Gentlemen!

When any impairment in motility—in other words, any state of general immobility—is manifest, we can learn nothing from this fact about the patient’s internal processes, his state of mind, and current ideation. Facial expressions leaves us none the wiser, for akinesia often extends through this aspect of expressive movements, so that a simple ‘demented’ [Ed] expression may be the result of the absence [Ed] of any expression. As a consequence, it is not possible to present a pure case of akinetic motility psychosis from the clinic; or at least, we cannot be sure that the case is pure, until the patient returns from a motionless state to give us information about his internal processes. This awkward position is, of course, merely the result of our lack of knowledge, and we must not despair of succeeding later on in recognizing, from its own definite and specific signs, a pure akinetic state. At the time of when immobility actually exists from its own definite and specific signs. However, at present I must limit myself to singling out a few examples of akinetic motility psychosis, as can best be used for teaching purposes. For this it might be most suitable to report on Frau K. (p. 223 seq), who I presented to you in a stage of remission from a hyperkinetic motility psychosis. This patient then progressed to a state of general immobility, interrupted by only brief periods of hyperkinesia; the immobility has been presented as permanent, because a loss of basic strength indicated that an unfavourable outcome was likely, and yet, it was actually transitory. She is therefore an example of the akinetic phase of a ‘cyclical motility psychosis’ [Ed], in which both phases are involved, rather than the motility phase alone. The report of the demonstration runs as follows:

On pricking her hands, very similar behaviour is seen. Initially they are turned back and forth, but are not withdrawn, although they are in no way restrained, being allowed to rest freely on the open palms of the examiner. The right hand in particular is not withdrawn.

On pricking her cheeks, nose, and lips with a needle, she contorts her face in a markedly painful way and starts to cry with suppressed sobs. Thus, reactive akinesia can be interrupted by painful irritation.

The patient is requested to sit up, but remains immobile, so she is raised up in bed.

Reaction of the patient to incentives for activating movement: When requested to stand up, she moves her legs a little as though attempting it, but falls backward with her trunk in a recumbent posture. She is then raised up again to a sitting position, whereupon, in spite of a proven good intention, she crosses her legs in a totally inappropriate manner. On further encouragement she attempts to get up, but succeeds only with considerable assistance. She is now taken by the hand and led around the room, offering no resistance, although at each step she must be given a slight tug on the hand. Her gait is of a clockwork character, individual steps being separated by marked pauses. In standing, her knees are slightly bent, feet together, and she sways back and forth, but does not adopt a stable position on her feet.

When once again, she is stood up, the patient, who has not stopped sobbing since being pricked with the needle, sways markedly, yet is supported by a female attendant, and apart from blinking more often, does not react in any way to demands made of her. She has to be put back to bed again, and is carried out.

It had been established in this patient, that during the hyperkinetic phase and in transitional periods between the opposite phases, in addition to motility, her orientation was affected by the disease, in all three areas of consciousness. I therefore chose the next case chiefly because she represents an unusually pure example of akinetic—or rather parakinetic—symptoms by themselves, while orientation remains quite normal; and not so much as a hint could be found in this female patient – who readily provided us with any information we required – of any explanatory delusions. Apart from headaches, any abnormal sensations about which the patient complained were probably exclusively aberrant ones from muscles, or ones of position, therefore to be classed amongst disorders of psychomotor identification (see later). The case involved a 47-year-old spinster, sister of a physician, so that her retrospective statements are unusually reliable.

Until the beginning of her illness, she had been a science teacher in a middle school, had no heredity taint, was formerly in good health, and became ill in September, 1897, in connection with menstruation. Her difficulties were thought initially to be hysterical, but increased over a few weeks to a state of general immobility. Tube feeding was needed for some weeks. Akinesia gradually remitted but stereotyped movements appeared. In place of mutism, there was verbigeration, but no real hyperkinesia. Encouragement and verbal suggestion led to improvement in her speech. There was then a cessation of all symptoms, giving us hope of full restitution. However, a relapse occurred in October 1898, similar to the present one, but worse, according to the patient’s own statement. Her left hand became constantly clenched into a fist. After a few weeks, there was another remission, with progressive improvement almost to the point of free mobility. According to her physician brother she was then apparently normal for a few weeks. Three to four weeks ago, another relapse took place, again coinciding with onset of menstruation. According to the patient, it is now becoming worse, day by day.

