic
assumption here is that without a thorough, systematic situation analysis, the
­
success of a strategy is more a matter of luck than of skill. Part III deals with the
development of the strategy, with particular attention paid to brand positioning
­
decisions. Part IV ­concerns the ­translation (e.g. into communication) and execution
(implementation) of ­strategic decisions. The three main parts result in three parts of a
marketing plan:

■■ a marketing report (insights as a result of the analysis, Part II)

■■ a strategic marketing plan (long-term decisions, Part III)
■■ a tactical marketing plan (the marketing instruments for one year, Part IV).

All marketing activities should be carried out with a single objective: to create value
for the customer through a recognizable brand image. This objective (customer and
brand) provides the basis for the description of the activities as well as practical advice.
2 Introduction and marketing planning

This book may be used for the development of a marketing plan and also as a guidebook
for re-examining a company’s marketing policy.
Part I begins with an overview. Chapter 1 describes the essence of marketing and
the role of a sustainable competitive advantage of a brand. Chapter 2 provides an
outline of the entire strategic marketing planning process that a company can follow to
develop a marketing plan. This process is the common thread running through the book.
 Chapter 1

The essence of
marketing

Key points in this chapter

■■ Outline what marketing is and describe how marketing developed.

■■ Introduce marketing (customer and brand) as the key to developing custom-
ers’ relationship with a brand.
■■ Describe aggregation levels in organizations.
■■ Stress the importance of a sustainable competitive advantage.

Introduction

This book covers the concept of strategic marketing from the customer and brand per-
spective. It is done step by step, leading to a marketing plan for a brand. Following the
route, the reader will be confronted with different theories and models, each of them
contributing to the marketing plan. There are no sideways (i.e. chapters with interesting
theories not directly being a step in the marketing planning process, such as a sideway
about ‘consumer behaviour’).
In this introductory chapter, we first deal with the content of marketing itself. A reason
for this is that there are many definitions of marketing and even some image problems
with marketing. Often, marketing is confused with communication or sales. In section 1.1
we start by describing a number of trends (‘landscape’), leading to a growing importance
of marketing. Then, in section 1.2, we outline the content of marketing as we see it. We
pay attention to the hierarchy in the marketing concept, as well as to developments in
marketing.

1.1 The changing landscape of marketing

As we will point out in section 1.2, the essence of marketing is to act in a customer-­
oriented way from a clear brand identity. Marketing is one business discipline, next to,
for example, finance, human resource management, and information and communication
4 Introduction and marketing planning

technology (ICT). All these disciplines operate in a volatile landscape. In this section,
we discuss a number of developments/trends in the marketing landscape. Some of them
affect the importance of marketing. Some of them (for example, the rise of social media)
affect the contents of the marketing plan: the planned marketing actions for a company.
In our view, however, the current marketing theory in itself, which in this book is limited
to the contents of marketing and the manner of how marketing decisions are reached,
is barely affected by these trends. So, we disagree with statements like ‘the SWOT-
analysis does not work anymore’. Or that ‘branding is dead’. The essence of marketing
does not need to change, but we should be flexible in handling how to implement it.
We will now discuss some trends directly affecting the importance of marketing
and also the way of how marketing should be done. We will separately go into another
important, global trend: climate change.
The following factors affect the importance and implementation of marketing.

1. There is a growing supply of products and services. Companies and customers are
faced with an increasing amount of new products and services. Also, products are
marketed using new varieties and with different brand names. Innovation is realized
at an increasing rate of speed. For customers, this looks great: more choice (offline
and online), so more possibilities to meet one’s own specific needs. However, a lot of
choice also leads to more stress because of the need to choose. Schwartz (2004) talks
about the ‘paradox of choice’: people grow tired of the need to always make choices,
whether they buy jeans, coffee in the supermarket, or coffee in the restaurant; there
is an enormous supply, and routine decisions are becoming more complex.
2. Communication leads to more communication. This is what we call the commu-
nication spiral. Brands are doing their best to come into consumers’ minds. As so
many brands are doing this, it is becoming increasingly difficult to realize this. A
natural reaction is to increase communication activities, etc.
3. There is more information about brands available through the internet. Not only
is information from companies themselves available ‘with one click’, but also and
especially consumers’ own evaluations may be found on the internet. A well-known
example is booking.com, where many reviews may be found about almost all hotels,
houses, etc. Scores are given, enabling consumers to choose from a ranking. In
addition, qualitative information is available about a consumer’s own experience. In
some countries, rankings are regularly published for some categories, such as about
hospitals and universities. For universities there are several rankings, enabling man-
agers to focus in their communications on those rankings where performance is best.
4. New forms of competition and distribution are developed through the internet. The
internet enables the introduction of new intermediate stakeholders between con-
sumers and suppliers. One example has already been mentioned: booking.com. But
airbnb.com and uber.com are further examples of new online competition. These
organizations are only using data and the internet in a smart way without offering
new products or services themselves.
5. Social media enlarge consumers’ power. The rise of social media empowers con-
sumers. This is because social media are an extremely fast way of spreading ‘word
of mouth’: in a few minutes many people can be informed about anything about a
company, such as a mistake, failure in service, etc. The ‘viral’ spread of information
 The essence of marketing 5

will even act faster if famous people participate, or if a journalist is involved who
might use other media as well to spread the news.
6. Governments in many countries are striving to accommodate market forces and
to stimulate competition. Even traditionally non-commercial organizations and
markets, such as postal services, energy, and health care, are placing more emphasis
on listening to the customer.
7. Consumers are becoming more critical. Due to some of the previous developments,
consumers are becoming more independent, are learning more, and are presumably
placing a higher value on transparency and sustainability.

