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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..6833f05 --- /dev/null +++ b/.gitattributes @@ -0,0 +1,3 @@ +* text=auto +*.txt text +*.md text diff --git a/30065-0.txt b/30065-0.txt new file mode 100644 index 0000000..5f67262 --- /dev/null +++ b/30065-0.txt @@ -0,0 +1,10002 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 30065 *** + + BENIGN STUPORS + + + THE MACMILLAN COMPANY + + NEW YORK · BOSTON · CHICAGO · DALLAS + ATLANTA · SAN FRANCISCO + + MACMILLAN & CO., Limited + + LONDON · BOMBAY · CALCUTTA + MELBOURNE + + THE MACMILLAN CO. OF CANADA, Ltd. + + TORONTO + + + + + BENIGN STUPORS + + _A STUDY OF + A NEW MANIC-DEPRESSIVE REACTION TYPE_ + + BY + + AUGUST HOCH, M.D. + + LATE DIRECTOR OF THE PSYCHIATRIC INSTITUTE OF THE + NEW YORK STATE HOSPITALS, WARD’S ISLAND, NEW + YORK. LATE PROFESSOR OF PSYCHIATRY, CORNELL + UNIVERSITY MEDICAL COLLEGE, NEW YORK + + New York + THE MACMILLAN COMPANY + 1921 + + _All rights reserved_ + + + PRINTED IN THE UNITED STATES OF AMERICA + + + Copyright, 1921, + By THE MACMILLAN COMPANY + Set up and printed. Published July, 1921. + + + Press of + J. J. Little & Ives Company + New York, U. S. A. + + + TO + MY FORMER COLLEAGUES + IN THE + NEW YORK STATE HOSPITAL SERVICE + + + + +EDITOR’S PREFACE + + +A word should be said as to the origin and history of this book. When +the late Dr. Hoch became Director of the Psychiatric Institute of the +New York State Hospitals in 1910, he found there an interest in just the +kind of psychiatric research which it was his ambition to further. His +predecessor, Adolf Meyer, had developed the conception that the +psychoses should be looked on as psychobiological reactions rather than +rigid nosological entities and had inculcated the habit of scrupulously +thorough examination and record of what the patient said and did. Meyer +had broken away from the sterile habit of making diagnoses in accordance +with the set terms used to label symptoms; and his work and that of his +assistants thus led to a collection of valuable material which could +serve as a useful starting point for the keen clinical investigation of +Hoch. Specifically, attention had already been fixed on the study of the +so-called functional psychoses, comprising what are generally termed +Dementia Præcox and Manic-Depressive Insanity. An urgent problem in this +field was to separate different reaction types in order to discover +which were recoverable and which chronic or progressive. In order to +understand psychological reactions, interrelation rather than mere +coincidence of symptoms must be studied and, to aid in this, free use +was made of the fundamental principles of unconscious mentation as +exposed in the theories of Freud and his followers. + +Almost at the outset it had been discovered that many patients presented +clinical pictures that would not fit into existing diagnostic pigeon +holes. Dr. George H. Kirby, whose skill and industry had made the most +valuable contributions to the archives of the Institute, published in +1913 a brief paper in which he pointed out, not only that many cases +with “catatonic” symptoms recovered, but also that clinically the +behavior of stupor showed it to be related to manic-depressive insanity +as well as dementia præcox. Dr. Hoch took up the problem at this point. +Using Dr. Kirby’s material and adding to it his earlier observations as +well as current cases, he endeavored to work out the essentials of the +stupor reaction. It was his ambition to describe stupor not only in its +psychiatric bearing but also as a life reaction. + +The significance of this task is to be realized only when one considers +the general import of the functional psychoses. They are, biologically, +failures of adaptation. The chronic and deteriorating cases give up the +struggle permanently, while the temporary insanities lay bare the soul +of man as he catches a glimpse of unreality but turns back to face the +world as it is. When one realizes that emotional disturbances are +characteristic of the benign psychoses, it is easy to imagine how much +such studies may ultimately illuminate the problems of normal life. + +The technical value of this work to psychiatry is more immediate. +Kraepelin laid the foundations for systematic classification with his +dementia præcox and manic-depressive groups. But the rigidity of the +latter, allegedly descriptive, term has confused the problem of +classifying many benign psychoses. It was Hoch’s ambition to prove that, +although elation and depression were the commonest mood anomalies in +this group, they had no more theoretic importance than anxiety, +distressed perplexity or apathy. These other moods, although less +frequent, are just as characteristic of the psychoses in this group. In +other words, the name “Anxiety-Apathy Insanity” would be as appropriate, +theoretically, as Kraepelin’s term. In 1919 Hoch and Kirby published a +report on the perplexity cases. This present book was designed to show +that the symptom complex centering around apathy is as distinct as that +which is recognized by all psychiatrists as mania with its predominant +characteristic of elation. + +In 1917 ill health forced Dr. Hoch to resign from his official duties. +He retired to California with the purpose of adding to psychiatric +literature the fruits of his long experience and unrivaled judgment. His +first task was this book. In the midst of this work came a sudden +collapse. As I had been in close touch with his researches, coöperating +in psychological speculations, and was free to devote some time to it, +he asked shortly before his death that I complete the book. This +obligation is incommensurate with the debt I owe for years of +inspiration, tuition and criticism. + +The task has been mainly literary. I found the first five chapters +practically completed, while it has not been difficult, as a rule, to +discover from his copious notes what his intentions were as to the +details of the following chapters. I have been greatly aided by the +assistance of Dr. Adolf Meyer and of Dr. Kirby. The latter has been good +enough to read the entire manuscript, making invaluable suggestions and +criticisms. + + John T. MacCurdy. + +New York. + + + + +TABLE OF CONTENTS + + + CHAPTER PAGE + + EDITOR’S PREFACE vii + + I. INTRODUCTION AND TYPICAL CASES OF DEEP + STUPOR 1 + + II. THE PARTIAL STUPOR REACTIONS 34 + + III. SUICIDAL CASES 50 + + IV. THE INTERFERENCES WITH THE INTELLECTUAL + PROCESSES 67 + + V. THE IDEATIONAL CONTENT OF THE STUPOR 82 + + VI. AFFECT 123 + + VII. INACTIVITY, NEGATIVISM AND CATALEPSY 132 + + VIII. SPECIAL CASES: RELATIONSHIP OF STUPOR TO + OTHER REACTIONS 149 + + IX. THE PHYSICAL MANIFESTATIONS OF STUPOR 174 + + X. PSYCHOLOGICAL EXPLANATION OF THE STUPOR + REACTION 186 + + XI. MALIGNANT STUPORS 205 + + XII. DIAGNOSIS OF STUPOR 223 + + XIII. TREATMENT OF STUPOR 229 + + XIV. SUMMARY OF THE STUPOR REACTION 234 + + XV. THE LITERATURE OF STUPOR 249 + + INDEX 279 + + + + +BENIGN STUPORS + +CHAPTER I + +INTRODUCTION AND TYPICAL CASES OF DEEP STUPOR + + +The fact that psychiatry lags in development and recognition behind +other branches of medicine is due in part to the crudity of its clinical +methods. The evolution of interest in science is from simple, obvious +and tangible problems to more intricate and impalpable researches. +Refined laboratory work has been done in psychiatric clinics, +particularly along histopathological lines, but clinical studies follow +antiquated methods. The internist does not say, “The patient has sugar +in his urine, therefore he has diabetes and therefore he will die.” He +finds a glycosuria and looks for its cause. If this symptom is found to +be related to others in such a way as to justify the diagnosis of +diabetes, a therapeutic problem arises, that of adjusting the chemistry +of the body. The prognosis depends not on the disease but the +interreaction of the organism and the morbid process. Both in diagnosis +and treatment an individual factor, the patient’s metabolism, is of +prime importance. Now in psychiatry, although the personality is +diseased, this personal factor has been almost entirely neglected. +Text-books furnish us with composite pictures which are called diseases, +not with descriptions of reactions brought about by the interplay of +personal and environmental factors. Educated people are not satisfied +with novels that fail to depict real characters. Clinical psychiatry, +however, has been content with the dime-novel type of character +delineation. This is all the more disappointing, inasmuch as the study +of insanity should contribute largely to our knowledge of everyday life. +This defect can only be remedied by looking on every case as a problem +in which the origin of each symptom is to be studied and its relation +traced to all other symptoms and to the personality as a whole. This is +an ambitious task and we do not pretend to any great achievement, merely +to a beginning. + +No better psychoses could be chosen for a preliminary effort than benign +stupors. Every psychiatrist has seen them, although they are wrongly +diagnosed as a rule, and they play no small rôle in the world’s history. +Euripides represents Orestes as having a stupor which is pictured as +accurately as any modern psychiatrist could describe an actual case.[1] +St. Paul is chronicled as falling to the ground, being thereafter blind +and going without food or drink for three days. While apparently +unconscious he had a religious vision. St. Catherine of Siena had +several unquestionable stupors, which are fairly well described. In +fact the mystics in general seem to have had communion with God and the +saints most often when they seemed unconscious to bystanders.[2] The +obsession with death, which seems so intimate a part of the stupor +reaction, is a fundamental theme in poetry, religion and philosophy. The +psychology of this interest is, speaking broadly, the psychology of +stupor. So, from a general standpoint, our problem is related to the +study of one of the most potent ideas which move the soul of man. + +Psychiatrically, stupors have long remained an unsolved riddle. In the +century prior to 1872 (See the digest of Dagonet’s publication in +Chapter XV) French psychiatrists wrote some good descriptions of stupor +and offered brilliant, though sketchy generalizations about the +condition. Two years later an English psychiatrist (Newington, See +Chapter XV) improved on the French work. Little light has been thrown on +the subject since then. The researches of the later French School showed +that stupor often occurs in the course of major hysteria, but this left +many of these episodes obviously not hysterical. When serious attempts +were made at classification, this ubiquitous symptom complex was hard to +handle. Wernicke wisely refrained from attempting more than a loose +descriptive grouping. He called all conditions with marked inactivity +and apathy “akinetic psychoses” and said that some recovered, some did +not. Taxonomic zeal began to blind vision when Kahlbaum formulated his +“Catatonia” and included stupor in the symptom complex. The condition +which we call stupor occurs in the course of many different types of +mental disease. It is true that it is frequent in catatonia but is not +exclusively there. Mongols have black hair and straight hair, but one +cannot therefore say that any black and straight haired man is a Mongol. +Fortunately Kahlbaum prevented serious error by leaving the prognosis of +his catatonia open. When Kraepelin included it in his large group of +Dementia præcox, however, it implied that stupor could not be an acute, +recoverable condition.[3] He unquestionably advanced psychiatry greatly +but his scheme was too ambitious to be accurate. Many observers saw +patients, classified as dements according to Kraepelin’s formulæ, +return, apparently normal, to normal life. Finally Kirby[4] published a +series of cases which showed decisively that this classification was too +rigid. + +Since his paper is the foundation for this present study, it should be +reviewed carefully. He first points out that Kraepelin’s “Dementia +præcox” includes much more than it should with its inevitably bad +prognosis. He shows how others have found patients with catatonic +symptom complexes proceed to recovery and speaks of these symptoms +occurring in epilepsy and even in frankly organic conditions, such as +brain tumor, general paralysis, trauma and infections. Kirby’s first +claim is that there are probably fundamentally different catatonic +processes, deteriorating and non-deteriorating. Lack of knowledge has +prevented us from understanding the meaning of the symptoms and hence +making the discrimination. He points out that stupor seems to represent +an attitude of defense, similar to feigned death in animals, and that in +a number of his cases it was clear that the stupor symbolized the death +of the patient. Apparent negativism, he found to be often a consciously +assumed attitude of aversion towards an unpleasant emotional situation. +In cases where there had been no prodromal symptoms pointing definitely +to dementia præcox the outcome was almost always good. To discriminate +the cases with good outlook from those with bad, he discerned no +difference in the stupors themselves, but observed that the mental +make-up and initial symptoms differed sufficiently for diagnosis to be +made. His most important point is, perhaps, that these benign stupors +showed a definite relationship to manic-depressive insanity in that some +patients passed directly from stupor to typical manic excitement, while +in others a “catatonic” attack replaced a depression in a circular +psychosis. + +Kirby introduces, then, the idea of stupor being a type of reaction +which can occur either in dementia præcox or in manic-depressive +insanity. The matter cannot be left there, in fact it raises new +problems: what constitutes the reaction? how are the various symptoms +interrelated? are they different in deteriorating and acute cases? what +is the teleological significance of the reaction? if it be an integral +part of the manic-depressive group, how does it affect our conceptions +of what manic-depressive insanity is? More than five years have been +spent in endeavors to answer these questions and the results of the +study are now presented. + +Naturally the first point to be settled is: what constitutes the stupor +reaction itself. We can say at the outset that it is seen in the purest +form in benign cases, hence they make up the material of this book. To +discover the symptoms of the disorder one cannot do better than to study +them in their most glaring form in deep stupors, where consistently +recurring phenomena may be assumed to be essential to the reaction. + + + CASE 1.