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“Wilma S. Bucci, Ph.D., who works on the border of cognitive science and
psychoanalysis, incisively delineates her most recent systematic theory of
human psychological organization. Rooted in current scientific research in
cognitive science and affective and social neuroscience, Bucci masterfully
applies her understandings of the formation and transformation of
emotional schemas to the change processes that occur in psychoanalysis and
psychotherapy. She treats us to a conceptual revision of such phenomena
as unconscious processes and to verbal and non-​verbal (sensorial) symbolic
processes. I believe this book will become a landmark in contemporary
applications of cognitive science to the theories and practice of psychoanalysis
and psychotherapies. This is a must-​read for all serious students of the
human mind.”
James L. Fosshage Ph.D.,
Clinical Professor, NYU Postdoctoral Program of
Psychotherapy and Psychoanalysis,
co-​founding Board Director and Faculty, National
Institute for the Psychotherapies,
Founding Faculty, Institute for the Psychoanalytic Study of Subjectivity

“This is a really important book. It answers the fundamental question of

both psychoanalytic theory and practice: Where do our worded thoughts
fit with the sprawling scenery of images, feeling, gesture, and emotions that
furnish our living world? To answer, Bucci reminds us that emotion and
cognition are not so distinct after all. Whether orienting us in continuous
dimensions or by neat symbols, they work together to interpret our world,
and Bucci’s mission is to describe the nature of that partnership. It has been
hard to get a scientific focus on non-​symbolic awareness. Bucci’s solution is to
use recent neurophysiological findings to particularize the unworded material
that feeds articulated reflection. That, in turn, suggests a new picture of
psychopathology, and a clearer and extremely plausible theory of therapeutic
action.
Not the least of Bucci’s accomplishments is to offer a more than
usually convincing demonstration that hard science can advance real-​life
psychoanalysis. Bucci’s classification of expression into symbolic (language),
sub-​symbolic and emotion schemas has helped expand our empathic
repertoire. This book will give the practitioner a new respect for the centrality
of nuance, a new tolerance for dimensional thinking, and a bit of a vacation
from categorical prisons.”
Lawrence Friedman, M.D.,
Clinical Professor of Psychiatry, Weill-​Cornell Medical College
Faculty, Psychoanalytic Association of New York
Affiliated with NYU School of Medicine
“Over 20 years ago, Wilma Bucci broke new ground with her ingenious
development of multiple code theory. As a result she had been regarded as
one of the most brilliant and creative minds in the psychoanalytic world.
However, with this extraordinary new book she has truly outdone herself.
Dr. Bucci has redefined the relationship between mind and body, and between
emotion and cognition in a compelling integrative effort that will change
forever the way we think about psychoanalytic and psychotherapeutic work.
I highly recommend this new contribution to our field to all those in the
mental health professions.”
Glen O. Gabbard, M.D.,
Clinical Professor of Psychiatry, Baylor College of Medicine

“A lot has been said and written on how the two contexts of our field—​clinical
and experimental—​can come together, but this book marvelously stands
out among the many attempts at exploring the interface between these two
contexts. Wilma Bucci goes directly into the heart of psychotherapy process,
and she does so in a truly interdisciplinary way: she looks simultaneously
from different perspectives such as psychoanalysis, cognitive psychology
and affective and social neuroscience. This is just what is needed, and the
theoretical parts come alive through many clinical vignettes. We also receive
a clear picture of the new developments of Wilma Bucci’s line of research
following her 1997 book, Psychoanalysis and Cognitive Science: A Multiple
Code Theory. This new book should be read by all those who are really
interested in the revision of psychoanalytic metapsychology and in the
scientific standing of psychoanalysis today.”
Paolo Migone, M.D.
Editor, Psicoterapia e Scienze Umane
(“Psychotherapy and the Human Sciences”)
www.psicoterapiaescienzeumane.it