The conclusion is that marketing is important for all companies and other organizations.
They should listen very carefully to their customers (target groups) and also ensure that
their activities are planned in accordance with the brand identity.

Sustainability

Worldwide agreement exists about the need for more sustainable behaviour. In 2017 the
World Economic Forum mentioned climate change as the most important threat to global
stability. Since ‘Paris 2015’ sustainability has strongly grown in importance. The year
2018 was the first in which a large city comprising a million people (Cape Town) expe-
rienced the risk of lack of water. Climate change, of course, is not a marketing problem.
It is a broad, complex problem where many disciplines are involved. Nevertheless, one
could wonder whether the need for sustainability should be part of marketing theory.
Some authors believe that this is the case. Kotler and Keller (2016) argue that marketing
should better acknowledge that a broader, more integrated perspective is often necessary.
Therefore, they introduced the holistic marketing concept, which consists of four dimen-
sions: relationship marketing, integrated marketing, internal marketing, and socially
responsible marketing. Socially responsible marketing is critical of excessive consumer-
ism and environmental damage caused by corporations. It is based on the idea that market
offerings must not be only profit-driven, but they must also reinforce social and ethical
values for the benefit of citizens. Sometimes the phrase ‘purposeful marketing’ is used
to indicate that companies should incorporate social goals beyond making a profit. This
terminology is a little confusing, since any company will have a purpose. For example,
the purpose of a coffee retailer may be to provide the best coffee experience, while a
social purpose may be to only buy coffee from local suppliers in a socially responsible
way for a good price. In our view, being responsible is important but it is not part of
marketing theory. Although marketing theory in itself does not need to change, we do
agree with Kumar (2018) and other authors in a special issue of Journal of Marketing that
the foregoing technological, environmental and other trends are so important that mar-
keting implementation will strongly change. Kumar introduces the term ‘transformative
marketing’ for this.

1.2 What is marketing?

Marketing is often associated with ‘advertising’ or ‘sales’. This is not the essence of
marketing as we see it. In this section, we first show that marketing exists on three
6 Introduction and marketing planning

Case 1.1 Marketing relevant for all organizations

One marketer on the value of bringing an ‘FMCG mindset’

to health care and utilities
Soviet politics and Eastern European studies don’t exactly ring marketing bells,
but you only need to take one glance at Belinda Moore’s CV to see she’s not one to
follow the conventional path to the top. Instead, her career has been a ­never-ending
quest for ‘a blank sheet of paper’ – a fresh challenge. Once found, Moore likes
to make her mark, only to continue her search for the next blank sheet. Moore’s
CV screams variety, creativity, adventure, and endurance, having worked across
numerous sectors from fast-moving consumer goods (FMCG) and health care to
travel, and most recently utilities as the director of marketing and communications
at energy brand E.ON.
“I enjoy starting things from scratch, challenging the status quo and really bring-
ing that ability to make things happen to businesses,” she says. Moore studied Soviet
politics and Eastern European studies at the University of Sussex and, despite the
course having “nothing to do with marketing”, she says it was a “big driver” in her
career direction. After graduating she set her sights on a job abroad, as she says
there weren’t many opportunities for her in London unless she wanted to work in
diplomatic services or become a teacher. “I didn’t even know what marketing was,
all I knew was that I was interested in people and how things worked,” Moore says.
Source: Marketing Week, 5 June 2018
 ThE ESSENCE OF MARKETING 7

Case 1.2 The importance of sustainability

Unilever’s sustainable brands grow best

The most sustainable brands of Unilever grow 46 per cent more than the rest of
the company. They represent 70 per cent of the growth in turnover. This is in line
with the mission of CEO Paul Polman, who wants to show that sustainability and
growth in turnover can be combined. All Unilever brands should lower environ-
mental pressure but the 26 sustainable living brands score best. The biggest of
these brands are Dove, Lipton, Dirt is Good, Rexona, Hellmann’s, and Knorr. More
than 40,000 employees of Unilever are involved in making sustainable plans at
Unilever.
Source: Financial Daily (Financieel Dagblad), 18 May 2018

levels within an organization (1.2.1). Next, we outline the developments in marketing

up until the beginning of the twenty-first century (1.2.2). We then discuss developments
in marketing after the year 2000: the role of brand identity (section 1.2.3) and certain
other developments (1.2.4). Section 1.2.5 describes the activities relevant for marketing,
which are the focus of this book.

1.2.1 Hierarchy in marketing

Marketing can be interpreted in different ways (Webster, 1992, 2005):

■■ As an organizational culture (the marketing concept or marketing paradigm): a

set of values and beliefs that drives the organization to make a fundamental com-
mitment to serving customers’ needs as the path to sustained profitability. Later in
this chapter, we argue that the brand identity should also be part of the marketing
concept.
■■ As a strategy: defining target markets and positioning product offerings.
8 Introduction and marketing planning

Marketing as a culture
Customer orientation and brand orientation

Analyses Marketing as a strategy

Internal and external Targeting and positioning

Marketing as tactics
4 Ps: product, price, place, promotion
(+ personnel)

Figure 1.1 Marketing hierarchy

■■ As for tactics: the day-to-day activities of the four marketing instruments: product
development, pricing, distribution, and communication. Sometimes, personnel is
also added as a fifth P.