Condition on 8 May, 1899: Nutrition level good, distorted features; organs and bodily functions in good order. Patient sits in a fixed position, left hand on the crown of her head, eyes straight ahead, paper and pencil lying on the table in front of her. Expression unhappy, perplexed; outburst of tears on seeing her brother. Facial expression not fixed, changing in comprehensible ways during the course of the examination. Patient stands up spontaneously, seizes paper and pencil in the right hand, indicates that she wants to go to the next room, her usual abode, sits there in her accustomed place, eyes directed to a fixed place on the opposite wall. This gaze is maintained forcibly, so that she looks neither at the questioner, nor down when she is writing. All answers are in writing, hastily written with the lead pencil in abbreviated form: For instance, to the question, ‘why so excited?’ [Ed]:—‘Can’t help it’. Complete mutism, yet, with urging, she attempts to repeat, but with evident effort. Instead of pronouncing the auditioned word ‘Anna’, prolonged verbigeration took place of the syllable ‘ruh-ruh…’, finally to be lost in toneless, rhythmic repetition of ‘r-r’. She denies that she can poke out her tongue; but then, after several attempts, succeeds spasmodically for an instant. Instead of written answers, often makes intelligent gestures, which she otherwise prefers to employ. However, both hands are usually occupied: one is always pressed to the back part of the crown of her head, the other, with its index finger extended, rhythmically taps some part of the body, face, trunk, or thighs.

Stress and many sleeping drugs were given as the cause of the illness. Had been worse in October. The following are excerpts from the patient’s written statements: She must cry, is confused, complains of restlessness, but not of anxiety, knows and understands everything, can write, but the examination strains her, it is hard for her to keep her eyes open. The brain is sound, only the brain nerves are sick. Writes name, age; that she has menstruated every 3 weeks. She definitely denies external influences, electricity, secret forces, and voices. When she closes her eyes, she sees bright colours. She must be watched, when she closes her eyes.

She leans back as if exhausted, closes her eyes, lets her right hand fall over the arm of the sofa, the left remaining on her head. The right hand now makes rhythmical convulsive movements. On my remarking that this is involuntary, a fleeting look of thanks, patient grasps my hand with her right and carries it to her mouth to kiss it. On passive removal of the left hand from her head—but at times spontaneously also—the right hand replaces the left on her head. However, the right hand is always used for any activities, although the left is freely movable. However, she is unable to offer me her right hand on leaving, making helpless gestures instead. Spontaneous gestures are few, then hasty, most often changing location as a result of inner restlessness. No flexibility. Patient must be waited upon, but is tidy, and willingly fed with a spoon. Sleep and nutrition good. Full understanding of the situation, becoming dependent on her ‘care-giver’, satisfactory interest and memory of daily events.

With some resistance the patient is brought to sit in a chair by the window and to fixate on a finger held before her; and for a moment she seems able to move her eyes voluntarily, yet the haste with which she strives to return her gaze to their former direction prevents a definite statement. As for the relationship that a certain spot on the wall has with her eye movements, it is impossible to learn anything positive despite all efforts. She tries to convey by various gestures that such a relationship does indeed exist; but she definitely denies that it is a command, electricity, magnetism, or some secret force.

It is very rare that such good information can be obtained in akinetic motility psychosis during its actual presence. Evidently it is possible only when the area of akinesia is as circumscribed as in this patient. However, this circumscribed condition is correspondingly rare amongst acutely ill cases.

Several more examples of akinetic motility psychoses provide us with further information about the quintessential symptoms belonging here. The first comes from my time in Berlin:

This 33-year-old university Professor B. had suffered severe articular rheumatism 3 years before, then remained healthy, and had no familial tendency to nervous disorders. For 2 years he has laboured beyond his strength on a scientific project. Three days prior to his mental illness he had an attack of dysentery with bloody stools, marked meteorism, and very intense pain. He is markedly run down physically, became delirious, mistook people’s identities, had visions, saw devils, and heard voices. This condition worsened, and, simultaneously a general muscular rigidity set in, at first in paroxysms, and then with longer duration. After 2 days of being almost motionless, he held a crucifix in his hand, convulsively, for half a day; raved excitedly about the devil; uttered inarticulate sounds, especially at night. Then these reactions to aberrant sensations ceased, and he remained in a perfectly motionless state for 8 days, usually accompanied by muscular rigidity, generally keeping his eyes tightly closed. He could swallow fluids occasionally, while at other times he spat out everything, and voided excreta into his clothes. In this condition he was taken by carriage to a mental institution, but because of his rigidity, could be transferred in and out of the carriage only with difficulty, and sat leaning back, poorly supported, with arms and legs stiffly extended. He could then be led into his room, or—actually—was slowly pushed. Absolute mutism prevailed, interrupted only from the third day of his stay in the institution by several hours of inarticulate outcries. Witless facial expression. On the 11th day of illness muscular rigidity ceased. On being addressed, lip movements but no sound; however, occasionally opens his eyes. Marked frailty during the following days, generally perfectly motionless, but occasional outcries. Patient then began to leave his bed occasionally; stood at the window for prolonged periods with raised, outstretched arms, and cried out several times. Went into the corridor in his night dress, once answered very slowly and softly: ‘I do not know’. On the 14th day, the first spontaneous utterance: Patient said to his attendant: ‘Look, Carl, see how I am’. The following day it was learned that the patient had pain over his entire body; does not know who he is, where he is, claims he has no head, and has been quartered. Speech is slow and childlike. Every request is felt to be arduous. On the 19th day, with his hand grasping his head: ‘This is not my head, my head has been exchanged, I have a strange head, I am perfectly hollow’. From the 22 day on: marked improvement, better statements; patient is tidy. Feeling in his head as though it were sore—a confused feeling, patient feels that he is very severely ill, and asks for reports. Then continued improvement, tries to orientate himself; provides information on his thoughts during the severe illness. He sometimes felt that his brain consisted of many parts, which moved up and down; at other times as if he had no brain, but a piece of ice in his head. Patient remembers that he had considered himself to be a steamship (an explanatory delusion), that he did believe that he has been the undoing of navigation on the Rhine, in that he has twisted all the rudders. He has believed the world would be separated and has been able to bring it back together, has been in the royal palace, destroyed the floor there, and then tried to replace it with tile; Prince Bismarck came and gave him a malicious look. Patient wonders how such perverse ideas can arise in a person. He knows no reason for the muscular rigidity. Progressive increase in insight into the illness, sleep and appetite good, appearance improved. A few complaints of an uncomfortable feeling of pressure at a certain place in the left parietal region, which later occurred only intermittently. Six weeks after onset of the illness, in full convalescence. After a consultation and a bad night following this, a state of mild excitement occurred, in which the patient accused himself of an indiscretion the day before, talked hurriedly in a tremulous voice, trembled all over, made nervous movements with his hands, began to cry. He was pacified by encouragement, later was in a stable mood, only occasionally complains of pressure in the head as described above, or of a pulsation in the head: a feeling as if the brain were moving back and forth. These troubles gradually disappeared, and about 6 months after the outbreak of his illness the patient was discharged from the institution, fully recovered. Since then 12 years have raced by, during which time, the patient, an honoured professor, has been functioning perfectly well in his former position.