“I have always had the utmost respect for Wilma Bucci’s thinking. I believe
it is important—​even classic. So, despite the fact that she and I don’t always
agree, I am delighted to see this body of work brought together in a single
source. The field of psychoanalysis and, more broadly, cognitive and affective
neuroscience, need this collection. Here you will find statements of dual/​
multiple code theory, for which Bucci is justly famous, as well as elaborations
and clinical applications of those views, including vivid case material. Bucci’s
highly significant work on dissociation—​classic in its own right—​is here too.
Psychoanalysts and their sympathizers should count their blessings that Bucci
has been there to represent them in the wider world of cognitive psychology
and neuroscience. This is a book with which every student of psychoanalysis
and neuroscience should be familiar.”
Donnel B. Stern, William Alanson White Institute, New York
Emotional Communication
and Therapeutic Change

In this book, Wilma Bucci applies her skills as a cognitive psychologist and
researcher to the fields of psychoanalysis and psychotherapy, opening up new
avenues for understanding the underlying processes that facilitate therapeutic
communication and change. Grounded in research geared to understanding
and demonstrating the clinical process (rather than the “outcome”) of ana-
lytic inquiry and therapeutic dialogue, Bucci’s multiple code theory offers
clinicians, researchers, trainers, and students new perspectives on the essen-
tial, often unlanguaged, foundations of the psychotherapeutic endeavor.

Wilma Bucci is Professor Emerita, Derner Institute of Adelphi University;

Co-​Director of Research at The New York Psychoanalytic Society and
Institute; Honorary Member of the American Psychoanalytic Association,
the New York Psychoanalytic Institute and Society, and the Institute for
Psychoanalytic Training and Research; and Member of Faculty of the
Research Training Programme of the International Psychoanalytical
Association.
Emotional Communication
and Therapeutic Change

Understanding Psychotherapy
through Multiple Code Theory

Wilma Bucci
Edited by William F. Cornell
First published 2021
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
52 Vanderbilt Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2021 Wilma Bucci
All rights reserved. No part of this book may be reprinted or reproduced or utilised
in any form or by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks,
and are used only for identification and explanation without intent to infringe.
British Library Cataloguing-​in-​Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-​in-​Publication Data
Names: Bucci, Wilma, author. | Cornell, William F., editor.
Title: Emotional communication and therapeutic change: understanding
psychotherapy through multiple code theory / authored by Wilma Bucci;
edited by William F. Cornell.
Description: Abingdon, Oxon; New York, NY: Routeldge, 2021. |
Series: Relational perspectives |
Includes bibliographical references and index.
Identifiers: LCCN 2020035687 (print) | LCCN 2020035688 (ebook) |
ISBN 9780367645601 (hbk) | ISBN 9780367645618 (pbk) |
ISBN 9781003125143 (ebk)
Subjects: LCSH: Psychotherapy. | Psychoanalysis. |
Psychotherapist and patient.
Classification: LCC RC480.B747 2021 (print) |
LCC RC480 (ebook) | DDC 616.89/14–dc23
LC record available at https://lccn.loc.gov/2020035687
LC ebook record available at https://lccn.loc.gov/2020035688
ISBN: 978-​0-​367-​64560-​1 (hbk)
ISBN: 978-​0-​367-​64561-​8 (pbk)
ISBN: 978-​1-​003-​12514-​3 (ebk)
Typeset in Times New Roman
by Newgen Publishing UK
Contents

List of figures  ix
Editor’s preface: A cognitive scientist meets the couch  xi
Acknowledgments: Building an interactive field  xx
A personal note on theory and practice  xxiv
Prologue: The need for evolution of the psychoanalytic
model  xxvi

PART I
Evolution of the basic theory: Concepts and
contexts of multiple code theory  1
1 Symptoms and symbols: A multiple code theory of
somatization  3
2 The need for a “psychoanalytic psychology” in the
cognitive science field  21
3 The referential process, consciousness, and the sense of self  41
4 Symptoms and symbols revisited: Twenty years later  61
5 The power of language in emotional life  75

PART II
Clinical perspectives on emotional communication  99
6 Converging perspectives on emotional change in the
interpersonal field  101
7 The primary process as a transitional concept: New
perspectives from cognitive psychology and affective
neuroscience  126
8 The interplay of subsymbolic and symbolic processes in
psychoanalytic treatment: It takes two to tango, but who
knows the steps and who is the leader?  144
viii Contents