We realize that defining the 4 P’s as ‘tactics’ (short term decisions for example for a year) is
somewhat ambiguous. We agree with Varadarajan (2010) that many 4 P-decisions are also
strategic in nature. For educational purposes we think Figure 1.1 is very helpful. The three
meanings of marketing have been interpreted as a hierarchy in marketing theory. The top
level (the marketing concept or marketing paradigm) defines the core content of market-
ing. It stresses the main issues in marketing in general and provides a rough indication of
what is important at the lower level: marketing strategy. The marketing strategy (targeting
and positioning) is chosen using the results of an internal and external analysis. Marketing
strategy should give a direction to the lowest level: marketing tactics (Figure 1.1).
Marketing strategy deals with segmenting, targeting, and brand positioning, raising
the question of how to compete (Adcock, 2000). The issue of branding is discussed
increasingly in the context of marketing strategy (Aaker, 1991, 1995; Keller, 2013), and
also in wider-ranging marketing textbooks (Kotler and Keller, 2016). Clear choices about
the target group and brand positioning impose boundaries on a company’s choice of the
appropriate marketing mix (relationship with the lowest level).
However, the relationship between the marketing concept and marketing strategy is
somewhat ambiguous. The marketing concept focuses on the customer (the demand side),
whereas marketing strategy mostly attempts to create a balance between the demand
side (the customer) and the supply side (the brand identity) of the market. Therefore,
the marketing concept should be updated by adding branding to the paradigm. Before
describing our view of the marketing concept, we discuss developments in the marketing
concept through the years.

1.2.2 Development of the marketing concept before 2000

In the first edition of his textbook, Kotler (1967) introduced the concept that companies
must be both customer- and market-driven. In an influential paper, Day and Wensley
 The essence of marketing 9

(1983) introduced the so-called strategic marketing concept. That concept is, in fact, an
expansion of the ‘classic’ marketing concept, which indicates that a company should use
the wishes and desires of its customers as the basis for its actions, otherwise known as
a ‘customer orientation’. The strategic marketing concept states that a company should
pay attention to:

■■ Customers (as in the classic marketing concept).

■■ Competitors (not just to be better but also perhaps to collaborate).
■■ Long-term relationships (including developing products for which there is a latent
need and thus a potential demand).
■■ Other interest groups inside and outside the organization (such as distributors,
employees, suppliers, financiers). Recently, Hillebrand et al. (2015) introduced the
name stakeholder marketing to stress the importance of multiple stakeholders.

These issues largely correspond to what is called ‘market orientation’ (Kohli and
Jaworski, 1990). Market orientation consists of three components:

1. A customer-oriented philosophy (customer orientation) would focus on the follow-

ing questions: Does the company make reasonable promises, and is it able to keep
those promises? Are customers treated as individuals? Is market research used con-
cretely to determine the wishes and opinions of the target audience? If so, does that
lead to actionable objectives for the company?
2. A competitor-oriented philosophy (competitor orientation). Here a company asks:
Do we have a lot of information about individual competitors? Is that information
analysed systematically and distributed throughout the organization? Does the
company know when it should respond to actions of competitors and how it can
differentiate itself from competitors? What are sustainable competitive advantages
given the marketplace?
3. Interfunctional coordination (integrated decision making). It is important to realize
whether the information is shared within the company. Are the strategies for various
functional areas integrated? Are joint decisions made? Is the whole organization
truly interested in its customers?

Over the years, the critical elements of the strategic marketing concept have shifted.
In the 1980s, strong emphasis was placed on a competitor orientation. In the 1990s,
another component of the strategic marketing concept moved to centre stage: the
development of long-term relationships, especially with customers. In this context, the
focus is no longer on one-time transaction-oriented marketing but rather on relationship
­marketing (Gummesson, 1987, 1999; Webster, 1992). Relationship marketing focuses on
­obtaining and sustaining a structural, direct relationship between a supplier and the cus-
tomer. In this context of relations, Morgan and Hunt (1994) theoretically and empirically
show that trust is a key factor in relationship commitment. Due to the need to create direct
(one-to-one) relationships, the use of databases increased. Therefore, ­relationship-based
marketing is sometimes called direct marketing or ­database ­marketing.
In the 2000s the shift continued, with increased attention given to customer value and
services. Customer value is the value that users derive from products. In theory, this is the
10 Introduction and marketing planning