--_Anna G._ Age: 15. Admitted to the Psychiatric + Institute July 25, 1907. + + _F. H._ The mother and two brothers were living and said to + be normal. The father died of apoplexy when the patient was + seven. + + _P. H._ The patient was sickly up to the age of seven, but + stronger after that. It is stated that she got on well at + school, though she was somewhat slow in her work. She was + inclined to be rather quiet, even when a child, a bit shy, + but she had friends and was well liked by others. After + recovery she made a frank, natural impression. She was + always rather sensitive about her red hair. She began to + work a year before admission and had two positions. The + last one she did not like very well, because, she alleged, + the girls were “too tough.” + + Three weeks before admission she came home from work and + said a girl in the shop had made remarks about her red + hair. She wanted to change her position, but she kept on + working until six days before admission. At that time her + mother kept her at home as she seemed so quiet, and when + the mother took her out for a walk she wanted to return, + because “everybody was looking” at her. For the next two + days she cried at times, and repeatedly said, “Oh, I wish I + were dead--nobody likes me--I wish I were dead and with my + father” (dead). She also called to various members of the + family, saying she wanted to tell them something, but when + they came she would only stare blankly. For a day she + followed her mother around, clung to her, said once she + wanted to say something to her, but only stared and said + nothing. + + Four days before admission she became quite immobile, lay + in bed, did not speak, eat or drink. She also had some + fever. + + The patient herself, when well, described the onset of her + psychosis as follows: She knew of no cause except that her + brother, some time before the onset (not clear how long), + was run over by an automobile and had his foot hurt. She + claimed that while still working she lost her ambition, + lost her appetite, did not feel like talking to any one; + that when she went out with her mother it merely seemed to + her that people stared at her. The day before she went to + the Observation Pavilion her cousin came to see her, and + she thought she saw, standing beside this cousin, the + latter’s dead mother. She also thought there was a fire, + and that her sister was sweeping little babies out of the + room. Then, she claimed, she felt afraid (this still on the + day before going to the Observation Pavilion) because she + had repeated visions of an old woman, a witch. This woman + said, “I am your mother, and I gave you to this woman + (i.e., patient’s real mother) when you were a baby.” She + also was afraid her mother was “going away.” + + At the _Observation Pavilion_ she was described as + constrained, staring fixedly into space, mute, requiring to + be dressed and fed. + + _Under Observation:_ 1. For five months the patient + presented a marked stupor. She was for the most part very + inactive, totally mute, staring vacantly, often not even + blinking, so that for a time the conjunctivæ were dry. She + did not swallow, but held her saliva; did not react to pin + pricks or feinting motions before her eyes. Sometimes she + retained her urine, again wet and soiled the bed. Often + there was marked catalepsy, and the retention of very + awkward positions. As a rule she was quite stiff, offering + passive resistance towards any interference. She had to be + tube-fed at first. Later she was spoon-fed, and then would + swallow, in spite of the fact that during the interval + between her feeding she would let saliva collect in her + mouth. For a time she had a tendency to hold one leg out of + bed, and when it was put back would stick the other out. + Sometimes she walked of her own accord to the toilet chair, + but on one occasion wet the floor before she got there. + + During the first month after admission, this stupor was + interrupted for two short periods by a little freer action: + she walked to a chair, sat down, smiled a little, fanned + herself very naturally when a fan was given to her, though + even then did not speak. + + There was, as a rule, no emotional reaction, but after some + months she several times wept when her mother came, though + without speaking. Once when taken to the tub she yelled. + + Her _physical condition_ during this stupor was as follows: + She menstruated freely on admission, then not again until + she was well. Several times she had rises of temperature to + 102° or 103° with a high pulse and respiration; again a + respiration of 40, with but slight rise of temperature, + though the pulse had a tendency to go to 130 and over. She + was apt to show marked skin hyperæmia wherever touched. + With the fever there was found a leucocytosis of from + 11,900 to 15,000, with marked increase of polynuclear + leucocytes (89%). She got very emaciated, so that four + months after admission she weighed 68 lbs. (height 5′ 2″). + + 2. About five months after admission she was often seen + smiling, and again weeping, and she began to talk a little + to the nurses, though not to the doctors. She also began to + eat excessively of her own accord, and rapidly gained + weight, so that by January she weighed 98½ lbs., a gain + of 30 lbs. in two months. Yet she continued to be sluggish. + + 3. For two more months she was apathetic and appeared + disinterested, often would not reply, again, at the same + interview, she would do so promptly and with natural voice. + This condition may be illustrated by the summary of a note + made on January 29, 1908, which is representative of that + period. It is stated that she sat about apathetically all + day, appeared sluggish, but was fairly neat about her + appearance and cleanly in her habits. There was at no time + any evidence of affect, except when asked by the examiner + to put out her tongue so that he could stick a pin in it + she blushed and hid her face. When asked whether she + worried about anything, she denied this. When questions + were asked, she sometimes answered promptly and in normal + voice, again simply remained silent in spite of repeated + urging. On the whole, it seemed that simple impersonal + questions were answered promptly; whereas difficult + impersonal questions or questions which referred to her + condition were not answered at all. She proved to be + oriented. Thus she gave the day of the week, month, year, + the name of the hospital, names of the doctors and nurses + promptly. She also counted quickly and did a few simple + multiplications quickly. But she was silent when asked + where the hospital was located, how long she had been here, + whether she was here one or six months, how she felt. + Questions in regard to the condition she had passed + through, or involving difficult calculations, she did not + answer. However, some questions regarding her condition + asked in such a way that they could be answered by “yes” or + “no” were again answered quite promptly. Thus when asked + whether her head felt all right she said, “Yes, sir.” (Is + your memory good?) “Yes.” (Have you been sick?) “No, sir.” + (Are you worried?) “No.” + + 4. This apathy cleared up too, so that by the middle of + March she was bright, active and smiled freely. With the + nurses she was rather talkative and pleased, though this + was not marked. Towards the physician only was she natural + and free. She then gave the _retrospective account_ of the + onset detailed above. When questioned about her condition + she claimed not to remember the Observation Pavilion, + although recalling vaguely going there in a carriage. She + was almost completely amnesic for a considerable part of + her stay in the Institute. She claimed it was only in + November or December that she began to know where she was + (five months after admission). In harmony with this is the + fact that she did not recall the tube- and spoon-feeding + which had to be resorted to for about four months of this + period. No ideas or visions were remembered. As to her + mutism she said, “I don’t think I could speak,” “I made no + effort,” again “I did not care to speak.” She claimed that + she remembered being pricked with a pin but that she did + not feel it. She remembered yelling when taken to the tub + (towards end of the marked stupor) and claimed she thought + she was to be drowned. + + When she went home (March 24, 1908) she got into a more + elated condition. She was talkative, conversed with + strangers on the street, said to her mother that she was + now sixteen years old and wanted “a fellow.” When the + mother would not allow her to go out, she said it would be + better if they both would jump out of the window and kill + themselves. She then was sent back to the hospital. In the + first part of this period after her return, she was + somewhat elated and overtalkative, though she did not + present a flight of ideas, and was well behaved. She soon + got well, however, and was discharged, four months after + her readmission, fully recovered. + + After that, it is claimed, she was perfectly well and + worked successfully most of the time with the exception of + a short period in the spring of 1909, when she was slightly + elated. + + In 1910 she had a subsequent attack, during which she was + treated at another hospital. From the description this + again seems to have been a typical stupor (immobility, + mutism, tendency to catalepsy, rigidity). According to the + account of the onset sent by that hospital (it was obtained + from the mother), this attack began some months before + admission, with complaints of being out of sorts, not being + able to concentrate and fearing that another attack would + come on. Finally the stupor was said to have been + immediately preceded by a seizure in which the whole body + jerked. She made again an excellent recovery. + + The patient was seen about two years after this attack, and + described the development of the psychosis as follows: She + claimed she began to feel “queer,” “nervous,” “depressed,” + got sleepless. Then (this was given spontaneously) she + suddenly thought she was dying and that her father’s + picture was talking to her and calling her. “Then I lost my + speech.” As after the first attack, she claimed not to have + any recollection of what went on during a considerable part + of the stupor but recalled that she began to talk after her + brother visited her. It is not clear how she was during the + period immediately following the stupor. + + She made a very natural impression and came willingly to + the hospital in response to a letter and was quite open + about giving information. + + + CASE 2.--_Caroline DeS._ Age: 21. Admitted to the + Psychiatric Institute June 10, 1909. + + _F. H._ The father died of apoplexy when patient was nine. + The mother had diabetes. A paternal uncle was queer, + visionary. + + _P. H._ The patient was always considered natural, bright, + had many friends, and was efficient. + + Some months before admission the patient’s favorite + brother, who is a Catholic, became engaged to a Protestant + girl, and spoke of changing his religion. The family and + the patient were annoyed at this, and the patient is said + to have worried about it, but was otherwise quite natural + until seven days before admission. Then, at the engagement + dinner of the brother, the psychosis broke out. She refused + to sit down to the table, and then suddenly began to sing + and dance, cry and laugh and talk in a disconnected manner. + Among other things, she said “I hate her,” “I love you, + papa” (father is dead), “Don’t kill me.” She struck her + brother. She was in a few days taken to the Observation + Pavilion. + + The patient stated after recovery that what worried her was + that the brother would marry a Protestant and that he would + leave home (favorite brother). + + At the _Observation Pavilion_ she was excited, shouted, + screamed, laughed, called out “Don’t kill me,” again + “Brother, brother,” “You are my brother” (to doctor). + + _Under Observation:_ 1. On admission, and for two weeks, + the patient presented a marked excitement, during most of + which she was treated in the continuous bath. She tossed + about, threw the sheets off, beat her breasts and abdomen, + put her fingers into her mouth, bit the back of her hands, + waved her arms about, sometimes with peculiar gyration, + etc., at the same time shouting, singing, again praying, + laughing or crying, sometimes fighting the nurses and + resisting them. She also talked quite a little as a rule, + but there were periods when, although excited, she would + not talk or answer questions. She was very little + influenced in her talk by the environment. When on one + occasion asked if she had any trouble, she said: “No--I + don’t want, somebody else gave me a book--all right I love + myself, Uncle Mike too--all right too--all right I am in + Bellevue--I love everybody except the Jews all right, all + right--give me water, give me milk, give me seltzer--white + horse uncle--Holy Father, he is killing me, I want my + mother,” or “Wait a minute, say, that’s a lie--oh no, Holy + water--no I didn’t wash the water away--oh, she forgets, I + am sick--mother why don’t you come--look at the baby, they + knocked my head against the wall--wait a minute, isn’t that + terrible?--I was married--I was so--I forgot--April fool--I + kiss you seven kisses and one more--I love papa and mamma, + I like others too--I am papa’s angel child--yes I confess I + love him, but I don’t want to die myself.” On another + occasion, when asked where she was, she said: “I am at the + ball--I am going to Heaven--don’t shoot me” (affectless). + (Why are you afraid?) “Because you see--high water (in the + tub)--white horse.” (What about the water?) “My name is + Caroline--if you love me, father, tickle me under my feet,” + or, rolling her eyes up, “Oh, isn’t that awful, that ring, + that diamond, that is the key to Heaven.” + + 2. For about ten days she was somewhat different. She + became quieter and at first lay muttering unintelligibly, + saying some things about being killed, but speaking little, + often restlessly tossing about and tremulous. She had to be + tube-fed. On one day (July 1) she smiled more and talked + more, said to the physician “You have been arrested for + me--you arrested the first man that I ever--New York + State--let me see that book” (note pad). Then she went on: + “Oh, I am all apart--diamonds--they didn’t know--must I + keep them clean?--what is your name?--that is another thing + I would like to know.” But when asked what house she was in + she said: “This is the same Ward’s Island” and then added, + “How long have I been here?--there is my picture up there + (register), who is that? (listening) it’s Ida ...” She + began to sing softly. Then again she whined. “O mamma, + mamma!” When asked how long she had been here, she said: + “Since Decoration Day, when my father went in my sister’s + house, nobody could catch up with me--somebody blackened + her eyes.” When asked whether she was sick, she said “No, + insane.” + + Although, as was stated, she said at one time, “This is the + same Ward’s Island,” usually questions regarding + orientation were not answered, as she gave few relevant + replies, but she repeatedly said spontaneously that she was + in “Hoboken or Bellevue,” and called the nurse by the name + of a former teacher. A few days after this state had + developed she had a fever. Once this rose to 104°. The + fever lasted two weeks, coming down gradually. It was + associated with a leucocytosis of 15,000 on June 29 (no + differential count) and with coated tongue. No Widal (two + examinations). No diazo (July 1). + + 3. Then while the temperature still lasted she developed a + stupor which persisted for about a year. During this time + her temperature rose to 100° without ascertainable cause. + She lay for the most part motionless, changing her position + but rarely; her expression was stolid; she retained and + drooled saliva, wet and soiled herself. She never answered + any questions; showed no interest whatever. At times she + was quite stiff and very resistive but never cataleptic. + Her extremities were cold and cyanotic. She had to be + tube-fed throughout. During this time she lost much hair. + + After some months she occasionally gazed about furtively, + or later watched everything when unaware of being observed; + at this time she also smiled occasionally at amusing + things, or perhaps said “yes” or “no” to questions, but + usually was stolid when interrogated. + + Then about nine months after admission, while in the + condition just described, she developed a lobar pneumonia. + During it she remained the same. But during convalescence + she began to speak and eat. + + 4. A period followed lasting six months during which she + was up and about, but sat or stood around a good deal. On + the other hand, she helped the nurses a little when urged. + Her face was often stolid, again she looked about. At times + (even nearly to the end) she drooled and soiled. She said + little. At no time was she resistive. On other occasions + she smiled or laughed, not always on provocation, or she + showed little playful tendencies, such as throwing a pillow + about the room, tearing leaves from the plants, taking the + doctor’s arm and walking down the hall, asking him to kiss + her. At such times she often looked quite bright, keen, + alert and amused. Towards the end she would give at times + playful answers, such as “I came to-day,” or “This is the + Hall of Fame.” This tapered off, so that by December, 1910, + she was perfectly well. + + _Retrospectively_, the patient claimed not to remember the + upset at the dinner, or what happened afterward, although + recalling the trip to the Observation Pavilion. She denied + any memory of the journey to the hospital, but could tell + what ward she came to. How well the condition after that + was recalled, was not inquired into, except that she could + or would not explain further the utterances during the + first period. For the stupor period it is stated that she + remembered many external facts, but it is not clear in + which period they occurred. + + _Catamnestic Note._ May, 1913: She has worked efficiently, + and is said to have been perfectly well. + + + CASE 3.