9 Dissociation from the perspective of multiple code

theory—​Part I: Psychological roots and implications for
psychoanalytic treatment  156
10 Dissociation—​Part II: The spectrum of dissociative
processes in the psychoanalytic relationship  174
11 Embodied communication and therapeutic practice: In
the consulting room with Clara, Antonio, and Ann  193
12 Nobody dances tango alone: The choreography of the
analytic interchange  217

Index  223
Figures

P.1 Grounding of emotion schemas in the interpersonal field of

psychotherapy  xxxviii
3.1 Consciousness, sense of self, and emotions and feelings  44
Editor’s preface
A cognitive scientist meets the couch
William F. Cornell

Normal emotional development depends on the integration of somatic,

sensory, and motoric processes in the emotional schemas; emotional disorders
are caused by failure of this integration … These sensory experiences occur
in consonance with somatic and visceral experience of pleasure and pain, as
well as organized motoric actions involving the mouth, hands, and whole
body—​kicking, crying, sucking, rooting, and shaping one’s body to another’s.
(Bucci, 1997)

This epigraph is taken from the chapter that begins this collection of Wilma
Bucci’s writing, which I read when first published in 1997 in an issue of
Psychoanalytic Inquiry devoted to exploring “Somatization: Bodily Experience
and Mental States”. I found this paper riveting and I noticed in the reference
list that Wilma had a book in press. I bought Psychoanalysis and Cognitive
Science: A Multiple Code Theory as soon as it came out, then contacted
Wilma, beginning what has proven to be a decades-​long collaboration. It has
now been more than two decades since that first book, and we decided the time
was right to assemble a new book that gathered together many of her papers
written since then. The result, Emotional Communication and Therapeutic
Change: New visions of the “Talking Cure” Through the Lens of Multiple Code
Theory, is a collection of papers, revised lectures, and case discussions that
show a relentless, incisive, perpetually questioning mind at work.
Bucci’s multiple code theory has been a very timely arrival as efforts to
comprehend the presence and meanings of bodily experience have been emer-
ging in contemporary philosophy, psychotherapy, and psychoanalysis. Since
Freud, the verbal and symbolic order has been the primary means and vocabu-
lary of psychoanalytic treatment, but the reach and means of analytic inquiry
are now increasingly exploring visual, sensate, motoric, and visceral modes
of experience and expression within the bodies of patient and analyst alike.
Bucci titles her acknowledgments section “Building an Interactive Field,”
and she demonstrates throughout the chapters of this book her capacity to
build, question, and rebuild her models through her ongoing engagements in
a profoundly enriching interactive field of fellow cognitive and neuroscience
xii Editor’s preface

researchers, psychoanalysts, and practicing clinicians from a broad range

of disciplines. This book brings the reader a research-​based model of psy-
choanalytic processes that remains alive in its efforts to grasp and demon-
strate the therapeutic forces in psychoanalytically based treatment models.
In its pages, the cognitive scientist faces the couch and the couch faces cog-
nitive psychology and affective neuroscience research. In her personal notes
at the start of the book, Bucci describes her own experience of a somewhat
successful psychoanalysis but then writes that, “I assumed at the time that the
practitioners of the analytic treatment I was receiving had a clear scientific
understanding of the mechanisms underlying this process.” She explored the
existing literature and Freud’s meta-​psychology but did not find what she was
looking for. So she undertook a research program that has carried on (per-
haps to her surprise) for decades. In a paper not included in this book, Bucci
(2008, p. 53) offers a concise challenge to classical psychoanalytic theory that
motivated and shaped her research:

Whereas Freud’s deep and generative insight concerning the multipli-

city of the human psychical apparatus remains valid, the psychoanalytic
premise of lower or more primitive systems—​unconscious, nonverbal,
irrational—​being replaced by more advanced ones needs to be revised in
the light of current scientific knowledge. We now recognize that diverse
and complex systems exist, function, and develop side by side, within and
outside of awareness, in mature, well-​functioning adults throughout life
… The goal of treatment is better formulated as the integration, or reinte-
gration, of systems where this has been impaired, rather than as replace-
ment of one system by another.