user benefit derived from product attributes minus the price and the effort made to obtain a
product. In practice, customer value is determined by measuring not only customers’ per-
ceptions of product attributes but also their benefits as well as the goals they hope to attain
by using a product (Woodruff, 1997). The difference from the relationship philosophy of
the 1990s is that at that time it was stated that companies should always strive for direct
relationships as the way to provide customer value. Now the theory suggests that customers
can receive customer value in various ways. In this context, Treacy and Wiersema (1993)
name three value strategies that may be summarized as customer leadership (customer inti-
macy), product leadership, and leadership in terms of convenience or price (operational
excellence). Providing customer value is an important but insufficient condition for
achieving customer loyalty. In addition, bonding and familiarity are necessary.
Later, Vargo and Lusch (2004) argue that marketing is focused on services. In their
view, marketers focus too much on products. Goods (tangible resources) are only distribu-
tion mechanisms for service provision. Put differently, companies should focus on value
creation, on solving the ‘problems’ of their customers. In building relationships with
customers, intangible assets such as knowledge about customers and customer-friendly
methods of dealing with complaints are highly relevant as well. These intangible com-
petencies are embedded in the people working in a company. Only if all the people in a
company are really interested in customers can that company really build relationships
(Gummesson, 1998). Thus, the service perspective of marketing is closely related to the
relationship orientation (Ravald and Grönroos, 1996).
It could be argued that the focus on customer value in effect represents a revival of
the classic marketing philosophy. After all, the point of departure for classic marketing
is that customers’ wishes must be satisfied. This is essentially no different from stating
that value must be provided to customers. This line of reasoning may be ‘not wrong’. The
most important factor here is that although fulfilling customers’ wishes has been a basic
principle of marketing for a long time, actual marketing practice appears to have lost track
of customer satisfaction. There are many examples of situations in which customers are
annoyed (e.g. telephone sales whether or not done under the guise of research), dissatis-
fied (user-unfriendliness of personal computers and cameras), and unhappy with a bad
settlement of complaints. Fournier and associates argue that it is important to avoid “the
premature death of relationship marketing” (Fournier et al., 1998). A central assumption
of marketing should be that it leads to win-win situations, both for the supplier and the
customer. In essence, the emphasis on customer relationships may be translated into an
increasing need to provide the customer with real ‘value’ (Webster, 1992). Suppliers should
strive primarily for customer loyalty: maintaining their most profitable customers. By con-
trast, in classic marketing, suppliers focused more on attempting to recruit new customers
(Reicheld, 1993, 1996). Figure 1.2 summarizes developments in the m ­ arketing history.

1.2.3 Developments in marketing after 2000: the role of brand identity

In summary, the marketing concept focuses on the demand side of the market: customers.
But both from a practical as well as a theoretical perspective it may be argued that this
focus is too narrow. In practice, for example, it is noticeable that consumers are often not
able to come up with ideas for innovation, simply because they cannot imagine what new
products can be made. So, ideas for innovation should often come from the company.
Another random document with
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The periods of puberty and early menstruation and of pregnancy
furnish the most favorable opportunities for the development of
cataleptoid seizures in predisposed individuals. In 3 of 10 cases
observed by Landouzy catalepsy appeared to be developed in
consequence of the sudden suppression of menstruation; in a fourth
it occurred in a young girl after a dysmenorrhœa with chronic
phlegmasia of the genitals. Masturbation is sometimes mentioned as
a cause, particularly in boys.

Reflex irritation undoubtedly often acts as an exciting cause of

catalepsy. Preputial irritation, relieved in part by circumcision, was
present in the case of Lloyd, and has been noted by others.
Handfield Jones mentions a case, recorded by Austen in his work on
General Paralysis, in which the cataleptic seizure was, to all
appearances, due to fecal accumulations. The attack disappeared
promptly after an enema had thoroughly operated.

Briquet believed that catalepsy, when it did not follow upon organic
disease, was ordinarily the result of moral causes, such as vivid and
strong emotions—fear, chagrin, indigestion, anger, or profound and
prolonged meditation. He refers to the able and curious thesis of
Favrot,6 who states that in twenty cases in which the causes of the
malady were indicated it had been always the result of a moral
affection. A magistrate insulted at his tribunal, seized with
indignation, is suddenly taken with catalepsy, etc. According to Puel,
its causes are always depressing moral affections, as chagrin,
hatred, jealousy, and terror at bad treatment. Unrequited love is set
down as a cause, but what has not unrequited love produced? Jones
mentions a case which occurred in a man sixty years old on the
sudden death of his wife.
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. Mancini7 relates a case of cerebral rheumatism
complicated or causing catalepsy. A blacksmith, aged thirty-three,
had nearly recovered from a rheumatic attack when he became
melancholic, complaining also of severe headache. When admitted
to the hospital he was found to be imperfectly nourished. He lay on
his back, his face without expression, speechless, motionless, pupils
insensible to the light, smell impaired, sensation of heat and pain
and reflexes absent, galvanic and faradic contractility increased, the
rectum and bladder paralyzed. He presented the phenomena of
waxen flexibility, the trunk and limbs remaining in whatever position
was given them. Considering the previous attack of articular
rheumatism and the sudden appearance of nervous disorder during
the convalescence of this disease, Mancini believed that the case
was probably one of cerebral rheumatism. The man recovered under
diaphoretics and counter-irritation.
7 Lo Sperimentale, March, 1878.

Among the important causes of catalepsy bad nutrition may

undoubtedly be placed. In the case of De Schweinitz the cataleptoid
phenomena rapidly improved, and eventually disappeared as the
child's general health was restored by tonics and good diet. Hovey's
case was insufficiently clad and badly fed. One of Laségue's cases,
quoted by Handfield Jones, died of gradual marasmus, another of
pulmonary phthisis. Attacks of catalepsy have sometimes resulted
from a combination of excitement, fatigue, and want of food. They
occur also in diseases or conditions like phthisis, anæmia, and
chlorosis, affections which practically gives us the same cause—
namely, bad nutrition. In these cases the nervous system, like other
parts of the body, takes part in the general exhaustion.
Rosenthal refers to the production of symptoms of temporary
catalepsy by the administration of narcotics and the inhalation of
ether and chloroform. In a somewhat ancient American medical
periodical8 Charles D. Meigs of Philadelphia gives an interesting
account of a case of catalepsy produced by opium in a man twenty-
seven years of age. The man had taken laudanum. His arms when in
a stuporous condition remained in any posture in which they
happened to be left; his head was lifted off the pillow, and so
remained. “If he were made of wax,” says Meigs, “he could not more
steadily preserve any given attitude.” The patient recovered under
purging, emetics, and bleeding. Darwin, quoted by Meigs, mentions
a case of catalepsy which occurred after the patient had taken
mercury. He recovered in a few weeks.
8 The North American Medical and Surgical Journal, vol. i. p. 74, 1826.