--_Mary F._ Age: 21. Admitted to the Psychiatric + Institute June 28, 1902. + + _F. H._ The mother died when the patient was five. The + father was living, an alcoholic and reckless man. Four + brothers and sisters died in infancy. + + _P. H._ The patient was the only surviving child. She was + brought up in a convent and orphan asylum until 11, when + her father remarried. At 12 she had to go to work, hence + she had but little education. She was bright, efficient, + well liked by her employers (in one position five years). + As to her peculiarities, she was thought to be, perhaps, a + little headstrong, and was also described as always very + exact, rather quick-tempered and inclined to be irritable + when crossed. + + She was married six months before admission and had a _baby + three weeks before admission_. The husband stated that when + the father found out she was pregnant, he spoke of killing + him. He frequently upbraided both husband and wife, though + he lived with them. Even after the child was born he + continued to be disagreeable. + + The patient was rather low spirited and quieter after her + marriage. She worried over her illegitimate pregnancy and + the scolding from her father. But nothing was thought of + all this, and it did not interfere with her activity. The + birth was normal. She had no flow, no unfavorable symptoms, + and sat up on the twelfth day. She is said to have appeared + natural mentally. + + A week before admission the family returned from the + christening, having left the patient apparently well. They + now found her sitting in her chair, limp, with closed eyes, + giving no answer to questions. Only after about twenty + minutes could she be aroused. After her father had given + her milk with whiskey in it, she claimed he had poisoned + her. In the evening she was bright and lively, singing and + dancing with the others, but in the night she woke up her + husband, seemed frightened, said somebody was in the room + and that he should get a priest as she was going to die. + The husband went to sleep again. The next forenoon the + patient claimed she had been frightened all night and + thought her father was going to kill her husband. + + On the second day, while sitting at breakfast, she groped + about for the bread plate for some time and then said she + had been blind for a short time. During the day she had + frequent spells in which she would close her eyes, become + perfectly quiet and difficult to rouse. Sometimes at the + beginning of these spells she would say “I am going.” She + was then taken to her aunt and walked there, a distance of + a few blocks. She was there for two days before going to + the Observation Pavilion. In this time she is said to have + been quiet for the most part, often apparently sleeping or + staring. Once she said she was “rather dirty, filthy.” Once + she tried to get out of the window, said it was a door and + that she wanted to get out and take a walk. Above all, she + had, in these two days, repeated peculiar seizures which + the aunt and the husband described as follows: When sitting + on a chair she would close her eyes, clench her fists, + pound the side of the chair, get stiff, slide on the floor, + then thrash her arms and legs about and move the head to + and fro. She frothed at the mouth. After the attack, which + lasted a few minutes, she breathed heavily for a while. + Once she wiped off the froth with a handkerchief and gave + the latter to the aunt, saying “Burn that, it is poison.” + Before the attack she sometimes said that it got dark over + her eyes and that her face felt funny, again that she had a + pain in the stomach which worked towards her right + shoulder. There was no cry in the beginning of the attack, + but once she wet herself. + + After recovery the patient herself told the development of + her psychosis thus: + + There was trouble between the father and the husband, and + she was afraid of her father. On the day of the christening + she took sick: a queer feeling came over her and she + wondered whether she was going to die, “Then I seemed to + lose myself, and when I came to I found my family standing + around me.” Her father gave her whiskey and she thought it + was poison. “That night I had spells of dancing and + singing, it must have been something I took, perhaps the + liquor.” The same night she was frightened, thought her + father might do some harm, and had a vision of a person in + white standing at her bed. After that she had repeated + spells in which she knew nothing until “I came to again.” + “It was a queer trembling.” + + At the _Observation Pavilion_ she was described as in a + state of “intense mental depression,” taking no interest in + things going on about her. She spoke, however; said she + wanted to die, that she had imagined her father had given + her poison, that every one was against her, and that people + were talking about her. + + 1. _On admission_ the patient had a slightly elevated + temperature, which soon subsided, full breasts but without + inflammation. Sordes were not mentioned. + + For a few days she was essentially somewhat restless, + getting out of bed, disarranging her clothes, wandering + about--all in a rather deliberate, aimless way, sometimes + vaguely resistive, again with free movements. She looked, + dazed, sometimes stared straight ahead and looked “dreamy.” + Occasionally there was a tendency to close her eyes. With + the restlessness she looked at times “a little + apprehensive,” or shrank away when approached. She spoke + slowly, with initial difficulty, but answered quite a + number of questions. The mental content of this period was + displayed in the following utterances: She would ask for a + priest, or say “Have I done something?” or “Do people want + something?” or, when asked why she was here, she said “I + have done damage to the city, didn’t I?” (What have you + done?) “I don’t know.” Or she spoke of people watching her. + When asked the day, she said “Judgment Day,” yet she knew + the month. Once when asked what the place was she said, + “This is the hereafter.” When asked what had happened at + home, she said: “Voices told me I was to be killed.” She + was not clearly oriented, called the place Bellevue, asked + “Isn’t this a hospital?” yet again said, “Ward’s Island, + where they work.” On the day of admission she thought she + came “the day before,” but knew she had come in a boat. + When asked her address, she said slowly, “Didn’t I live at, + etc.,” giving the address correctly. To the physician she + said, “Are you my brother?” And on another occasion, “My + God! You are Charlie” (brother). It was difficult to get + her to eat, and she had to be spoon-fed. + + 2. Then she became more preoccupied, the restlessness was + much less in evidence, it became necessary to tube-feed + her, she retained her urine, answered a few questions, and + when asked where she was, she said, “Calvary, ain’t it?” + (What house?) “Heaven, ain’t it?” She still called the + physician by the name of her brother. After a few days this + gave way to a more marked stupor which lasted nearly two + years. This was characterized most frequently by a complete + inactivity. She usually lay or sat motionless, sometimes + with mouth partly open, letting the flies crawl over her + face, gazing in one direction, soiling, wetting, resisting + moderately or markedly any interference, and had to be + tube-fed. But this was not the invariable state. The most + constant feature was her mutism, but even that was a few + times interrupted. Thus, when after a visit from her uncle + (towards the end of July, 1902) she tried to get out of the + window and was prevented, she swore at the nurse. Or in + August, 1902, when she got into another patient’s bed and + was taken out, she resisted and said promptly: “I think it + is a damned shame I can’t get into my own bed.” But this + was the extent of her talk for a year and a half. Nor was + she always totally inactive. In the middle of July, 1902, + she sometimes tried to get out of bed, wandered about, got + into other patients’ beds. It was on such an occasion that + the above incident happened. In August, 1902, she sometimes + tried to get out when the door was opened, and we have + seen that she tried to get out of the window, but she did + not change her placid expression at such times. Her motive + was not known. On two occasions towards the end of 1902, + when she was taken to a dance and was made to take part, + she waltzed with considerable animation but did not speak. + This was quite striking in that these incidents occurred in + a setting of marked inactivity (i.e., a condition in which + she had to be pushed to the table, pushed to the closet). + She did not soil any more, but she sometimes drooled and + had to be spoon-fed. However, on a third occasion when this + was tried, she had to be dragged around. Finally, though + her facial expression showed at times a preoccupied + staring, she more often looked around, sometimes quite + freely and often looked up promptly enough when accosted. + But there was very little evidence of any affect at any + time. We have seen that twice she swore a little when + opposed. On another occasion she slapped a patient when the + latter helped her. Twice she was seen crying a little + without apparent provocation, but she did not laugh, and + the only suggestion of pleasurable emotion was that at the + two dances mentioned she could be led into a certain + animation. Usually, even when she got less resistive + towards the end, she was essentially apathetic. + + Once in January, 1903, she could be made to write her name + but wrote her maiden name. In the end of 1903 she improved + gradually (a condition not well observed), so that by + December she answered some questions in a low tone. Even in + April, 1904, she was still described as apathetic, though + she had begun to do some work. + + 3. Then she improved markedly and began to work, looked + after herself in a natural way, spoke freely, was entirely + oriented and her mood generally presented nothing striking. + But her mental attitude was still peculiar when she was + questioned. She seemed somewhat inattentive, sulky, + sneering. Thus, when asked why she was here, she said, “You + will have to ask those who brought me here.” + + She denied ever having been pregnant, said the nurses on + the ward had spoken of her having had a child and that they + had showed her a child (one was born on that ward about + August, 1903) but that it was not hers. She thought it was + wrong for the nurses to speak on the ward of her having + been pregnant. Again questioned about her marriage, she + first said she had not been married, again that she was + married “a year ago” (was in the hospital then). Again she + spoke of her husband as her “gentleman friend,” claimed she + called herself Mary M. (maiden name) until a girl friend + wrote her a letter addressed to Mrs. F. From then on, she + called herself by her married name. But she thought that + probably they sometimes spoke of her marriage in fun. If + she were Mrs. F. she would be living in Mr. F.’s house. + + On June 29, when again asked about her marriage, she said + she was to have been married in December (correct date). + (Were you?) “So they say.” (Do you remember it?) “In a + way.” (When was the baby born?) “You will have to ask + somebody more superior to me, more experienced.” Then, when + further questioned about the age of the baby, she said, + “The baby I saw in the ward was about a year old,” and she + claimed not to remember ever having a baby. When asked why + she had come here she said, “Well, I don’t know, perhaps + you know better, through sickness I guess,” and later: + “Well, don’t you ever get a cold and want doctors to + examine you?” (What kind of a place?) “This is a nice place + for sensible people who have enough knowledge to know and + realize what they come for.” But she knew the name of the + place, the date, the names of persons. + + Questioned about the trouble with her father or her + husband’s trouble with him, she denied it, “If he did (sc. + have any trouble), I don’t remember.” About her not + speaking, she said, in answer to questions, “I didn’t know + what I was here for, what was the object in keeping me + here”; and to other questions about her condition, “I don’t + know, those who examined me can tell you more about that.” + Finally, she said in reply to the question, why she came + here, “I don’t remember _unless it was through fire_,” but + would not explain what she meant. + + In the beginning of July, she again said that she had no + recollection of her marriage. + + She then improved a great deal and finally appeared very + natural, gave the retrospective account noted in the + history, had a clear appreciation of the fact that she was + married and had a child. She claimed that she had + previously forgotten about her marriage and thought she was + still merely keeping company with Mr. F. She claimed not to + remember coming to the hospital, did not know what ward + she came to, who the doctor and nurses were, in fact + claimed that it was about a year before she knew where she + was. But she remembered having been tube-fed. She could not + say why she did not speak. But she appreciated that she had + been ill. + + Ten years after discharge the husband, in answer to an + inquiry, stated that she had been perfectly well and had + had no trouble at three successive childbirths. + + + CASE 4.--_Mary D._ Age: 20. Admitted to the Psychiatric + Institute September 17, 1907. + + _F. H._ The grandfather and the father of the patient were + alcoholics. The father died three years before the + patient’s admission; he was killed in an accident. The + mother stated that she herself was nervous, but she made a + normal impression. + + _P. H._ The patient was described as bright at school and + efficient in her work as a dressmaker, but she was rather + quiet, inclined to stay at home and had not much + inclination to consort with the other sex. She was rather + proud. As an example of this is stated the fact that she + was always somewhat sensitive, because the family lived in + the basement of the house in which her mother was + janitress. She did not menstruate until 16. It was about + this time that her father was killed in an accident. She + was considerably upset by this, talked a good deal about + the way he was killed, but did not break down. The patient + on recovery stated that it worried her because the father + died without having any chance to get a priest. + + Six weeks before admission the patient was given a + vacation, as there was not work enough in the shop, but she + worked at home. + + Two or three weeks before admission her appetite failed + somewhat, and ten days before admission, without any + appreciable cause, she began to sleep badly, seemed + somewhat nervous, became a little “fidgety” and said she + worried because her mother had to work so hard. Later she + began to speak about people saying that the ambulance would + come for her and she heard voices saying “You will be + dead.” It is not known in what emotional setting these + remarks were made. Her mother took her to a dispensary. On + the way she asked the mother where she was going and said + “I can’t tell the number and I don’t know where I am going. + I think I am losing my mind.” She also said she could not + understand any more what she read. She was put to bed. She + then talked less, appeared stupid, and was inclined to + refuse food. + + Four days before admission she claimed that she could see + her dead father beckoning to her, again she said a certain + young man was God. She was sent to the Observation + Pavilion. On the day she went there she was reported to + have shown a slight jaundice. + + The patient, after her recovery, added to the above account + of the mother, that about two weeks before admission, for + no reason which she could state, she began to feel quiet, + and that after that her father’s death began to prey on her + mind, and that later she had a vision of her father. She + claimed that in this period she had no fear but that her + head felt dizzy and her vision seemed dim. + + At the _Observation Pavilion_ the patient was described as + constrained, refusing food, mute, resistive of attention, + sometimes muttering to herself and having the appearance of + uneasiness. + + _Under Observation:_ 1. On admission the patient had a + slight jaundice, which disappeared in a few days, and the + bile test in the urine was negative on admission. She was + rather thin, but otherwise in good physical condition. Her + temperature was 99.2°. + + For three months the patient was very inactive, moving very + little. She had to be dressed and undressed, when taken out + of bed. She often was markedly constrained, either lying + with her head raised from the pillow, or for long periods + of time holding her arms or hands in rather constrained + positions on her body. But there was at no time any + catalepsy when tested by moving her arms. In the beginning, + however, before she lay so persistently with her head + raised, she was found holding it up from the pillow after + her hair had been fixed. Again, she did not correct other, + rather uncomfortable, positions in which she had been left. + There was also at times a slight or occasionally a somewhat + more marked resistance in her arms and neck, but this never + amounted to a pronounced resistance. She sometimes did not + react to pin pricks, sometimes flinched a little, never + warded off the pin, indeed she would put out her tongue + repeatedly when asked to do so in order to have a pin stuck + into it. She very often wet and soiled, once even + immediately after she had been taken to the closet, on + which occasion she did not urinate. Her face was usually + dull, vacant and immobile, but sometimes, when questioned + or when something obtrusive happened, a little puzzled. + Occasionally she looked slowly about or followed