Bucci’s research steps out of the outcome-​focused research models that have
come to pervade and pervert the functions of scientific inquiry into the psy-
chotherapeutic project and produce results that are eagerly promoted by
insurance companies, arguing that, “Comparing the outcomes of competing
theories is not useful if we do not identify the psychological mechanisms that
bring about the observed results” (Bucci 2013, p. 16). Bucci has stepped out
of the silos of preferred theories and efforts to prove that one is superior to
another. She asks a fundamental question: How can we understand and dem-
onstrate the means through which therapeutic change comes to be? Through
the evolution of her multiple code theory and the elucidation of the referential
process, Bucci has devoted herself to the study of therapeutic processes and
the identification of factors in psychodynamic therapies that foster change.
Consistent with a fundamental attitude in psychodynamic approaches to
therapy, the therapeutic work studied by Bucci is not focused primarily on the
alleviation or elimination of symptoms, but rather on grasping their meaning.
As Bucci stresses in her closing comments in Chapter 4:
 Editor’s preface xiii

A major distinction that I hope I have made clear through this chapter
and that I want to emphasize particularly here is that symptoms may
operate as symbols—​have symbolic functions—​in the sense that their
expression may enable entry into a symbolic mode. In therapy, somatic
symptoms may provide a pathway to symbolizing emotional experience
that has been dissociated, particularly where other modes of expression,
such as memories, fantasies, and dreams, may not be accessible.

Virtually every aspect of the multiple code theory calls the adequacy of
manualized, cognitive-​behavioral treatment into serious question for any
therapeutic goal beyond symptom relief and insurance reimbursement. Bucci
critiques the underlying assumptions of the theories underlying cognitive-​
behavioral models of treatment and issues a challenge to clinicians of both
psychoanalytic and cognitive behavioral models to carry out research to iden-
tify and demonstrate potentially common factors that contribute to the effi-
cacy of varying methodologies:

The field of psychotherapy research has recently focused on outcome

rather than process studies, with outcome mainly evaluated in terms of
symptoms and behaviors. This emphasis has occurred for many reasons,
including professional, ethical (and financial) considerations—​as well as
the fact that process research is difficult, time consuming and expensive.
(Bucchi 2013, p. 22)

Following a graduate education in phenomenology, I trained simultaneously

in psychodynamic psychotherapy (transactional analysis and subsequently
contemporary psychoanalysis) and a neo-​ Reichian approach to body-​
centered psychotherapy. After more than twenty years of practice, I still had
not found a coherent means of integrating these rather incompatible models,
theoretically or clinically, to my satisfaction. Freud privileged mind over
body, and language over action and affect, perspectives that have carried on
for over a century in classical psychoanalysis. Reich sought to reverse the
Freudian order, declaring that mental processes were often woven so deeply
into the warp and woof of characterological and somatic defenses as to need
to be circumvented through his body-​based interventions. It was my Reichian
training that brought the body directly into my therapeutic work. However,
in stark contrast to Freud, Reich and his followers privileged affect and
action over language and thought. Each had value, but the integration of
these models proved elusive. I got my first glimmers of means of integration
through the work of Winnicott and Bollas, but the waters remained murky.
Then along came “Symptoms and Symbols” and Cognitive Science and
Psychoanalysis, which were a revelation to me—​they provided a framework
within which I could see the potential for thinking about and truly integrating
xiv Editor’s preface

the divergent models that had informed (and sometimes frustrated) my work.
Here was the demonstration of bodily experience—​sensate and motoric—​as
a form of psychic organization, as a means of coming to know and be known
by another. The subsymbolic domains are seen through the multiple code
theory as essential forms of psychic organization, as means of knowing and
learning, informing us about ourselves and others, consciously and uncon-
sciously. There is vast potential for understanding and emotional contact
when we open ourselves to how something is said to us, as well as how we
respond in pace, tone, postural shifts, facial expression, and so on. The mul-
tiple code theory provides a structure within which language and cognition,
so valued by Freud, and affect and the body, so valued by Reich, each have a
place, a value, and necessary functions through the interrelationship of three
fundamental forms of psychic organization: verbal symbolic, nonverbal sym-
bolic, and subsymbolic. Bucci began to recognize that the key to therapeutic
change was the gradual evocation of all three modes of experience within the
therapeutic process and their gradual linkage (the referential process) within
a psychodynamic relationship that is sufficiently emotional and personally
engaged.
In his classic book, Character Analysis, Reich insists that “the beginnings of
living functioning lie much deeper than and beyond language. Over and above
this, the living organism has its own modes of expressing movement which simply
cannot be comprehended with words (Reich, 1980, p. 359, italics in original).
Reich, in many ways foreshadowing contemporary neuroscience and parent–​
infant research, grounded his therapeutic approach within the foundations of
the emotional and physical qualities of the mother–​infant relationship and
the autonomic nervous system as they were known at that time.
Winnicott, in his emphasis on the developmental indwelling of the psyche
in the soma through the mother–​infant relationship, also saw somatic experi-
ence as being at the heart of health and vitality:

Here is a body, and the psyche and the soma are not distinguished except
according to the direction from which one is looking. One can look at
the developing body or at the developing psyche. I suppose the word
psyche here means the imaginative elaboration of somatic parts, feelings,
and functions, that is, of physical aliveness … Gradually the psyche and
the soma aspects of the growing person become involved in a process of
mutual interrelation … At a later stage the live body, with its limits, and
with an inside and an outside, is felt by the individual to form the core for
the imaginative self.
(Winnicott, 1958, p. 244, italics in original)

For Winnicott, the infant discovers and elaborates the self through movement
(for which he created the notions of muscle pleasure and motility) through
their immersion in the subsymbolic realm:
 Editor’s preface xv

So in every infant there is this tendency to move and to get some kind of
muscle pleasure in movement, and to gain from the experience of moving
and meeting something …What will quite soon become aggressive
behavior is therefore at the start a simple impulse that leads to a movement
and to the beginnings of exploration.
(Winnicott, 1984, pp. 93–​94)

The summation of motility experiences contributes to the individual’s

ability to start to exist, and out of this primary identification [with the
body] to repudiate the shell and to become the core. The good enough
environment makes this possible.
(Winnicott, 1958, pp. 213–​214)

In more poetic language, Bollas extends Winnicott’s grasp of the subsymbolic:

If the developing child feels increasingly free to release the body to its
being, to embody their subjectivity, they will develop a very peculiar
expression which we know as “sensuality.” This capacity to use the senses
is an acknowledgment of the body’s freedom of movement and the sen-
sual self has matriculated desire into gestural being. But sensuality is not
achieved by the self alone.
(Bollas, 1999, pp. 152–​153)

Sensualisation is a form of embodied perception and reverie-​like phys-

ical expression, the subject moving in the physical world of body-​to-​body
communication.
(Bollas, 1999, p. 155)

Bollas infuses Winnicott’s properly British “good enough” with a vivid sense
of the eroticism and vitality of the forces of our early development.
Winnicott famously framed psychotherapy as a form of “play”:

Psychotherapy takes place in the overlap of two areas of playing, that of the
patient and that of the therapist. Psychotherapy has to do with two people
playing together. The corollary of this is that where playing is not possible
then the work done by the therapist is directed towards bringing the patient
from a state of not being able to play into a state of being able to play.
(Winnicott, 1971, p. 38, italics in original)

The thing about playing is always the precariousness of the interplay of

personal psychic reality and the experience of the control of objects. This
is the precariousness of magic itself, magic that arises in intimacy, in a
relationship that is being found to be reliable.
(Winnicott, 1971, p. 47)
xvi Editor’s preface