That imitation is an exciting cause of catalepsy has been shown by

the often-told story of epidemic hysteria, but more especially by
accounts given of certain peculiar endemics of catalepsy. Handfield
Jones9 gives an account of an endemic which prevailed at
Billinghausen near Wurzburg: “The population consists of peasants
who are well off, but who intermarry very much, and are small and
deformed. The affected individuals constitute half of the number,
males as well as females. They are called there the stiff ones
(starren). A chill is commonly said to be the exciting cause of the
attacks. The patients are suddenly seized by a peculiar sensation in
their limbs, upon which all their muscles become tense, their
countenances deadly pale; they retain the posture which they first
assume; their fingers are bent and quiver slightly, and the eyeballs in
the same way, the visual axis converging; their intellects and senses
are normal, but their speech consists only of broken sounds. The
attack ceases in from one to five minutes, and the body becomes
warm.”
9 Op. cit., quoted from Schmidt's Jahrbuch.

SYMPTOMATOLOGY.—The cataleptic seizure, when it is not the result of

some hypnotizing procedure, usually takes place in the following
manner: The patient usually, after some patent exciting cause,
suddenly ceases whatever she may chance to be doing, becoming
rigid and immobile in the last position which she had been in before
the attack ensued. “She remains,” says Rosenthal, “as if petrified by
the head of Medusa.” The features are composed, the eyes usually
directed forward. She is pale; breathing, pulsation, and temperature
are usually somewhat reduced. At first the limbs may be found to
offer some resistance; soon, however, and sometimes from the
beginning, they can be moulded like wax into any possible position,
where they will remain until again changed by external agency.

Attacks of catalepsy, as a rule, come on suddenly, without special

warning; sometimes, however, special phenomena, which may be
compared to epileptic aura, may precede the attack. Thus,
Rosenthal speaks of two cases that were ushered in, and also
bowed out, by hiccough. The attacks may terminate as suddenly as
they begin, but sometimes the patients come out of the state
gradually. They are quite likely to appear dazed and stupid when
emerging.

Perverted consciousness is another marked symptom of catalepsy.

According to some authors, the loss of consciousness is absolute,
and upon this symptom they base their diagnosis from two or three
other somewhat similar conditions. As I have already indicated in
discussing the general subject of Hysteria, this question of
consciousness or unconsciousness is not one to be decided in
haste. In catalepsy, as in hystero-epilepsy, the conditions as to
consciousness may differ. What might be termed volitional
consciousness is in true catalepsy certainly in abeyance. Flint10
divides catalepsy, according to the condition as to consciousness,
into three kinds—namely, complete, incomplete, and complicated.
He, however, regards trance and day-mare as instances of
incomplete catalepsy, in which the intellectual faculties are not
entirely suspended and the senses are not materially affected, the
patient being unable to move or speak, but conscious of all that is
going on around him. He believes that such cases resemble more
closely the cataleptic condition than they do that of ecstasy. In
genuine catalepsy with waxen flexibility, analgesia, etc. there may be
greater or less depths of unconsciousness, but some degree of
unconsciousness or of obtunded consciousness is necessary to the
existence of true catalepsy.
10 Buffalo Medical Journal, xiii., 1857-58, p. 141.

Catalepsy presents well-marked disturbances of sensation, although

these, like the conditions as to consciousness, differ somewhat in
different cases. Anæsthesia in its different forms, and especially
analgesia, are always present in some degree. Experiments without
number have been tried on cataleptic patients, showing their
insensibility to painful impressions: they have been pinched, pricked,
pounded, burned with heated irons, and rubbed down with blocks of
ice. Skoda reports a case in which general sensibility was abolished,
but a lighted paper rotated rapidly before the eyes gave rise to
tremors of the limbs, and strong odors induced slight movement,
redness of the cheeks, lachrymation, acceleration of the pulse, and
elevation of the temperature.

Hyperæsthesia, although rare, has been noted in a few isolated

cases of catalepsy. Puel records a case in which, during the
cataleptic paroxysm, the slightest touch or noise caused the patient
to grind the teeth and cry out. In some cases sensibility to certain
special impressions, as to a strong current of electricity, has been
retained, while all others were abolished. In a case of hystero-
catalepsy at the Philadelphia Hospital, when all other measures had
failed an attack was aborted and evidence of pain produced by the
application of a strong faradic current with metallic electrodes.