people + with her eyes. There was no evidence of any affect as a + rule, but not infrequently she smiled, even quite freely at + times, when the physician came to her or on other + appropriate occasions. For example, once when a nurse came + into the ward whom she had known outside she flushed and + smiled a little. Once when the mother came to see her a few + tears appeared, the only time this occurred. + + Although for the most part immobile, when she did move, she + was distinctly slow. When asked to do certain things, she + usually did not comply, but now and then, after urging, + would show her tongue after delay, or merely open her + mouth; or she would bring the hand forward slowly when the + physician offered his hand in greeting. Once she fumbled + with her braids slowly. When out of bed, she stood about + aimlessly or sometimes walked somewhat slowly. + + She was almost entirely mute, but a few times she returned + a greeting quite promptly, or on another occasion + (September 23) she said quite promptly, when asked how she + felt, “I feel better. I took off my clothes” (correct--she + had been up and put to bed again). Again she sometimes + answered simple questions by “yes” or “no,” though + sometimes in a contradictory and rather aimless manner, but + promptly enough. Once she said to her mother, “I can’t, I + have to remain here.” There were some other replies which + we shall presently take up. Several times it was possible + to make her write. On these occasions she wrote her name + promptly, or might write only after much delay or stopping + in the middle of a word. + + This leads us to her capacity to think, the defect of which + was perhaps most clear in her writing. Thus, though having + been told to write her name, and having written it quickly + enough, when, immediately after it, she was asked to write + her address or the name of the hospital, she had to be + urged much, and then wrote each time merely a repetition of + her name, this time much more slowly. On October 13, when + she was asked to write her name, she wrote it correctly; + then for the address she wrote the house number correctly, + but for 90th street she wrote “90theath”; and, urged again + for the address, she added “Dr. Wyeth.” Again when asked to + write the word “watch” she was slow, and finally put down + “10.” When on October 23 she was asked to write “Manhattan + State Hospital,” she wrote “Manhatt Hhospshosh,” and for + “Ward’s Island” (which she was told), “Ww Iland.” Then she + was asked to write “I wish to go home.” She wrote “I wish + to go home, go West.” Here again the first part was written + promptly. + + We now can add some of the other replies which she gave. + Once she was asked “Do you know where you are?” She + promptly said, “Yes.” (Where?) No reply. On another + occasion, at the initial examination, she said she was home + or “in papa’s house.” Once when asked “Do you know me?” she + said “Yes.” (What is my name?) “Miss D.” (her name). On the + occasion on which she had stated that she had taken off her + clothes, she was asked “Where have you taken off your + clothes?” She made the irrelevant reply, “That was the girl + the one I had.” + + 2. Then she improved somewhat. On January 5 she walked + about a little more, though slowly, and still looked + slightly puzzled when questioned. She spoke more readily, + counted promptly though once stopped in the middle of the + exercise. In calculation she multiplied correctly 3 × 7, + but for 4 × 9 repeated the 21, and when given 9 × 9 she did + not answer. A few days later, though she lay again + motionless with her head raised as before, and, as she had + sometimes done, smiled brightly when accosted, she gave few + replies, but when asked to write down the month she slowly + wrote “December.” Asked to write it the second time, she + did it promptly. She also replied promptly by saying “Yes” + when asked whether Christmas, and again whether New Year’s, + had passed, but did not reply to the questions how long ago + Christmas, or how long ago New Year’s, had occurred. On + January 23 she was decidedly more free and prompt in her + replies, yet she still wet and soiled (in fact this did not + cease until the end of the month, when great improvement + occurred). At this time she gave quite a number of + calculations promptly, about an equal number wrongly. She + knew where she was, knew the names of a number of people + about her, but thought she had been here about two weeks + (four months), and gave the year and the date, the latter + as the 28th of January. When then told that it was + Thursday, January 23, and that she must remember it, and + asked five minutes later what she had been told, she again + said “January 28” and left out Thursday. To some questions + to which she did not know the answers, since she had an + amnesia for the time of their occurrence (the incidents of + coming here), she simply remained silent. Even on February + 7, when she was much freer, helped the nurses, and said + herself she was “smarter,” she had difficulty in thinking, + said she was 17 (21), gave the date of her birth correctly, + but the current year as 1909 (1908) and still insisted she + was 17. She then did the calculations on paper, and with + considerable difficulty got correctly “22.” But she could + not straighten out the discrepancy. At that time, also, she + still wrote “Hospitital,” calculated even simple + multiplications with some mistakes, could not get the point + of a story, and to retention tests gave poor results. + Indeed, even seven days later, when she wrote a very + rational letter and appeared quite natural, she made some + omissions in her writing, and a few mistakes in spelling. + + However, she now improved rapidly, and by March 31 she made + a very natural impression, was frank, free, had good + insight, calculated well, etc., understood a story, + retention was good. + + She then gave the retrospective account embodied in the + history, and in addition told that she had no recollection + of going to the Observation Pavilion, the coming here, or + the first part of her stay, including presentation of the + case at a staff meeting, a physical examination and a blood + examination, and she claimed for a long time not to know + where she was, “I was in a kind of dazed condition.” She + also said she could not understand the questions which were + asked her. This probably refers, however, to the second + part, i.e., the partial stupor lasting for two months. She + did not “feel like talking,” the limbs “felt stiff-like.” + + + CASE 5.--_Annie K._ Age: 22. Admitted to the Psychiatric + Institute January 7, 1907. + + _F. H._ The father was an alcoholic, who died when patient + was a child. A paternal aunt had a nervous breakdown, with + recovery. The mother appeared to be normal. + + _P. H._ The mother stated that the patient was a rather + delicate child. She attended school irregularly, never felt + much interest in it, and was always glad to be at home and + help the mother take care of the other children. On the + other hand, she is said to have been quite lively, rather a + tomboy, with a temper. She left school at 14; learned + dressmaking for a year, but did not get along well. Then + she took several other positions, which she held for about + a year, getting on pretty well. + + She married at 20. Her husband never supported her well and + often beat her. She had to borrow money to get along and + worried much. During pregnancy she seemed to worry more, + had crying spells, and often seemed absorbed in thought. + + Three weeks before admission she gave birth to a child. The + labor was somewhat difficult, but she had no fever. She got + up on the tenth day, and then seemed to lose all interest, + did not attend to the baby, said she was not strong enough. + She sat about, appearing depressed. The mother then took + her and the baby to her house. There she sat or walked + about, said very little. But she repeatedly came to her + mother, said she had something to tell her, or that she had + “done something,” although she could never be induced to + say what. Once she came to her and said, “You are not going + to die.” She often moaned. Finally, she claimed a neighbor + had been saying she was poisoning the baby. + + The patient herself gave, after recovery, the onset as + follows: When she married she knew her husband was not what + he should be, but not that he was so bad as he proved to + be. He was a gambler, did not support her, and this caused + her much worry. When she became pregnant, eight months + after marriage, this increased her worry, and throughout + the pregnancy she spoke much to a neighbor about her + worries, and said she did not know how she could manage, + pay the doctor, and the like, but she did not say much + about it to her mother (because the latter would have made + such a fuss about it, or would have said, “It serves you + right”). Then the childbirth came. This further accentuated + her worries. She felt her difficult circumstances, wondered + how she could get the necessary money, “I lay there + worrying.” And she claimed she did not sleep at all. About + her statement, mentioned by the mother, that she had done + something, she said that she thought she had poisoned the + child by giving it fennel tea, and that she thought a + neighbor who visited her said she had poisoned it. She was + then put to bed again, and one night she had a vision of + her father. This frightened her. She thought this meant he + had come for her and she wanted to die. + + At the _Observation Pavilion_ she was dull, staring, + resisting attempts at passive motions. + + _Under Observation:_ 1. There was nothing noteworthy in her + physical condition, except for a rise of temperature to + 100° occasionally during the first month of her admission. + For the first four months she was often found lying in bed + with her head half raised from the pillow, or standing or + sitting about in constrained positions, immobile, + frequently she let saliva collect in her mouth. She usually + wet and sometimes soiled the bed. Sometimes, when sitting + in a constrained position, she let herself gradually slide + on the floor. She often began to feed herself when urged, + but would not finish, and had to be spoon-fed, as a rule. + She was never tube-fed. She was often quite stiff and + showed marked resistance. This was manifested either when + passive motions were tried, at which times she usually + resisted passively, i.e., she became more tense; or when + there broke through a more active aggression and she would + strike. Above all, the opposition showed itself towards the + nurses’ attention; in this she also showed either a + passive, aimless opposition and stiffness, or a more active + one; but even in the latter an open show of angry affect, + or plain irritation, though present at times, was by no + means constant. When it was present, she would strike quite + aimfully; once she struck the nurse and said, “You are the + cause of it all,” and once, when the nurse tried to give + her some milk, she said, in an irritated tone, “I wonder + people would not let me alone some time.” Again, she bit a + patient who tried to hold her. On another occasion she + quickly jumped up and pulled the hair of a patient who + evidently disturbed her by her noisy shouting. As was + stated, she usually wet the bed, resisted being taken to + the toilet, or when taken there, would not urinate or + defecate, but would do so as soon as she was returned to + bed; or she urinated while standing. The same perverse + opposition was seen when she would refuse a glass of milk, + but grab it when it was taken away and then refuse to let + go. She often would grasp the bedclothes or other things + and hold on aimlessly. + + She rarely spoke, answered almost no questions, complied, + as a rule, not even with the simplest commands. To pin + pricks she did not react except at times by flushing. But + she did not stare, rather looked about, and was at times + easily attracted by noises or happenings about her, and + would then look in that direction not without some + interest. Often there was then an expression of + bewilderment. Her mood, however, was, as a rule, apathetic, + but at times, as stated, she showed some anger. Once she + wept, and a few times she smiled or snickered. As a rule, + this happened without appreciable cause. But once, when a + cheering remark was made, she smiled; or, when her picture + was taken (to show the peculiar constrained attitude with + the head raised from the pillow), she laughed loudly. + + Although she spoke rarely, she made a few utterances in the + first few days. Thus she suddenly said: “I want to see Mr. + N.--what I said to him was not right,” or “Listen! there + are the priests calling,” or “You are all faking--it is me + that done it--they are all dressing up downstairs,” or “I + told you she was not able to nurse the baby,” or “I have + nobody, I am lost--I want to know the truth--my mamma,” or + she called her sister, “They are dead since last night.” + + Even during the more stuporous state she could, a few + times, be made to write a little. Then she either wrote + very slowly and not more than a letter, or if she wrote + more, it was remarkably mixed up. Thus when asked to write + the date, she wrote, “Jane (mother’s name) to me to + Chrichst,” or when asked to write her name: “Annie take you + ktusto.” + + As to her orientation, nothing could be made out as a rule. + At first, however, a few weeks after admission, she spoke + correctly of the month as January and spoke of the Island. + When at that time she was asked if she had a baby, she + said, in an annoyed tone, “I don’t know.” + + 2. In the beginning of May, i.e., four months after + entrance, her condition changed somewhat, and for two + months she presented the following state: She stood about, + or walked around slowly, usually with her arms folded. She + had a tendency to stand near the door. She had to be + assisted in dressing, pushed rather than led to her meals, + and urged to eat. For the most part, she would not answer + questions, but would either smile in a sneering way, or + just walk away, or say, “Oh, don’t bother me,” or “I don’t + want to talk,” and generally her attitude was rather sulky. + Nor was this only towards the physicians but towards the + husband, sister and child as well. When on May 17 the + sister came, she would not speak to her but said “Go away.” + The baby she simply pushed away sulkily when it was brought + to her. To the husband she said on May 31, “Go away, you + stink.” In the first part of this period, she presented + some bursts of elation, on one occasion turned somersaults, + indulged in a few pranks with laughter, or once, when a + knock at the door was heard, she called out “Holy gee, + cheese it, the cop.” But these occurred only in the first + part of the period. On June 1 she spoke to the nurse, said, + “What is the matter with these people, they must be crazy,” + asked to go home, and was then by the nurse found to be + oriented, and to know the names of people around her. But + when she was asked about the baby she would not answer, and + questioned whether she was not married, she said “I don’t + know.” Yet when the physician desired to talk to her, she + was just the same as before and remained so for two more + weeks. Another somewhat isolated occurrence was when on + June 18 she spoke a little to the physician, but she sat in + a constrained position when taken into the office and + answered many questions by “I don’t know,” namely, those + regarding her condition and feelings, the questions about + orientation, about her mother’s address, and her child’s + age; but when asked how long she had been married she said + correctly “Two years.” + + At the beginning of July she improved quite rapidly, and on + July 5 appeared fairly free and gave a fair retrospective + account, with some urging, and it was thought that she + smiled somewhat too freely. However, on July 27, she seemed + perfectly well, had normal insight, and then gave the + second retrospective account, which, together with the + first, will now be taken up. + + _Retrospectively:_ She claimed to remember things at home, + and at both interviews said she recalled being taken to the + Observation Pavilion. While there she thought she knew + where she was, remembered that she did not talk. She had a + feeling she was going to die and said “I thought I would + die if I kept still.” However, the transfer to this + hospital was vague in her mind, as was the entrance on the + ward, and she claimed not to have known for quite a while + where she was. She added that she used to wonder where she + was, how she had gotten here, and how she could get out, + and thought the questions which were asked were queer. + Individual occurrences, too, specifically inquired into + were not recollected, such as an examination in a special + room. Of the mixed-up writing at the end of the second + week, she had no recollection even when it was