Contained within Winnicott’s conceptualization of play is the active (motoric

and verbal) exploration of the self in the world through movement (motility),
imagery, fantasy, and nonverbal as well as verbal exploration and communi-
cation. This conceptualization of play captures what I have come to see as the
heart of the referential process.
These sensory and motoric processes are not limited to infancy or primi-
tive states of being. As Bucci demonstrates, we do not grow out of them as
we mature; these are the vitalizing forces of life. The subsymbolic domain is
the foundation of intimacy, play, eroticism, aggression, sexuality, and nurtur-
ance throughout life. Within the context of a reasonably responsible envir-
onment, this vital domain of experience forms the basis of a resonant and
resilient sense of self. When the interpersonal/​developmental environment is
one of neglect or impingement/​trauma, the capacity to integrate experience is
diminished and the self learns to survive through varying degrees of dissoci-
ation (Chapters 9 and 10). Often split off from the experience of one’s self,
these are the formative forces that can emerge to inform and motivate dynam-
ically informed psychotherapies (Chapter 11). Bucci’s stress on the centrality
of subsymbolic experience and its gradual integration into symbolic modes,
both verbal and nonverbal, challenge many assumptions of both classical
psychoanalytic and cognitive-​behavioral theories that endeavor to explain the
treatment processes and outcomes. In my own book, Somatic Experience in
Psychoanalysis and Psychotherapy (Cornell, 2015, p. 44), I note that:

Shaping one’s body to another’s represents quite a challenge to the classical

analytic process. Somatic processes place unique demands upon psycho-
analytic theory, the psychoanalyst, and the therapeutic relationship. In
these sensori-​motoric realms, the therapeutic process becomes a kind of
psychosomatic partnership that can often be wordless, entering realms of
experience that may not easily come into the comfort and familiarity
of language. We experience the successful or unsuccessful shaping of our
bodies in all of our vital, intimate relationships of any age and develop-
mental stage. There is a fundamental knowing of self and other which
forms first through the experience of one’s body with another’s. In life,
and in psychoanalysis, healthy development involves the integration of
motoric and sensate processes within the context of a primary relation-
ship, establishing subsymbolic, somatic schemas of the self in relation to
one’s own body, to cognitive and symbolic processes, and to the desire for
and experience of the other.

It is, of course, the good enough environment, a vitalizing base (Cornell,

2001, 2015)—​be it parental or psychotherapeutic—​that facilitates the mat-
uration of the developmental/​referential process of developing one’s capacity
to utilize and move among the different modes of experience within one’s
self and in relation to others. When Winnicott speaks of the mother–​infant
xxviii Prologue

But in order to change a situation one has first to see it for what it is … To
accept one’s past—​one’s history—​is not the same thing as drowning in it;
it is learning how to use it. An invented past can never be used; it cracks
and crumbles under the pressures of life like clay in a season of drought.
How can the American Negro’s past be used? The unprecedented price
demanded—​and at this embattled hour of the world’s history—​is the
transcendence of the realities of color, of nations, and of altars.

Clearly it is not only the American Negro (using Baldwin’s term) for whom
such change is needed, but also the many people in the towns and countrysides
of America who are controlled by their fears of strange people from other
lands, or the young men who are driven to kill by their lack of power and
hope and love, and the many others—​perpetrators and victims—​about whom
we see and hear and read every day. Baldwin focuses on the need to transcend
the accepted categories of color, nations, and altars. He would probably have
referred as well to changes in the categories of gender and sexuality, but that
broadened perspective was not yet sufficiently accessible in 1962.
We can see a related process of transcending accepted categories in scien-
tific thought about the physical world. In Einstein’s general theory of rela-
tivity, the categories of space and time were redefined in terms of one another
as part of a single continuum, known as space-​time. Einstein’s discoveries
concerning the interdependence of these dimensions opened a revolution in
the characterization of the physical world that continues today.
The chapters of this book focus on the need to revise or transcend accepted
concepts and categories in the fields of psychoanalysis and psychotherapy,
and on the need for a systematic theory of psychic organization and thera-
peutic change, rooted in current scientific work and able to be examined in
a research context. In the years since the publication of my 1997 book, the
development of multiple code theory has been informed by new directions of
investigation and exponentially growing advances in knowledge concerning
emotion, cognition and somatic functions, as well as by new recognition
of the inherent interconnections of these functions—​within oneself and
with others. These advances have come from research in fields of cognitive
psychology and affective and social neuroscience. Advances in theory have
also come from the writings of clinicians based on their observations in the
therapy context.

The relativity of emotion, cognition and bodily

experience
There is increasing recognition in the field of affective neuroscience that the
functions that have been categorized as emotion and cognition are not dis-
tinct, but instead need to be redefined in terms of one another. The insep-
arability of emotion and cognition, to the point where it is misleading to
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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