A marked change in the state of reflex irritability is another of the

striking symptoms of true catalepsy. Varying conditions as to reflex
irritability have been observed by different authors. So far as I am
aware, few special observations have been made upon the tendon
reflexes in catalepsy. In the case of De Schweinitz the knee-jerk was
apparently absent on one side and present on the other, although
the cataleptic symptoms were not unilateral.
The symptom known as flexibilitas cerea, or wax-like flexibility, to
which I have referred under Synonyms, is, as has been stated, by
some considered pathognomonic of this affection. While I do not
hold to this view, I regard the symptom as the most important
phenomenon of the disease. It is a symptom which from its very
nature can be, up to a certain point, readily shammed, and when
considering Diagnosis some methods of determining its genuineness
will be given.

Careful observation as to the pulse, respiration, and temperature are

lacking in the reported cases of catalepsy. According to Eulenburg,11
“the respiration is generally of normal frequency, sometimes rather
slow, more frequently of diminished or irregular intensity, so that
lighter and deeper inspirations alternate. The pulse may also be
slower, with slight excursion and diminished tension of the arteries.
The temperature generally remains normal, but in certain cases is
decidedly lowered.” The lowering of temperature, and particularly the
presence of extreme coldness of the surface, with exceedingly weak
pulse and respiration, have doubtless always been present in the
cases—a few, at least, authentic—in which catalepsy has been
supposed to be death.
11 Op. cit.

Hypnotic Catalepsy.

The investigations into the subject of hypnotism made in recent

years have given to the profession a series of interesting
phenomena which should be considered, at least briefly, under the
symptomatology of catalepsy. In a general review of the subject of
hypnotism12 by me many of the facts observed and theories
advanced by Braid, Heidenhain, Charcot, Richer, and others were
examined. I will here recall those observations of Heidenhain13 and
of Charcot and Richer14 which relate to the production of a cataleptic
or cataleptoid state, and to the phenomena which take place in this
state.
12 Am. Journ. Med. Science, Jan., 1882.

13 Animal Magnetism: Physiological Observations, by Rudolph Heidenhain, Prof.

Physiology in the University of Breslau, London, 1880.

14 Etudes cliniques sur l'Hystero-epilepsie, ou Grande Hystérie.

The method of Heidenhain was similar to that employed by Braid.

The latter, however, did not make use of passes. In the first place,
the individual was made to gaze fixedly at a shining faceted glass
button for some six or eight minutes, the visual axes being made to
converge as much as possible. Heidenhain, like Braid, found the
most advantageous direction of the visual axes to be that of upward
convergence. According to Carpenter, in the fixation this upward
convergence is very important; it suffices of itself in blind people or in
the night to produce hypnosis. After the fixation of gaze had been
continued for some six or eight minutes, the operator stroked over
the face, without immediately touching the surface, from the
forehead to the chest, after each pass bringing the hands, which
were warm, around in an arc to the forehead again. He either
allowed the eyelids to be closed or gently closed them. After ten or
twelve passes he asked the person to open his eyes. When this
occurred without hesitation or with only slight difficulty, he again
made the person stare at the glass for some six minutes, and then
repeated the passes, which often brought about the hypnotic state
when the simple fixation did not succeed.

The symptoms of the hypnotic state were in the main those which
have just been described as the symptoms of catalepsy—namely,
diminution of consciousness, insensibility, increased reflex irritability,
and fixity of the body or limbs in any position given.

In the slighter forms of hypnotism the subjects were able to

remember what had occurred during their apparent sleep. In more
fully-developed forms they had no remembrance of what had taken
place, but by giving hints and leading questions of their various
actions they were able to call them to mind. In the most complete
forms of hypnotism no remembrance whatever was retained. It can
nevertheless be proved that even during the most completely
developed hypnosis sensory perceptions take place, but they are no
longer converted into conscious ideas, and consequently are not
retained by the memory; and this is undoubtedly because the
hypnotized individuals have lost the power of directing their attention
to their sensations.

A symptom of the hypnotic state in its most complete development

was highly marked insensibility to pain. A pin could be run right into
the hand, and only an indistinct feeling of contact was brought about.
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.
 Unilateral Catalepsy.

Hemi-catalepsy or unilateral catalepsy is sometimes observed, and

has been studied both in hypnotic investigations and as a special
nervous affection. Charcot and Richer found that hemi-catalepsy or
lethargy may be produced on a patient, and that they may both exist
simultaneously in the same subject. When, for instance, a patient
was plunged into the cataleptic state under the influence of a bright
light, shutting with the hand one of the eyes, the patient at once
became lethargic on the same side only; the other side remained
cataleptic. Heidenhain and Gruetzner studied some remarkable
phenomena, which they have recorded under the name of unilateral
hypnosis, in which some surprising sensory disturbances occur.
They also found, among other things, a striking disturbance in the
process of accommodation and in the perception of colors in the eye
of the cataleptic side. In a case of hystero-epilepsy upon which I
performed numerous hypnotic experiments which have been
reported15 the patient nearly always presented unilateral cataleptic
phenomena. These were present on the left side, the patient being
subject to convulsions which were more marked on the right side,
this being also much wasted.
15 Philadelphia Med. Times, Nov. 19, 1881.