shown to + her. She did not recall having her picture taken (with eyes + open) two months after entrance. Yet a sudden angry + outburst ten weeks after admission was remembered. She + stated that she struck the patient because the latter + annoyed her by her shouting. She had a general recollection + of being stiff, having her head raised, and of soiling and + drooling, but could not account for it. She felt stubborn. + She also claimed not to have been hungry and not to have + felt pin pricks. + + In regard to ideas which she had, she claimed to be afraid + at first that she would be cut up. She remembered repeated + visions of her father at night, also once of her dead aunt, + who said “Come to me.” She thought she was in a cemetery, + all the family were dead, the baby dead. In the beginning, + too, she sometimes heard a priest whom she had known, say + “Be good and God will look after you.” + + In regard to the later period, she recalled that she got up + in May and felt cross. She did not answer because she did + not want to be bothered. She pushed the baby away because + she did not think it belonged to her, the husband because + she did not like him. (She did not think she was not + married.) She evidently remembered the visits, thought she + knew where she was, knew she stood near the door “because I + wanted to go home.” Besides the idea that the baby was not + hers, she recalled none, and thought she had no + hallucinations. + + She was discharged perfectly well six months after + admission to the hospital. Soon after that, she left the + husband, once had him arrested in 1908 and sent to the + workhouse. She was again examined in 1913, and was found to + be perfectly well, and she stated she had been well since + the discharge. + +These five cases will have to suffice for the present. They were given +in full in spite of the fact that we shall leave out of our present +considerations the history of the cases and certain of the stages, and +confine ourselves to that stage of each case which is best qualified to +give us a good general survey of the essential features of the stupor +reaction. + +These phases are: stage 1 of Case 1, lasting five months; stage 3 of +Case 2, lasting one year; stage 2 of Case 3, lasting two years; stage 1 +of Case 4, lasting three months; stage 1 of Case 5, lasting four months. + +We gather from these descriptions that the essentials of the stupor +reaction are (1) more or less marked interference with activity, often +to the point of complete cessation of spontaneous and reactive motions +and speech; (2) interference with the intellectual processes; (3) +affectlessness; (4) negativism. + +_Inactivity:_ There is a complete cessation or more or less marked +diminution of all spontaneous or reactive movements. This includes such +voluntary muscle reflexes as contain a psychic component. For instance, +there is, often, an interference with swallowing (letting saliva collect +and drooling), winking, and even with the inhibitory processes used in +holding urine and feces (soiling and wetting). Often there is no +reaction to pin pricks or feinting motions. The inactivity also often +interferes with the taking of food so that spoon-feeding or tube-feeding +has to be resorted to. The patient may keep his eyes covered or stare +vacantly, the face often presenting a remarkably immobile wooden, or +stolid, expression. Complete mutism is the rule. When activity is not +totally interfered with, those movements which are present may be slow. +The patient may have to be pushed around and be able to take a few +steps, but soon relapses. More often they are of normal rapidity. Speech +then may also be slow and low, but usually shows no change except for +the fact that it is diminished in amount. Sometimes awkward positions +are assumed and retained, and there may be catalepsy. + +_Negativism:_ A common symptom is perverse resistiveness. It may consist +in a marked stiffening of the body which is assumed spontaneously or +appears only when attempts at interference are made, or there may be a +more active turning away or even a direct warding off, sometimes with +scowling or anger or even swearing and striking. Retention of urine, +which is seen at times, should, perhaps, be mentioned here. Now and then +we find that a patient is put on the toilet and cannot be induced to +urinate or defecate, while soiling and wetting occur at once on +returning to bed. + +_The intellectual processes:_ Little is known about the intellectual +processes from direct observation in these more pronounced cases, except +for the fact that in Case 5 questions or obtrusive occurrences sometimes +produced a somewhat puzzled facial expression. Moreover, the patient +retrospectively stated that she was unable to understand the questions, +which points to marked difficulty in apprehension. We also find that +occasionally there is evidence of an interference with the intellectual +processes which showed itself in what may be called “paragraphic” +writing when the patient could be induced to write. Above all, we see +that retrospectively very little is remembered of what took place during +the stupor, even of such obtrusive events as the moving from one ward to +another, tube-feeding, physical examination, the presentation at a staff +meeting, and the like. + +_Affect:_ Complete affectlessness is an integral part of the stupor +reaction. Modification of the statement will later be mentioned. The +patient is indifferent so far as his basic condition is concerned, and +it is only by certain stimuli that at times emotional reactions can be +elicitated, some tears at a visit of a relative, an appropriate smile at +a joke or a comical situation when the stupor is not too deep or an +angry reaction called forth by interference. + +_Catalepsy:_ Waxy flexibility or merely a tendency to maintain +artificial positions is a frequent but not an essential symptom. + +_Physical Condition:_ Not infrequently we find in the beginning or in +the course of the stupor an elevation of temperature to 101°, 102° or +even 103°. In one case we found a marked cyanosis in the extremities. +Case 2 showed marked loss of hair. Gain in weight is never observed and +marked emaciation is the rule. This we may attribute to the refusal of +food. + +A perusal of these cases, then, shows that the dominant (and well-nigh +exclusive) symptoms of the stupor are inactivity, apathy, negativism and +disturbance of the intellectual functions. Benign stupor can be defined +as a recoverable psychosis characterized by these four symptoms. The +meaning of such vague physical manifestations as the low fever is not +clear. + + +FOOTNOTES: + +[1] MacCurdy has discussed the psychological phenomenon of a dramatist +depicting a psychosis correctly in “Concerning Hamlet and Orestes.” +_Journal of Abnormal Psychology_, Vol. XIII, No. 5. + +[2] Many of these states seem to be hysterical rather than +manic-depressive stupors, but so far as the unconsciousness goes, there +is probably as much psychological as symptomatic resemblance between the +two types of reaction. + +[3] Kraepelin recognizes, of course, the occurrence of stupor symptoms +or states in the course of manic-depressive psychoses. It is stupor as a +clinical entity, as a separate psychosis, that he regards as one form of +the catatonic, and therefore of the dementia præcox, reaction. + +[4] Kirby, George H.: “The Catatonic Syndrome and Its Relation to +Manic-Depressive Insanity.” _Jour. of Nervous and Mental Disease_, Vol. +40, No. 11, 1913. + + + + +CHAPTER II + +THE PARTIAL STUPOR REACTIONS + + +The cases thus far considered, namely, those of marked stupor, are +fairly well known and have been studied by others. Less well known and +formulated, but even more important from a practical as well as from a +theoretical point of view, are what may be called partial stupors. + +The reader has noted that the states of deep stupor described in the +last chapter, did not end abruptly with a sudden return to health or a +sudden change to another type of psychosis. They all gradually passed +away, not by the disappearance of one symptom after another, but by the +attenuation of all. Sometimes a more or less stable condition persisted +for months, in which there was no stupor in a literal, clinical sense +but when apathy, inactivity, interference with the intellectual +functions and negativism all existed. Had these been the only states +observed in these patients, there might have been some ground for doubt +as to the diagnosis. As it was, it was clear that we were dealing with +mild stages of stupor. When a psychiatrist meets with an undeveloped +manic state, he calls it a hypomania and does not hesitate to make this +diagnosis in the absence of complete development into a florid +excitement. This procedure is not questioned, because the manic +_reaction_ as distinguished from a _mania_ is well recognized. We +believe that there is just as distinctive a _stupor reaction_ which may +be exhibited either in deep stupors or what we may term partial stupors. +Theoretically, complete apathy, inactivity, etc., make up the clinical +picture of a deep stupor. When these symptoms appear rather as +tendencies than as perfect states, a partial stupor is the product. That +partial stupors occur as well-defined psychoses, developing and +disappearing without the appearance of deep stupor, we shall attempt to +show in the following three typical cases: + + + CASE 6.--_Rose Sch._ Age: 30. Admitted to the Psychiatric + Institute August 22, 1907. + + _F. H._ Both parents were living (father 74, mother 68), as + were two brothers and two sisters. All were said to be + normal. + + _P. H._ Nothing was known of the patient’s early + characteristics, except that she herself said she was slow + at learning in school and did not have much of an + education. But when well she made by no means the + impression of a weak-minded person. The husband had known + her for ten years. He married her eight years before + admission, by civil process, keeping this from his own + family because he was a Jew and she a Christian. He said + that this undoubtedly worried the patient at times and that + she often asked him when he would take her to his family. + The patient herself later also said that this used to worry + her. Finally, one and a half years before admission she + agreed, on account of the children, to accept the Hebrew + faith, and they were then married in the synagogue. But he + still did not take her to his family. + + There were four pregnancies: the first child died; of the + survivors one was 8, a second 5 years old. Finally, a year + before admission, she became again pregnant. During the + pregnancy one of the children had whooping cough and she + herself was thought to have caught it. The baby was born + three months before admission. It was a blue baby which + died two days after birth. The patient flowed heavily for + three weeks and was taken to a hospital, where she + continued to flow intermittently for some weeks more. + + Finally, three weeks before admission, a hysterectomy was + performed. Several days after this, when the sister-in-law + visited her, the patient begged her to take her home, said + the doctor wished to shoot her and to give her poison. + Later the patient confirmed this, saying that she thought + they wanted to give her saltpeter, and that she heard them + say they wanted to shoot her. + + When taken home she refused food; gazed about, was + absorbed, seemed obstinate, and several times tried to jump + out of the window. Retrospectively the patient stated that + she heard children on the street call “Katie.” She thought + they meant her child, heard that it was to be taken away + from her, and a similar idea again came out later in her + psychosis, namely, that somebody was going to harm her + children. + + At the _Observation Pavilion_ she appeared stupid, rather + immobile, her attention difficult to attract. + + _Under Observation:_ On admission the patient appeared + sober, impassive, moved very little, was markedly + cataleptic, though not resistive. On the other hand, her + eyes were wide open and she looked about freely, following + the movements of those around her not unnaturally. When + questioned, she looked at the questioner rather intently, + and was apt to breathe a little more rapidly, and made some + ineffectual lip motions but no reply. To simple commands + she made slow and inadequate responses. She flinched when + pricked with a pin, but made no attempt at protecting + herself. She had to be spoon-fed. The catalepsy persisted + only for two days. + + After this she continued to show a marked reduction of + activity, moved very little, said nothing spontaneously, + had at first to be spoon-fed (later ate naturally enough). + But she never soiled herself and went to the closet of her + own accord. + + Emotionally she seemed dormant for the most part, though + for the first few days she appeared somewhat puzzled, and + one night when a patient screamed she seemed afraid and + did not sleep, whereas other nights she slept well. She + answered only after repeated questions and in a low tone. + Very often, though her attention was attracted easily + enough, her answers were remarkably shallow and also showed + a striking off-hand profession of incapacity or lack of + knowledge. This was often without any admission of + depression or concern about her incapacity. She would + usually say “What?” or “Hm?” or repeat the question, but + most often would say, “I don’t know,” this even to very + simple questions. For instance, when asked, “What is your + name?” she answered, “My name? I don’t know myself” (but + she did give her husband’s name), or when asked to write + her name, she said, “I don’t know how to write,” or “Call + Annie, she will write my name.” When requested to read or + write (even when asked for single letters), she would make + such statements as “I can’t read.” However, she finally + named some objects in pictures. This condition was + characteristic of her for two weeks. + + Then her condition changed a little. She spoke a little + more freely but was similarly vague. The following + interview of September 9, is characteristic: When asked how + she was, she said, “Belle.” (Are you sick?) “No.” (Is your + head all right?) “Yes.” (Is your memory all right?) “Yes.” + (Do you know everything?) “Yes.” (Understand everything?) + “Yes.” (Are you mixed up?) “No.” (Do you feel sick?) “No.” + But when asked where she was, how long she had been here, + what the name of the place was, what was the occupation of + those about her, she said, “I don’t know.” (How did you + come here?) “I couldn’t tell how I came up here.” (What are + you here for?) “I am walking around and sitting on + benches,” but finally, when again asked what she was here + for, she said, “To get cured.” She now gave and wrote her + name and address correctly when requested, also gave the + names of her children. Yet when asked about the age of the + girl, said, “I don’t know, my head is upside down.” When an + attempt was made to make her repeat the name of the + hospital, or the date, or the name of the examiner, she did + so all right, but even if this was done repeatedly and she + was asked a few minutes later, she would say “I couldn’t + say,” or “I forget things,” or “I have a short memory,” or + she would give it very imperfectly, as “Manhattan Island,” + or “Rhode Island” for “Manhattan State Hospital, Ward’s + Island.” (How is your memory?) “All right.” But when at + this point the difficulty was pointed out, she cried. + (Why?) “Because I forget so easily.” All this was while her + general activity was much reduced, and she seemed to take + very little interest in her surroundings. + + Then she improved somewhat, asked the husband some + questions about home, and on one occasion cried much and + clung to him and did not want to let him go without taking + her. She also began to work quite well, but still said very + little spontaneously. During this period when asked + questions, she spoke freely enough, but seemed somewhat + embarrassed. What was still quite marked were striking + discrepancies in giving dates, and her utter inability to + straighten them out when attention was called to them, as + well as to her inability to supply such simple data as the + ages of her children. Her capacity was later not gone into + fully but it was certainly less defective on recovery than + at this time. She was rather shallow in giving a + retrospective account during this period. Even later, when + she had developed a clear insight and made, in respect to + her activity and behavior, a natural impression, she was + not able to give much information about her psychosis, + although she apparently tried to do so. + + She was discharged recovered four months after admission, + her weight having risen from 93 lbs. on admission to 133 + lbs. on discharge. For the first two weeks of her stay in + the hospital, her temperature varied between 99° and 100°. + + _Retrospectively:_ She said in answer to questions about + her inactivity and difficulty in answering that she did not + feel like talking, felt mixed up, could not remember well, + did not want to write. + + Before she was quite well she knew of her entrance to the + Observation Pavilion and her transfer to Ward’s Island, of + which she could give some details, but thought she had been + in the Observation Pavilion two weeks instead of three days + and in the admission ward one month instead of a few hours. + As to the precipitating cause of the attack, she spoke of + her flowing so much after childbirth and of her operation. + + She was seen again in March, 1913, when she seemed quite + normal mentally and claimed that she had been well ever + since leaving the hospital. + +With the exception of negativism, which appears only in the anamnesis, +all the cardinal stupor symptoms are found in this history. Particularly +noteworthy is her intellectual deficiency which seemed to be made up of +a real incapacity plus a remarkable disinclination for any mental effort +whatever. It is important to note that her attitude towards this +disability was usually one of indifference and that, in general, there +was no show of affect whatever. Freedom of speech was the last thing for +her to regain. + + + CASE 7.