A CASE OF MILD STUPOROUS INSANITY In which it was possible to induce Illusions, Hallucinations, and Automatic Acts by Suggestion. BY ALLAN MoLANE HAMILTON, M. D., and w. s. brown; M. D. REPRINTED FROM THE Neto York j^eHIcal journal for April 4, 1896. Reprinted from the New York Medical Journal for April f 1896. A CASE OF MILD STUPOROUS INSANITY IN WHICH IT WAS POSSIBLE TO INDUCE ILLUSIONS, HALLUCINATIONS, AND AUTOMATIC ACTS BY SUGGESTION. By ALLAN McLANE- HAMILTON, M. D., and w. s. brown7m.d. Those who see much of the insane are familiar with various atonic mental and physical states that are presented particularly by asylum patients and in cases of apathetic in- sanity, with mental and physical depression, which, whether they follow prodromal excitement and muscular activity or not, are attended by more or less inhibition. Some of these cases may present little or no real intellectual perversion in the true sense of the term, there being an absence of delu- sions, hallucinations, or concept disturbance; there is only a torpor, which indicates a lowering of tone of more or less gravity. These patients are at times in such a state of re- ceptivity that it is possible to convey by suggestion certain impressions and ideas which may, under proper stimuli, be converted into corresponding expressions, the blankness of the receptive apparatus and the feebleness of controlling power being such that the result is a suspension of in- Coptright. 1896, bt D. Appleton and Company. 2 MILD STUPOROUS INSANITY. hibition, so that the superior cortical cells do not act at all in a directing way, but the middle and lower cortical lay- ers alone perform their functions. In other words, there is a condition which suggests that which exists during the dream state. The muscular inactivity is one indicating an apparent suspension of will, except so far as the simplest acts are concerned, and these are possible only after the individual is roused, and are not repeated unless fresh stimuli are brought to bear. The muscular condition is sometimes one of rigidity, of a cataleptoid nature, which not only may be evoked by pas- sive movement, but seems, as it did in the case to be presently reported, to indicate a sudden disruption of com- munication between the cerebro-spinal centres and the muscles themselves-sudden distractions, which'signaled the exercise of a higher kind of power than that which inaugurated the primary action, being sufficient to create new impulses, leaving the particular voluntary act unfin- ished and the muscles in such a condition that they became the seat of cataleptoid rigidity. A well-known symptom complex, which is different from that under consideration, is catatonia, but in this there seems to be none of the extreme rigidity under considera- tion, which, as a rule, occurs under the most varying cir- cumstances. Paretic dementia and certain varieties of hys- teria are all accompanied at times by muscular stiffness, amounting sometimes to catalepsy, but in this disease the mental state is more or less clouded. Janet, in his valuable treatise upon hypnotism, alludes to the indirect forms of hallucination and delusion that may follow certain sugges- tions in insane patients, and refers to Moreau, De Tours, and others, who have studied the voluntary production or transfer of hallucinations by direct suggestion or by the influence of an existent subconscious idea which is stimu- MILD STUPOROUS INSANITY. 3 lated by primary suggestion and leads to expression of false perceptions. The peculiarity of the case the history of which we are about to relate is that at the time that certain experiments were made, there was no apparent perversion of ideas, but simply a want of energy, the patient being able, when suf- ficiently urged, to reply correctly to questions and to state facts properly ; but when an indirect act was suggested to him in such a way that the subsequent steps and conse- quences might easily be inferred, it was possible to start a train of uninhibited thought during which it was possible to draw forth the expression of hallucinations which were the creation of the original basal idea. Mr. S., born in Buffalo, is eighteen years of age, and before he became ill was engaged as clerk in a bank. There is a neurotic tendency in the family, the grandfather on the ma- ternal side having been insane, and there was also an aunt on that side who was very peculiar. About fifteen months before the present attack the pa- tient had to resign a position as telegraph operator on a rail- road, as the responsibility oppressed him and led to a nervous condition accompanied by symptoms of mental disorder; he avoided policemen, as he feared being arrested for some negli- gence while in the railroad office, etc. There is evidence that masturbation was to some extent responsible for his con- dition at this time. He recovered after a few months, and after taking a course in a business college secured employment as mes- senger in a bank. He was well and cheerful during the sum- mer, and was so industrious that at the end of the year he was promoted. His new position kept him closely confined in a badly ventilated basement, and made long hours and constant application necessary. This soon proved too great a strain, as he slept poorly and talked of his work during his sleep. Eventually he had to remain at home; was quiet, but confused ; after a few days he 4 MILD STUPOROUS INSANITY. became very restless, requiring several men to restrain him. He would wander aimlessly about the house, or endeavor to go out into the street in the middle of the night. His con- versation at this time was totally incoherent, and he took very little food. When admitted into an asylum, on January 16, 1894, the patient was scarcely able to walk and was in a semi-stuporous state; his tongue was thickly coaled, his lips and teeth were covered with soi-des, and his pulse was rapid and feeble. While he appeared to appreciate in a vague way what was occurring about him, he was too confused and apathetic for his impressions to have the .proper significance. He held on to his father's hand when he was leaving, but was not per- ceptibly distressed after he had gone. January 17th.