I witnessed some curious unilateral cataleptoid phenomena in the

case of a medical friend, who has made a note of his experience.16
He says: “In the course of some experiments on table-tipping, which
were conducted mainly to satisfy the curiosity of persons who had
never seen anything of the kind, I became the subject of a very
peculiar and marked hypnotic influence. The ordinary tricks of
tipping, answering questions, guessing numbers, etc. had been
performed with the table, during the greater part of which I had been
one of the circle, when my right hand began to contract so as to form
an arch, and was then lifted from the table. These movements were
not volitional; I was unable to control them. While my hand was in
this position one of the persons sitting at the table suddenly put his
hand on my forehead, and I sank back in the chair, passing into a
conscious but apparently powerless state, but only for a few
moments. Later in the evening the hypnotic influence in the right
hand was still more distinctly manifested. If allowed to remain a short
time on the table, the fingers began to vibrate vertically and
horizontally, the motion finally extending to the forearm and
becoming so violent as to throw the hand about in a rapid and
forcible manner. While thus affected I found it utterly impossible to
sign my name. I would be able to form the first letter or so, and then
most extraordinary gyrations would be made. In one instance I wrote
very slowly, using all the muscular control at my command, and
succeeded in writing the full name, but in a form wholly different from
my ordinary signature.”
16 Polyclinic, Sept. 15, 1883.

My attention was called to these phenomena, and the experiments

were repeated the next week in my presence, with like results. In
addition, I succeeded in forcibly placing the affected arm in various
positions—bent at right angles, the hand resting on the top of the
head, etc.—from which positions he was unable to move it. He
seemed to have lost the connection between volition and the motor
impulse. The experiments were continued for several hours at each
sitting, but owing to the depressed mental state which was produced
for a short time, apparently by them, they have not been repeated.

Occasionally, cases of unilateral catalepsy associated with rotatory

phenomena are met with, especially in hysterical children. In 1882, I
studied in the nervous dispensary of the hospital of the University of
Pennsylvania an interesting case with rotatory and unilateral
cataleptoid symptoms. This case has been reported by James
Hendrie Lloyd.17 The patient was a boy eight years old. His paternal
grandfather hanged himself. On the mother's side there was a
history of tuberculosis. Two years before coming to the hospital he
had had four attacks of spasms. For two weeks he had been having
from twelve to twenty similar spasms daily; some of these were
observed in the dispensary. “The boy's head was suddenly drawn
upward and to the right to its extreme limits by the action chiefly of
the sterno-cleido-mastoid muscle. The eyes turned also to the
extreme right, with slight convulsive (clonic) action, and became
fixed in that position, with very wide dilatation of the pupils. In a
second or two he began to rotate his whole body to the right, and
turned completely around, perhaps ten or twelve times. On some
occasions he had fallen down, his mother said, toward the end of the
spell. If taken hold of and steadied—which required but little force by
the physician—the rotation could be stopped, though the head and
eyes remained drawn, and the boy's arms could be placed in any
desired position. If now he was once more let loose, his body again
rotated, while his arms were held in true cataleptoid rigidity. The
whole duration of the attack was from one half to one minute. The
boy was intelligent, and said he knew what was taking place about
him while he was in the fit, though he gave no satisfactory evidence
of such knowledge at the time. There was no history of headache or
any disease. His ears were subsequently examined and found
normal. He had taken worm medicine in abundance from the family
physician without results. There were no psychical traits of
importance to suggest foolish or wilful simulation. The only accident
had been a fall from a wagon years previously. As the patient had an
adherent prepuce, Wood advised circumcision, and took pains to
explain the operation to the mother. This evidently made a great
impression on the child's mind, which is worthy of notice in
considering the case. The potassium bromide was continued. At the
third visit, which had been appointed for the operation of
circumcision, the mother reported the patient much better. The boy
had been having great fear of the proposed operation, and now said
that he thought he could control the spells. A psychical element was
thus distinctly indicated, and its likeness to chorea major to some
extent increased. It was thought best, however, instead of
circumcision, to break up adhesions and retract the foreskin, which
was done by J. William White. At the fourth visit, after ten days, a still
greater improvement was noted.”
17 Philada. Med. Times, vol. xii., June 17, 1882.
Lloyd in reporting this case discusses the physiology of the
condition, and refers to other cases in medical literature. According
to Brown-Séquard, the great cause of rotation phenomena is a
convulsive contraction in some of the muscles on one side of the
body. Carpenter believes they are due to weakness of the sensori-
motor apparatus of one side. Laycock holds that the cerebellum is
involved. Lloyd likens the case to chorea major. He refers to cases
reported by Radcliffe18 and J. Andrew Crawford.19
18 Reynolds's System of Medicine, art. “Chorea.”

19 Cycl. of Pract. Medicine, art. “Chorea.”

At the Pennsylvania Training School for Feeble-minded Children at

Elwyn is a little patient familiarly spoken of as the Dervish. I have
examined this boy several times, and have frequently watched his
performances. I. N. Kerlin, superintendent of the institution, has
kindly furnished me with some notes of this case. The antecedents
of the patient are unknown. He is about fifteen years of age, is of
small stature and weight, a demi-microcephalic, epileptic, and mute
idiot. His epilepsy, however, supervened only in 1884, and the
seizures continue now at the rate of three or four a month. At all
times he is subject to certain automatic tricks with his hands, putting
and twisting them into various positions. Periodically almost during
every day he gives exhibitions of the habit which has led him to be
called the Dervish. He commences by tattooing his chin with his left
hand; next he delicately and rapidly touches the fingers of his left
hand to the wrist of the right, makes two or three salaams, and then
impulsively gyrates the body from left to right. The right heel is
pivotal, and the force is maintained by touches of the left toe or heel
upon the floor. He will usually take from three to seven turns at a
time, with a salaam or two between every series. Fifteen minutes or
more will be thus consumed before he darts away toward a window,
where he remains a few moments in a dazed state, from which he
rouses to recommence his hand tricks. Perhaps he will select a
broad belt of light in which to display his hand for visual enjoyment.
He has a cataract of the right lens, and possibly partial amaurosis of
the left eye. A supplemental performance sometimes indulged in is
to stand at one fixed point and throw his head and shoulders from
side to side, describing with the former two-thirds of a circle, the
occiput being flexed backward as far as the neck will permit. These
movements, rapidly made, reach three and four hundred under
favorable conditions.