--_Mary C._ Age 26. Single. Admitted to the + Psychiatric Institute April 7, 1907. + + _F. H._ The father had repeated attacks of insanity, from + which he recovered, but he died in an attack at the age of + 60. A sister also had a psychosis, from which she + recovered. + + _P. H._ The patient was rather quiet and easily worried. + When 14 she had some dizzy spells, with momentary loss of + consciousness. After that time she had no such attacks, + except after a tooth extraction when about 24. + + The patient came to the United States six months before + admission. She went to live with a cousin who died a week + after she arrived at his house. She worried and said that + she brought bad luck. Then she took a position, where she + was well liked, but she was not particularly efficient. In + this situation she often felt homesick and lonely. + + Two weeks before admission an uncle died, which affected + her considerably. She spoke of his leaving three children, + and would not go to the funeral. Then she thought she was + going to die. She felt dizzy, weak, walked with a stooped + position, was sleepless. In the midst of this she suddenly + felt frightened and walked into her mistress’ room, to + whom she complained that some one was talking outside but + could not tell what was said. She heard shooting. + Retrospectively, after recovery the patient said that at + that time she suddenly got “mixed up,” and that her “memory + got bad.” + + She was taken to a general hospital, where she thought + there was a fire, and screamed “Fire!” She was soon + transferred to the _Observation Pavilion_, where she + appeared dazed, moving slowly, yet showing a certain + restlessness. She spoke of “the boat” being shut up so that + no one could go out. Again, she said “The boat went down + and all the people keep turning up.” Retrospectively the + patient stated about this condition that she remembered + going to the general hospital but not her stay at the + Observation Pavilion. (The trip to the Manhattan State + Hospital was again clearer to her.) About the ideas she had + at the time, she remembered only that the room seemed to go + around, and that after she had come to the Manhattan State + Hospital and was clearer, she thought she was in Belfast, + was on a ship, and that people were drowning. + + _Under Observation:_ On admission she had a temperature of + 100°, a coated tongue, suffused conjunctivæ. There were + herpes of the lower lip, a general appearance of weariness + and exhaustion, a flushed face, trace of albumen in the + urine, which was absent on the third day, no leucocytosis, + but 41 per cent. lymphocytes. + + Then and henceforth she was inactive and very slow in all + her movements; she never stirred spontaneously, and had to + be pushed to the toilet and to the table; she ate slowly. + She did not speak spontaneously, and her replies were very + slow in coming. She had to be urged considerably before she + would speak and, as a rule, she did not answer. On one + occasion she was for a day totally inactive and looked + duller. That day and on a few other occasions she wet the + bed. There was at times an appearance of dull bewilderment. + When, soon after admission, asked whether she felt cheerful + or downhearted, she said “downhearted,” but this was the + only time. Often she answered “I don’t know,” when asked + whether she was worried, and she could never say what she + was worried about. Again she directly denied worry. + Sometimes she smiled appropriately, and repeatedly, when + asked how she felt, said, “I feel better.” In answer to + questions as to how her head was, she replied several + times, “My memory is gone,” also “I can’t take in my + surroundings,” or “I don’t know where I am,” or “I cannot + realize where I am.” Again, she spoke of being dizzy and + once said it was as though the room went round. Sometimes + she knew where she was or knew names, again said “I + forget,” but she always was approximately oriented as to + time. There were no special ideas expressed and no + hallucinations, except in the very beginning when she still + thought at night, when she heard the boats on the East + River, that people were being drowned. She later, as stated + above, said she thought she was on a boat and people were + being drowned. + + By June, i.e., two months after admission, she began + rhythmical swaying of the body, twisting of the fingers, or + pulling out some of her hair. She ascribed this behavior + simply to “nervousness.” + + On July 16, after a visit from her cousin, who said to her + that if she worked she would soon get better, she began + spontaneously to occupy herself somewhat. She became more + active, said she felt stronger and brighter, and that her + memory was better. By the beginning of August she was + fairly free, but still spoke in a rather low voice, + although answering well. Her capacity to calculate also + remained poor. When asked about the more inactive state, + she said she had been afraid to stir. (What afraid of?) “I + didn’t know where to go or what to do.” Further, she + recalled that she had had a numb feeling in her tongue, + could not speak quickly, and that her mind had felt + confused and “she could not take in things.” Further review + with her of the earlier period of her psychosis showed that + there was a blank for external events and most of the + internal events during this time. + + She made a perfect recovery and was discharged August 7, + 1907, four months after admission. + +This case, although very like the last, differs from it in two +particulars. For one day her symptoms were sufficiently marked to +suggest a deep stupor. Secondly, her intellectual incapacity was not so +marked (always approximately oriented for time) and with this there was +some subjective appreciation of her defect. Apparently, however, this +insight did not cause her any worry. The affectlessness was equally +prominent in both of the foregoing cases, the fact that Mary C. (Case 7) +once admitted feeling downhearted in response to leading questions, +having little significance in the face of her expression, actions and +usual denial of worry. It is interesting to note that, during the bulk +of her psychosis, her only complaints were of mental hebetude and +dizziness. Possibly the latter was merely an expression of her +subjective confusion. + + + CASE 8.--_Henrietta H._ Age: 22. Admitted to the + Psychiatric Institute March 6, 1903. + + _F. H._ The father stated that both parents were living and + well, also eight brothers and sisters. + + _P. H._ The patient came to this country when she was a + baby. She was bright at school and industrious. From the + age of 17 on, she worked in a drygoods store and gave + satisfaction. About her mental make-up no data were + available, except for the statement that she always made a + natural impression. + + When 21 (February, 1902), without known cause, she broke + down and was sent to the Manhattan State Hospital, but was + not observed in the Institute ward. She remained in the + hospital for three months. It was claimed that the attack + came on suddenly two days before she was sent away. She + suddenly appeared anxious, said something had happened and + became excited. This lasted for about a week, and then she + was, as the description says, “depressed and cataleptic.” + She remained in this condition for about a month, during + which time there was a slight rise of temperature. Then she + improved gradually and was discharged three months after + admission. After recovery from the present attack the + patient stated that during the first sickness she had + visions of dead friends. + + She was perfectly well in the interval. + + Six days before admission she suddenly became excited, + refused to eat, and began to talk, repeating phrases over + and over. Then she became elated and excited. + + After recovery the patient described the onset of her + psychosis as follows: Six days before admission, after + having been perfectly well and without any known cause, she + was feverish and vomited, but slept well. Next day she felt + nervous, and her thoughts were clear. She constantly + thought of dead friends, heard them talking, when she tried + to do anything the voices said, “Don’t do that.” She also + thought somebody wanted to harm her people. Soon she + started singing and felt happy. + + Then she was sent to the _Observation Pavilion_, where she + appeared to be in the same condition which was observed in + the Institute. + + _Under Observation:_ 1. On admission she was in good + physical condition, except for her skin seeming greasy. She + presented for nine days the following picture: She was + essentially elated, laughing, singing, jumping out of bed, + good-natured and tractable, and very talkative. Her + productions showed a good deal of sameness and a certain + lack of progression. She spoke at times in a rather + monotonous voice, but again often in very theatrical tones, + with much, rather slow, gesturing. The following are very + representative samples: + + “I have been suffering from my own blood, my own blood sent + all away from home. I just came from Bellevue. I left here + last May (correct) a healthy girl. A sister is a sister--I + wonder why shorthand is shorthand, a stenographer is a + stenographer (seeing stenographer write)--a kind brother, + Bill H.--why H. his wife is a sister-in-law to us, she has + four children--four beautiful children--sister-in-laws and + brother-in-laws--telephone ringing (telephone did + ring)--dear Lord, such a remembrance--remembrance was + remembrance, truth was truth--honesty is honesty--policy is + policy--if she married him, she is my sister-in-law and he + is my brother-in-law--Max knows me--she changed her name to + Mrs. R.--two children who are Rosie and Maud, if names were + given, names should not be mistaken--they are Julia, + Lillian--Rosie and Maud--why should wonders wonder and + wonders cease to wonder, why should blunders blunder and + blunders still blunder; sleep is one dream and dream means + sleep--if move is moving, why not move?” When she + accidentally heard the word wine, she said “Guilty wine is + not in our house--wine is red and women are women, and + women and wine and wine and women and wine and song.” + Again, “You are not Mr. Kratzberger, Mr. Steinberger, Mr. + Einberger--you are not Mr. Horrid or Mr. Storrid--perhaps + you are Mr. Johnson or Mr. Thompson--no, you are Dr. C.” + (correct). + + She was quite clear about her environment. + + Although the mood was throughout one of elation, on the + ninth day in the forenoon she cried at times, wanted to see + her mother, and spoke in a depressed strain (content not + known). A few hours after that she suddenly became quiet. + + 2. Then for four days (March 14-17) she was markedly + inactive, though at times got out of bed. She looked about + in a bewildered manner, did not speak spontaneously, but + could with urging be induced to make some replies. She did + this now fairly promptly, now quite slowly. Questions were + apt to bring on the bewilderment. Thus, when asked where + she was, she merely looked more bewildered, finally said + “Bellevue--I don’t know,” and questioned who the doctor was + whom she had called by name in her manic state, she said, + with some bewilderment, “Your face looks familiar.” (Where + have you seen me?) “In New York.” She claimed to feel all + right. There was no real affect. She made the statement + that at home she heard voices saying “You will be killed.” + + 3. Henceforth this bewilderment ceased, and for 16 or 17 + days she was essentially inactive for the most part, for a + short time with a tendency to catalepsy and some + resistiveness, and at that time lying with eyes partly + closed. As a rule she said nothing spontaneously, but + replied to some questions, usually with marked retardation, + again more promptly. She constantly denied feeling sad or + worried, repeatedly said she felt “better,” only on one + occasion did she cry a little. When asked to calculate she + sometimes did it very slowly, again fairly promptly. The + simple calculations were usually done without error, the + others with some mistakes. As to her orientation the few + answers obtained showed that at times she knew the name of + the place and the day, again she gave wrong answers + (Bellevue). Once asked on March 23 for the day, she said + April. She wrote her name promptly on one occasion, again + a sentence slowly but without mistakes. Once during the + period she sang at night. Once she suddenly ran down the + hall but quickly lapsed into the dull condition. + + On April 4, at the end of this period, she suddenly + laughed, again ran down the hall, said she had done nothing + to be kept on Ward’s Island. But she quickly lapsed again + into the dull state. Later, on the same day, when the + doctor was near, she said, in a natural tone, “Thank God, + the truth is coming out.” (What do you mean?) “That I have + been trusting in a false name and that Miss S. (the nurse) + should not nurse me.” Then she got suddenly duller, + calculated slowly and with some mistakes, 3×17=41, 4×19=56, + and when asked to write Manhattan State Hospital she wrote + (not very slowly) “Mannahaton Hotspalne.” + + 4. Next day it was noted that she was more stuporous, and + she remained so for two weeks, now showing a decided + tendency to catalepsy and more resistance than before, + though not marked, except in the jaw. She lay often with + head raised, sometimes with eyes partly open, or staring in + a dull, dreamy way, neither soiling nor drooling, however; + a few times she looked up when spoken to sharply. There was + no spontaneous speech. Usually she did not answer at all, + but a few times a short low response was obtained. Once she + wrote slowly a simple addition, put down on paper. When, on + one occasion, asked how she felt, she, as before, said, “I + feel better.” + + 5. Then, with the exception of a day at the end of the + month, when the more stuporous state was again in evidence, + she returned to her former condition without catalepsy or + resistiveness and without staring, but essentially with + inactivity or slowness. She now even dressed herself, + answered slowly though not consistently, but she again + denied feeling troubled or sad, “I feel better.” + + On July 7 she got brighter but was still rather slow. She + then even began to do some work. She again denied feeling + sad. + + In a few weeks, while having a temperature of 102° with + vomiting and diarrhea, she suddenly got freer. She then + said, in answer to questions, that she did not speak + because she was not sure whether it would be right, again + because she seemed to lose her speech. She did not move + because she was tired, had a numb feeling. She said she + had not been sad, “but I had different thoughts,” “saw + shadows on the walls of animals, living people and dead + people.” She was not frightened, “I just looked at them.” + People moved so quickly that she thought everything was + moved by electricity. She thought her head had been all + right. + + After a few days she relapsed into a duller state again, + but then got quite free and natural in her behavior. On + August 28 she gave a _retrospective_ account of her + psychosis, a part of which has been embodied in the + history. She had insight in so far as she knew she had been + mentally ill. She claimed to remember the Observation + Pavilion and her coming to the hospital, also the incidents + during the manic state, when she heard cannon and thought a + war was on, and voices she could not recognize nor + understand. Then she became stupid, although neither sad + nor happy. + + Then, she claimed, she got stupid, but neither sad nor + happy. She claimed to have known all along