An even more acute type of illness is presented by the 26-year-old Doctor of Laws, of Jewish descent, who I was able to present to you a few days ago. He had become acutely ill with anxious ideas and most profoundly disarrayed, had refused food for several days and made four suicide attempts, all of which, fortunately, had been averted. We found him sitting in bed with congested face, hot head, feverish appearance, his pulse was not accelerated, yet remarkably weak. His facial expression was somewhat rigid and immobile. Patient did not answer any questions, but followed the questioner with his eyes. He did not comply with any requests, did not show his tongue, or open his mouth. Our efforts to prise apart his lips brought about rather the opposite effect—involuntary closure; the grasped hand was held as though it raised his hackles. Otherwise, the patient sat quite immovable, in a normal posture, except that, from time to time, slight shivering and trembling movements occurred, as if a cold shiver were passing over his body. If the patient was taken out of bed—to which he offered no, or only slight resistance—it was noticed that he tottered, and did not have full command of his movements. Finally he succeeded in standing alone, and then, it was striking that he held his right leg half-bent, resting only the outer border of his foot on the floor, while the left leg gave support to his body. He remained unsupported in this position for several minutes, with the same immobile facial expression. We now attempted to put his head into another position, by bending his neck. This was met with considerable resistance, which continued beyond the medium position, so that finally he stood with head and trunk bent forward. He never used his hand to defend himself. Meanwhile, during these imposed movements he could not regain his old position, and was swaying; in this new position he shifted from one leg to another, now standing on the right, with the left half-bent and resting it only slightly on the outer border of the foot. Next day we found him squatting in bed with his legs under him; the flaccid positioning of his legs was noticeable. Today, approach of a hand triggers the withdrawal of the upper limb on approach, and of the trunk on the same side, while touching the legs has no such effect. Not a trace of any real defensive movements can be seen. I now place my right hand in the patient’s right palm; his hand then closes, while I begin to execute a slow tug with my hooked fingers. The more I pull, the more firmly he clamps his fingers against it, and so I could draw his upper body into a leaning position over the edge of the bed. He remains in this position as long as I pull, and gradually returns to his former position, once I stop pulling. This patient is now taken out of bed, and seems about to collapse, as though his lower extremities have failed him completely. But if one proceeds cautiously and supports him on both sides, we see that he can use them well; yet, owing to their abnormal position, an unusual amount of force must be employed. He remains in a squatting, almost sitting posture, with legs crossed, and is thus able to move forward unsupported, and to regain his balance when he loses it. It seems as if he might fall at any moment, yet he actually keeps himself securely on his legs. (The patient passes his excrement into his clothing, absolutely refuses food, and was tube-fed several times during the narcosis. Death from pneumonia after a few days.)

Another patient, who has also been taken ill very recently, has lain in bed groaning, answering requests very rarely, and usually seems preoccupied first in pursing her mouth, and then in everting it in snout-like fashion; she is taken out of bed and made to walk; then plants one foot before the other slowly and cautiously at definite distances in a dancing manner, somewhat like a tightrope walker. When she is left to stand quietly for a while, she rests on one leg and flexes the other, so that she touches the floor only with her toes; indeed, she also lifts it completely off the floor.