Kerlin regards the displays made by this boy to be the pure

automatic phenomena of idiocy which have been developed to an
artistic finish, and out of which the patient gets enjoyment. This
enjoyment probably exists in some anæsthetic or stuporous
condition of certain nerve-centres, something like the sensation of
common dizziness. He does not look upon the case, therefore, as
one of genuine catalepsy, but I have recorded it here in connection
with the case just given because it illustrates a phase of automatism
and rotation movements closely allied to cataleptoid conditions.

Catalepsy and Cataleptoid Phenomena among the Insane.

Catalepsy and cataleptoid or cataleptic phenomena are of

comparatively frequent occurrence among the insane. Niemeyer
says20 that they are especially common among persons suffering
from melancholia. Kahlbaum21 has described a form of insanity
which he names katatonia, from the Greek κατατονος, stretching
down. This disease is “characterized by alternate periods,
supervening with more or less regularity, of acute mania,
melancholia, and epileptoid and cataleptoid states, with delusions of
an exalted character and a tendency to dramatism.”22
20 Textbook of Practical Medicine, Felix von Niemeyer, American trans., 1876, vol. ii.
p. 387.

21 Klinische Abhandlungen über psychische Krankheiten, 1 Heft, “Die Katatonie,”

Berlin, 1874.
 22 A Treatise on Insanity in its Medical Relations, by William A. Hammond, M.D., New
York, 1883, p. 576.

Kiernan23 has written a valuable memoir on this affection. He has

collected fifty cases, a few of which he gives in detail. Hammond and
Spitzka discuss the disorder, giving new cases, in their treatises on
insanity.
23 American Journal of Insanity, July, 1877, and Alienist and Neurologist, October,
1882.

Katatonia may begin in various ways, but it usually pursues a certain

cycle. First appears stuporous melancholia, accompanied or
followed by cataleptoid manifestations; then a period of mania with
illusions, hallucinations, and delusions. Melancholia reappears in
some form, with cataleptoid, waxy condition of the muscles, and a
disposition to talk in a pompous or dramatic manner; convulsions or
choreic movements may be present.24 Sometimes some phase of
the cycle is absent.
24 Hammond.

In some cases in which the peculiar cycle and special phenomena

which characterize katatonia are not present marked cataleptic or
cataleptoid states may be observed among the insane, either as
episodes or as long-continuing conditions.

As cases illustrating cataleptoid phenomena among the insane have

not yet been published in large number, and are not well understood,
I will record here, under the Symptomatology of Catalepsy, some
illustrative cases which have either fallen under my own observation
or have been supplied to me directly by medical friends.

M. A. Avery, assistant physician to the insane department of the

Philadelphia Hospital, has kindly furnished notes of the following
interesting case:
T——, aged twenty, single, dressmaker. The patient was somewhat
below medium height, slender and emaciated, of nervous
temperament, expression melancholy. The attack of insanity for
which she was admitted was her first. It began four months before
admission. No satisfactory history of the attack could be obtained;
she was said to have been depressed in spirits and to have
delusions of poisoning. She had attempted suicide by throwing
herself from the window.

Upon admission, Sept. 20, 1883, she was quiet and gentle in her
manner, but much depressed; she answered questions rationally. No
delusions were detected. Sept. 21st she sat quiet and motionless.
Her eyes were fixed, with marked double, inward squint. She was
apparently insensible to external impressions. This condition lasted
about three hours, when she suddenly sprang up, rushed through
the ward, and made vigorous efforts to escape. On the 22d she lay
in bed in a perfectly passive state, with eyes open and fixed, but the
squint had disappeared. There was a constant slight tremor of the
lids. The conjunctiva was apparently insensible to touch. She
seemed to be unconscious of what was going on around her. Her
arms remained raised in any position in which they were placed.
About three o'clock in the afternoon this condition passed away, and
from that time until she went to bed at eight o'clock she was bright
and cheerful and talked in a rational and intelligent manner. For five
days she was quiet and melancholy, with one spell of a few hours in
which she was in a passive and cataleptic state, as on the 22d.

On the 28th she stood erect with arms extended, whirling rapidly.
She continued this for about half an hour, and then, after a short rest,
began again. She paid no attention to what was said to her, and
seemed unconscious of what took place around her. The next day
she remained in a stupid condition most of the time, but occasionally
sprang up and danced violently or spun round rapidly with arms
extended for a few moments at a time. On the 30th her cataleptic
condition was uninterrupted. She lay motionless, with pulse slow and
feeble, extremities cold; her limbs were easily placed in any desired
position, and remained so for about twenty minutes; then they
returned slowly to a more natural and comfortable position. She
continued for several days in this condition, then aroused and ate
heartily. She seemed brighter and more cheerful, 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.

Wilks25 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.
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 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