where she was, + but felt mixed up at times, her thoughts wandered and she + felt confused about the people. She thought she was in + everybody’s way, thought others wanted to get ahead of her, + did not speak because she did not know if it were right or + wrong, felt she might cause disturbance if she answered. + (It is not clear whether she had complete insight into the + morbid nature of these statements.) She also claimed again + that all along she “saw shadows on the wall,” “scenes from + Heaven and Earth,” “shadows of dead friends laid out for + burial.” She had insight into the hallucinatory nature of + these visions. Sometimes she thought she was dead also. She + claimed that she began to feel better when these shadows + stopped appearing in June (the actual time of her + improvement). + + She was discharged recovered a month later, after having + been sent to another ward. + +In this case, then, we find that the two months of stupor were ushered +in by a brief state in which, in addition to the usual inactivity, there +was a certain bewilderment, increased by questions, while the +orientation which in the preceding manic state had been good became +seriously interfered with. The psychosis bordered on deep stupor for +brief periods when the inactivity seemed to be complete or she lay in +bed with her head raised from the pillow. On the other hand, there were +occasional sudden spells of free activity even with a certain elation. +She could often be persuaded to answer questions or to write, the +slowness of this spoken or written speech varying considerably. Her +replies revealed the fact that she was essentially affectless and that +her intellectual processes were interfered with, even to the extent of +paragraphic writing. We have, therefore, here again features similar to +those of the preceding cases. In addition we must add as important that +this patient said retrospectively that she thought she was dead, that +she saw “shadows from Heaven and Earth,” “shadows of dead friends laid +out for burial,” all this without any fear. We shall see later that this +is a typical stupor content. + +We will here include state 3 of Anna G. (See Chapter I, Case 1) who +after the pronounced stupor was for two months merely dull, somewhat +slowed and markedly apathetic. Although her orientation was not +seriously affected, there was considerable interference with her +intellectual processes, as shown in her wrong answers or her lack of +answers when more difficult questions were asked. + +A similar picture was presented in state 2 of Mary D. (See Chapter I, +Case 4.) Here, to be sure, there were more marked stupor features in +that the patient wet and soiled, in addition to occasional spells when +she lay with her head raised. But she spoke and acted fairly freely +(even while soiling). By her replies she showed a considerable +intellectual inefficiency, although, like Anna G., her orientation was +not seriously disturbed. Here again there was complete affectlessness. + +This gives us, therefore, five states which may be analyzed for the +symptoms of partial stupor. The pictures of all five are unusually +consistent. There is inactivity, marked but not complete; poverty of +affect without perfect apathy; and a marked interference with the +intellectual processes. The last can be studied better than in the deep +stupors because these partial cases are more or less accessible to +examination. There is a tendency for the patient to think much of death +either in the onset or during the psychosis. Negativism seems much less +prominent than in the deep stupors. + +A natural criticism is that these cases merely had retarded depressions. +Although this topic will be discussed fully in a later chapter, two +differential characteristics should be mentioned now. First, depression +is a highly emotional state in which the sadness of the patient is as +evident from his facial and vocal expression as from what he says, while +these stupor reactions are by observation and confession states of +indifference. Secondly, there is no such disturbance of the intellectual +processes in depression as is here chronicled. Let the retardation once +be overcome so that the will is exercised and no real defect is +demonstrable. In our experience the cases of apparent depression with +intellectual incapacity are found on closer study to be really stupors +as other symptoms show. + + + + +CHAPTER III + +SUICIDAL CASES + + +An important “catatonic” symptom is a tendency to sudden, impulsive, +unexplainable acts. Such actions occur occasionally in benign stupors +and, since we attempt an understanding of the reaction as a whole, an +effort should be made to study these phenomena as well. The cases chosen +showed persistent, quite affectless, yet very impulsive attempts at +self-injury. They characterized the first of the three cases throughout, +were present in one stage (the second) of the second patient, while in +the last for one day there was behavior which can be similarly +interpreted. + +Mention has been made of the prominence, approaching universality, of +the death idea in stupor. This is a subject to be discussed in length +presently, but for the present we may say that there may be a delusion +of death with dramatization of that state or a mere abandonment of the +mental activities of life. It is but a step from corpse-like behavior to +suicidal attempts, psychologically speaking, yet this transition +necessarily modifies the clinical picture, since one necessitates +inactivity and the other activity. Secondarily, other atypical clinical +features appear, as will be seen. + + + CASE 9.--_Pearl F._ Age: 24. Admitted to the Psychiatric + Institute July 26, 1913. + + _F. H._ A paternal aunt was insane. Both parents died long + ago; the mother when the patient was a baby; the father + when she was a girl. She came to this country when 17. In + this country she had generally been a domestic. An older + brother and sister were also in America. + + _P. H._ She was described as sociable, good-natured, bright + enough, not inclined to be depressed. She had little + education. There was no former attack. + + Four months before admission, the patient did not + menstruate but was said not to have worried about this. A + month later she began to show symptoms. She said she did + not want to live, had done something wrong but could not or + would not say what it was. Again she said a young man was + going to sue her, a young Jewish fellow whom she had seen + only a few times. She talked of turning on the gas. She + also complained that people were looking at her and that + the food was poisoned. + + The patient after recovery gave the following version of + the onset: She had a position on 99th St. for 2½ years. + She liked the people there and often went to see them + later. Her next position was in the Bronx. She was there + for nine months. In the same house lived “Harry.” After the + work she used to talk to him in the yard and, after she + left, she used to think of him and long for him. But she + denied, with a very natural attitude, that she worried + about him at the beginning of her psychosis. After the + position in the Bronx she went to one on 96th St., where + she was for four months. In the same house was a girl whom + she liked and who was lively. When she left, the patient + left too. This was a month before the psychosis began. When + she left there, she got word that her employer on 99th St. + had developed consumption and had to go out West, but did + not worry over this news, she claimed. She looked for + another position and had one for two weeks, but felt + lonely, did not care to live. Then her sister took her to + her home. She thought people were looking at her and were + making remarks because she was not working. During this + time she had a dream one night in which her dead mother + appeared to her (in ordinary street clothes) and said to + her that she (the patient) “was going away.” She woke up + frightened. She was worried, thought she had not prayed + enough for her mother, and asked her sister to pray also + and to give money to the poor. She did not recall, or at + any rate denied, speaking of the young man suing her. + + She was then taken to a _private sanatorium_, where she was + for two months preceding her admission to this hospital. + There she was described as quiet, mute, tube-fed, + resistive. + + When well, the patient said that in this sanatorium she was + first spoon-fed, cup-fed, later tube-fed, “I used to be + scared of them, they used to put a spoon way down my throat + and I had no appetite--I did not like them around me, they + were mean to me. They used to let me stand without clothes, + used to spite me.” “If I did not want to dress myself, they + used to hit me.” “I used to feel lonesome for home and I + imagined my people were there and that my sister passed the + place without stopping.” She was afraid of the nurses, + thinking they wanted to kill her. + + At the _Observation Pavilion_ the patient was described as + dull, but brightening up under examination. She made few + spontaneous remarks, but in answer to questions said she + was melancholy, tired of life, because she was in love with + a Gentile fellow who refused to marry her. She also said “I + get peculiar thoughts that I am going to die.” + + _Under Observation:_ The patient’s condition lasted for + about two years. Much of the time she lay in bed, often + with the covers pulled over her, sometimes with her legs + drawn up, again in a more natural, comfortable position, or + she sat up with her head bowed. She obeyed almost no + commands. For months she soiled and wet herself, but never + drooled. For a time she refused food consistently, lost + flesh and had to be tube-fed. For the most part she said + very little and, when one accosted her, she was apt to turn + away. A few times, when further urged, she swore at the + examiner. There was also persistent marked resistance + towards any interference, sometimes merely passive or quite + often, especially at first, with wriggling or severe + scratching of her own body. There was often with this + evidence of irritation or she moaned. Again she was + described as quite affectless. One of the most striking + features throughout a large part of the course were her + suicidal attempts. She would try to strike her head against + the iron bedpost, throw herself out of bed, throw herself + about generally, try to strangle herself with the sheets, + try to pull out her tongue, all of which seemed to be done + with great impulsiveness. Almost her only utterances had to + do with death. She said she wanted to die, wanted to drop + dead, did not want to live, wanted to kill herself, that + she did not eat because she wanted to die. When once she + was found tossing about and was asked whether she worried, + she said “I know I am going to die.” (You mean you will be + killed?) “I don’t care.” + + There were a few episodes which still have to be mentioned. + Quite early in the course of the stupor, when she was + restless, scratching herself and moaning, she once spoke + quite freely. She said “Give me that fellow (Harry), I + don’t care, I can’t help it. I must have him, even if it + costs me my life.” “I would feel happy if I could get him. + O God, I love him--I will never get him even if I drop + dead, I know I won’t get him, the darling” (cries). (What + if you did get him?) “I know I would lose him again.” Then + with shame she claimed she had had sexual relations with + him (when well, denied). At the same interview, when the + doctor sneezed, she said “Gesundheit.” In June, 1914, she + was seen smiling at times. But the first was the only + episode when she spoke more freely, and the two occasions + the only ones when she showed a frank affect. + + The improvement commenced in April, 1915. Although still + very inactive, she sometimes began to laugh and sing and + talk a little to other patients. She also answered a few + questions on April 22, 1915. Thus, when asked whether she + wanted to go home, she said “No, I want to stay here.” (Do + you like it here?) “Yes” (smiles), “I can’t get no other + place; I have got to like it here.” She smiled freely. To + orientation questions, she knew the place, month, but not + the year. + + She continued inactive and above all diffident, but + improved steadily and, when examined by the writer on + November 15, she made a very natural impression and gave + the retrospective account of the onset embodied in the + history. She was quite frank, thanked the doctor for the + interest he took in her case, and said for example, “You + know I never thought I would get well. I quite gave up--I + am very glad I am well now.” + + When questioned about her stay here, the patient evidently + remembered much. She was able to say which wards she had + been in and approximately how long she had been in each + one. She claimed that at first it “seemed strange.” “I did + not eat, I did not want to eat, I used to tell them to + poison me and that I wanted to die, I was _disgusted_, I + thought I would never go home.” She also says she felt + _angry_, wanted to kill herself. She bit and scratched + “because I was nervous.” She remembered talking about + Harry, “I said I was in love with him, I thought I wanted + to die because I could not have him.” She also talked of + having been _stubborn_. Sometimes she felt like running to + the river. She also claimed she imagined people were false + to her. + + In one of the wards she said she thought people were there + on her account, were waiting for her death. She did not + care for a time whether she died or not. She knew she tried + to choke herself occasionally. Asked how she behaved, she + first said she was quiet. (Were you not restless?) “I used + to get tired and have backache and roll around in bed.” She + also felt like running away sometimes, wanted to get out of + bed and wanted to walk about. (What about going to the + river?) “I used to say that.” She claimed not to have been + mixed up at any time and to remember everything. Remarkable + is the fact that she claimed she _did not worry at all_, + “_I felt I was lost and would not worry._ I used to worry + at home and at Dr. M.’s (the private sanatorium) but not + here. Here I never worried, I did not care where I went.” + She said she did not talk because she was bashful in the + presence of doctors, sometimes she felt afraid of them, + afraid they would kill her, put poison in her food when + they fed her. “When my people came, I said I did not want + to live, wanted to kill myself. I used to cry.” Again asked + why she did not talk, she admitted she really did not know. + Once she said she was bashful because she soiled her bed. + She did not want to go to the closet because she was afraid + of the nurse. She denied hearing voices. + +In addition to the activity incidental to her attempts at self-injury, +this patient showed an unusual degree of resistiveness and with this +some affect, for she appeared to be irritated and at times moaned. Still +more unusual were the appearances of delusions not associated with +death but with a vivid form of life, namely, a love affair. Occasionally +she spoke of her imaginary lover “Harry.” Another atypical feature was a +fair memory for the period when she was in stupor. She claimed to +remember much of her movements and this claim was substantiated by her +answers to questions after recovery. + + + CASE 10.