-He was given trional, ten grains, and slept well; he seems stronger this morning and pulls at his cloth- ing; at intervals will keep all his muscles in a condition of tonic contraction for a considerable time. He does not speak except to mutter some name, and it is difficult to get him to take food. He has had a mild bronchitis and some elevation of temperature, but the temperature subsided after the obsti- nate constipation from which he was suffering had been relieved. 80th.-Is decidedly stronger, blit refuses food and is fed with a nasal tube. 83d.-Sat up nearly all day ami took a fair amount of solid food with evident relish. Some symptoms of a cataleptic tendency were observed to-day. 89th.-He sleeps well and takes his food well; he will answer questions after much urging, his replies showing that his memory and appreciation are not greatly impaired. lie is emotional at times, but this is probably due to an hysterical tendency rather than to any mental distress. The mental condition is evidently one of extreme torpor, with fleeting illusions; for example, he addressed the matron as Queen Victoria. The cataleptic tendency has grown much more pronounced. 30th.-Dr. Hamilton called and examined the patient to- MILD STUPOROUS INSANITY. 5 day; the catalepsy was well marked, the limhs remainingin any position they were placed in until the muscles were ex- hausted. As muscular rigidity is practically absent, and there is no other evidence of a lesion of the muscles, the catalepsy must be considered as a symptom of and dependent upon the peculiar mental condition. This condition is similar in some respects to that of a person under the influence of hypnotism. He receives suggestions as facts without reference to their absurdity, and as a result a suggestive illusion or hallucination is produced. For example, it was suggested that he saw a mouse on the table, and when asked if he saw one, indicated that he did, and described its attack upon an imaginary cheese. A pen and a piece of paper were placed in his hands, and he was told to eat the soup, which he attempted to do, using the penholder as a spoon and the paper as a plate. February 3d.-He was visited by relatives to-day, and, while evidently pleased to see them, he was too apathetic to speak or give expression to his pleasure. 13th.-The catalepsy is very pronounced to-day; this symptom varies from day to day and is gradually diminish- ing. There is additional evidence that it depends upon the cerebral disturbance in the fact that it is always more marked after anything which exhausts or depresses him mentally. 19th.- The patient was visited by his father and mother to- day ; though he recognized them, he remained perfectly pas- sive, and gave no evidence of affection. He wets and soils his clothes at times, and allows the saliva to dribble from his mouth- 24th.-He has been very dull and apathetic to-day, but will answer after repeated questioning. His answers are in- telligent and show that his memory and appreciation are much more active than his appearance would indicate. March 2d.-Visited by relatives who brought him flowers; he did not speak until repeatedly coaxed and encouraged. This failure to speak was undoubtedly due to the extreme cerebral torpor, as his expression indicated his pleasure ; and when he finally spoke he thanked them very kindly for the flowers, but it required an unusual stimulus to produce any response. 6 MILD STUPOROUS INSANITY. 10th.-The patient was more stupid than usual this morning and while out exercising he was encouraged to run. When once started he kept on in a straight line, and would have run into the side of the house if he had not been prevented. He plays ball considerably, tossing and catching the ball fair- ly well, but easily becoming tired. When very stupid he fre- quently leaves his arm fully extended, in the position it was in when the ball left his hand, until he sees it coming at him. If, for any reason, the ball is not returned, he will remain with his arm extended until he is spoken to or the muscles are exhausted. This cataleptic manifestation, as before stated, evidently depends upon the cerebral disturbance, and is in some re- spects analogous to an automatic action. After the impres- sion regarding the ball has produced the impulse and re- sulted in the ball being thrown, the continuance of that impulse keeps the arm extended until some other impression is received and acted upon, or exhaustion follows; the mus- cular action being continued in the same way in which it was, so as to cause him to continue to run until he came against the wall of the house. April 10th.-He conversed very intelligently this evening regarding his home and the work he had been engaged in be- fore his illness. He afterward wrote a letter, the beginning of which was connected and intelligible, but it became dis- connected toward the last, which seemed to indicate that the effort had exhausted the cerebral energy. His mental state is greatly influenced by the condition of his alimentary tract, as constipation or any disturbance of digestion will produce profound stupor. Active physical ex- ercise always makes him brighter and more responsive, though he may be very tired physically. 30th.-The patient was very stupid this morning, and would not take his food voluntarily, although every effort was made to induce him to do so. When the tube was introduced the discomfort of the operation aroused him sufficiently to make him ask to be allowed to drink the milk. We think we are warranted in concluding that in this MILD STUPOROUS INSANITY. 7 case the catalepsy was dependent entirely upon the cerebral torpor or amentia. This is evident from the fact that muscu- lar rigidity or other evidence of a lesion of the muscles was absent; it was always more pronounced after anything which caused cerebral exhaustion ; and, finally, it has gradually di- minished and at times disappeared as the patient's mental condition has improved. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. 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