--_Margaret C._ Age: 23. Single. Admitted to the + Psychiatric Institute November 13, 1913. + + _F. H._ Heredity was absolutely denied. The mother is + living and made a natural impression. The father died at + 65, nine months before patient’s admission, of cardio-renal + disease. Two brothers and one sister died of acute + diseases. One sister died in childbirth. Three brothers and + one sister were said to be well. + + _P. H._ The patient was bright and passed successfully + through high school. For seven years prior to the psychosis + she worked for the same company as clerk. She was described + as efficient, conscientious, systematic, though sometimes + upset by her work; as lively, talkative, cheerful, with + somewhat of a temper and easily hurt, also as quite + religious. She was more attached to her mother than to her + father, but still more to her older sister, whose death + precipitated her psychosis. She never had any love affair + and was said not to have cared for men. Two months before + admission, when her favorite sister was confined, the + patient was quite worried about her, but relieved when she + heard good news. A few hours later, however, the sister + died suddenly. When the patient learned of the sister’s + death, she screamed, and screamed several times at the + funeral. She did not cry, said she could not. After this + she slept poorly, seemed nervous, went to church more, but + there was no other change. She continued to work and, + according to the employer, worked well. + + Nine days before admission she would not get out of bed in + the morning, said little and refused food. A few days later + she was induced to take a walk, but she seemed to have no + interest in anything. When she talked at all it was about + her sister and of wanting to go to a convent. When asked + to do anything she said she would if it were God’s will. + She did not menstruate after her sister’s death. When + practically recovered, the patient attributed her breakdown + to this tragedy. She added to the description above given + that, soon after losing her sister, she had a fright at + home. “It was the house in which my father died and one day + when I was in bed I thought somebody came in.” But she + denied a vision and could not further explain. + + At the _Observation Pavilion_ she was very inactive, so + that she had to be fed and cared for in every way, mute, + often covering her head with a sheet, turning away when + questioned and resistive when the physical examination was + attempted. But at times she smiled or laughed. + + _Under Observation:_ 1. For two months the patient was + generally inactive, sometimes lying in bed with her eyes + tightly closed, or with her face covered by the sheets or + buried in the pillow; or she sat inactive, staring, or with + eyes closed, or her head buried in her arms. On one visit + she had to be brought into the examining room in a wheel + chair and lifted into another seat. A few times she was + observed holding herself very tense with her head pressed + against the end of the bed. But this inactivity was often + interrupted by her going quickly into various rooms to + kneel down, though she was never heard praying. Or she ran + down the hall for no obvious reason. Or, again, she was + found lying on the floor face down. She ate very poorly and + had to be tube-fed a considerable part of the time. When + this was done, she sometimes resisted severely, as she did + in fact most nursing attentions. Thus she soon began to + struggle when her hair was combed. She also resisted being + taken to the toilet or being brought back. She did not soil + or drool, however, but sometimes seemed to be in + considerable distress before she finally literally ran to + the closet. This resistance just spoken of consisted + chiefly in making herself stiff and tense. Sometimes at the + feeding she pulled up the cover when preparations were made + and held to it tightly. Quite striking was the fact that + with such resistance she sometimes, though by no means + always, laughed loudly, as she did occasionally when she + was talked to, or even without any external stimulation. + This laughter always was one of genuine merriment and quite + contagious, and by no means shallow or silly. + + Usually the patient was totally mute. The exceptions + occurred mostly when her resistance was called forth. Thus + one day when fed she said, “I wish you people would have + more to do,” or on another occasion, when she had resisted + being brought into the examining room, she said, “I will + get out of here if I break a leg.” But once when the nurse + accidentally tickled her, she said, “Since I am ticklish, I + must be jealous--I should worry.” She also answered very + few questions and such responses as she made were chiefly + expressions of resentment. Thus, when one kept urging her, + she finally would say “stop,” or after much urging “I am + going to hurt you pretty quick.” Sometimes she said “Go + away,” or “Let me alone.” She was just as silent with the + mother and the priest as with the physicians. On one + occasion she told the nurse that the priest had told her to + talk to the doctors, but that she had nothing to say. + Sometimes she did not even look at the visitors, but turned + away from them, as she did from the physicians, but at one + visit from a priest, though she scarcely said anything, she + held on to him when he was about to depart and would not + let him go. Throughout this period, since scarcely any + answers were given, nothing was known about her + orientation, except when on admission she gave a few + answers. She then thought she was at the Observation + Pavilion, seemed unable to tell even that the physician was + a doctor, but knew the date. When asked how she came to + Ward’s Island, she said “By ambulance.” The physical + condition presented nothing of note, except for a certain + sluggishness of the skin with marked comedones. + + 2. By _January_, 1914, the picture changed somewhat and she + then presented the following state for an entire year: The + mutism persisted and indeed became even more absolute, and + she began to wet and soil constantly. This commenced as + what seemed to be an act of spite as a part of her + resistiveness, for the first time she soiled she seemed to + do it deliberately when the nurses insisted that she allow + them to put on a dress. Later this explanation no longer + held. Tube-feeding too was for the most part necessary, the + resistiveness continuing as before. But the inactivity was + broken into much more than before by constant impulsive + attempts to hurt herself in every conceivable way--by + bumping her head against the wall, putting her head under + the hot water faucet, trying to pound the leg of the + bedstead on her foot, striking herself, pinching her + eyelids, pulling out her hair, trying to pick her radial + artery, throwing herself out of bed, knocking her head + against the bed rail, etc. This was done in silence but + with what appeared a great determination that occasionally + showed itself in her face. She also sometimes scowled and + frowned. With the difficulty in feeding her and the + constant impulsive excitement in which bruises could not + always be avoided (once an extensive cellulitis developed + in the arm which had to be lanced), the patient got weak, + emaciated and exhausted; much of her hair fell out, + although some she pulled out. It should be stated that + during this entire impulsive state she could not be taken + care of in the Institute ward, but was sent to a special + ward in the Manhattan State Hospital, where suicidal + patients are under constant watch. These impulsive attempts + at self-injury lessened only towards the end of the period. + Her laughter, which had been such a prominent trait, + disappeared almost entirely during this entire phase. With + all this, the general resistiveness, as has been stated, + remained towards feeding or any other interference. It was + only in the beginning associated with laughter as in the + previous stage. + + Although there were, as a rule, no spontaneous remarks and + no replies, she on one occasion said spontaneously, + probably referring to her unsuccessful attempts to kill + herself: “I can’t do it, I have no will.” During the same + period she once said: “I don’t want to eat, I don’t want to + get well, I want to do penance and die.” + + By _January_, 1915 (i.e., a year after the second phase had + commenced), she began to dress herself and eat, and also + became clean. But she remained for the most part very + inactive, sitting stolidly about all day and still without + interest in her environment. The impulsive attempts at + killing herself disappeared. Although she remained for + months to come still inactive, she gradually began to talk + a little, began to play a little on the piano, but said + little to any one. + + By _August_, 1915, she still was inactive, shy, standing + about, or sitting picking her fingers, occasionally going + to the piano, but evidently unable to finish anything. She + had to be coaxed to come to the examining room and talked + in a low tone. Often she commenced vaguely to speak and + then stopped and could not be made to repeat what she had + been saying. Affectively she was remarkably frank, + sometimes a little surly, or she showed a slight empty + uneasiness. She could, however, be made to laugh heartily + at times, or did so spontaneously on very slight + provocation. + + Some of her utterances were in harmony with her apparent + indifference. It was difficult to get her to say how she + felt even when thorough inquiries were made. Once she said, + when asked about worrying, “I don’t worry,” or again “I get + angry sometimes,” or “I used to worry about my health, I + don’t now,” or, when asked what her plans were, she said + directly: “I don’t care what happens.” Again she said “I + guess I am disagreeable,” or “I guess I am a crank.” + Another interesting indication of her state was expressed + in her repeated statement, “I don’t know what I want.” But + she was oriented in a way, though not sure of her data. She + would give most of her answers with a questioning + inflection, “This is the Manhattan State Hospital, isn’t + it?” or she would say, “I don’t know exactly where I am, + it’s Ward’s Island, isn’t it?” and in the same way she gave + the day, date and year correctly. But she did not know the + names of the physicians. At that time she could give many + data about her family correctly, but was slow, even if + correct, in calculation, and, though she got the gist of a + test story, she left out some important details. + + A retrospective account at that time showed she was + uncertain about the Observation Pavilion, that she was not + certain how she came to Ward’s Island, “On a boat, I + believe.” It was clear that she did not remember the + admission ward, about the Institute ward (in which she had + been for the first two and a half months and in which she + was again examined); she said it was familiar to her, but + she was not certain that she had been in it. About the + physician who saw most of her in these first two and a half + months, she said that his voice seemed familiar, and she + asked him whether he had tube-fed her (she had been + tube-fed by him many times), but she again said, “No, you + are not the one,” and described as the man who had fed her + the one who did it on the second ward where she was for a + year. But she knew that she had been sent to the second + ward, because she constantly tried to injure herself. These + injuries she recalled but was unable to say why she + attempted them, “I suppose I didn’t know what I was doing.” + She claimed she heard voices and had “all sorts” of + imaginations, but could not be gotten to tell about them. + When it was difficult for her to give an answer, she was + apt to keep silent and then could be prodded without much + success. + + In _October_, 1915, there was further improvement, inasmuch + as she began to converse some with other patients, played + the piano and seemed able to carry a piece through. She was + put in the occupation class and did quite well. At the + interview with the physician she was still apt to laugh + boisterously at slight provocation. Even now she had great + difficulty in describing her condition and at the + examination was often still quite vague. Thus, when asked + how she felt, she said, “I do know I feel + ridiculous--sometimes I feel kind of angry--I don’t + know--they say I am crazy but I am not, but I am hungry--I + don’t know whether I am or not, I don’t know what I can do + well,” etc. This is quite characteristic. When asked + whether she was worried, she said: “I don’t know, am I + worried?--yes, a little sometimes, I am to-day--I am so + untidy--don’t know what is the matter with me.” Again: + “Sometimes I lose my speech--I can’t say what I feel, I + don’t know what it was.” Later, half to herself: “I don’t + know what is the matter with me--I don’t care anyway.” + + In _December_, 1915, there was still further improvement, + and on the ward and in superficial conversation she made, + towards the end of the month, in many ways a natural + impression, though the laughter before described was still + somewhat in evidence. It usually came not without occasion, + but was, as a rule, quite out of proportion to the + stimulus. She again said she could not explain why she + tried to injure herself, claimed she did not feel it, and + even claimed she did not remember doing it in the Institute + but only in the second ward. + + The defect in thinking which still remained is very + difficult to formulate. She was now entirely oriented, no + longer with any hesitation about the correctness of her + information. She subtracted 7 from 100 very quickly and + could from memory write a long poem, but there was a + certain vagueness about her which partly may have been due + to a still existing indifference. This vagueness consisted + chiefly in a difficulty of attention or in her capacity to + grasp fully what was wanted. It is best illustrated by a + few examples: After she had been asked about the _onset_ of + her sickness and she had said that what was on her mind + then were prayers for the salvation of her relatives, she + was asked exactly when it was that she thought of this; she + answered “Now?” (What period were we talking of, the + present or past?) “The present.” (What did I ask you?) + “About this period of my sickness.” (Which one?) “What + sickness?” She said herself at this point, “I am rather + stupid” (quite placidly). Or again she said she did not + know why she pounded her head, but finally said, “To get + better and go home.” (Do you think if you pounded your head + against the wall you would go home sooner?) “I don’t + know--maybe.” (How would it help you?) “You mean to go to + the city?” (Yes.) “I don’t know.” Again when asked how her + mind worked, she said, “Pretty quickly sometimes--I don’t + know.” (As good as it used to?) “No, I don’t think so.” + (What is the difference?) This had to be repeated several + times, at which she said, “There is no difference.” (What + did I ask you?) “The difference.” (The difference between + what?) “You did not say.” Equally striking was the fact + that when she was jokingly told “If it snows to-night, we + shall have a black Christmas,” she did not grasp the + absurdity at once, but in a rather puzzled way asked, + “Why?” + + She was then discharged on parole, two years and one month + after admission. Soon after discharge her menstruation, + which had been absent throughout her psychosis, returned. + On her discharge she had regained her normal weight, and + during the two subsequent months gained fifteen pounds. + + She then recovered completely, so that three months after + discharge she made a very natural impression. She said, on + looking back over her state with impulsive excitement, that + she constantly had the idea that she wanted to punish + herself, but that _she did not know why_, and did not think + she was sad or worried. + +Considering only the second phase of the psychosis, this deep stupor +showed many interruptions, due not merely to her suicidal efforts but +also to her resistiveness. The condition, too, was not so completely +affectless as one expects a deep stupor to be. In the first stage there +was much sudden laughter, reminding one of dementia præcox (except for +its never being shallow or silly) and this persisted into the first part +of the second phase. The actual attempts at self-injury brought out +emotion, for with them she scowled and frowned as well as showing +considerable energy. + +To these may be added the following case. It is not unlike the ordinary +stupor in the fact that there was intense inactivity and mutism with +great tenseness. The remarkable trait was, however, that for a whole day +she forcibly held her breath until she got blue in the face. The case in +detail is as follows: + + + CASE 11.--_Rosie K._ Age: 18. Admitted to the Psychiatric + Institute January 24, 1907. + + _F. H._ Both parents were living. The father was a loafer. + Nine brothers and sisters were said to be well, with the + exceptions of one brother who had an irritable temper, and + of a markedly inferior sister. + + _P. H._ The patient was a Galician Hebrew, a shirtwaist + operator. Not much was known about her make-up, but it is + certain that she was a bright girl. The patient herself + said after recovery that her father was nagging her + constantly with complaints that she was not making enough + money, although he himself did not work and she contributed + much to the support of her family. She disliked him very + much and claimed that all her relatives worried her, except + her mother. + + Nine weeks before admission a messenger came into the shop + where she worked and said, “Rosie, your father is dead” + (the message was intended for a fellow worker). In spite of + the fact that the matter was explained, she was upset and + nervous enough to be taken home. Though she continued to + work for over two weeks, she worried over many trivial + matters and talked much about this. She also said that + everything looked queer at her home and complained of + having difficulty in concentrating her mind. Finally she + became elated and talkative. Nothing is known of any + special ideas. + + At the _Observation Pavilion_ she appeared to be typically + manic. + + Then she was sent to an institution where she remained for + six weeks. The report from there stated that she was for + ten days “elated, excited, talkative, with flight of + ideas.” Then her condition suddenly changed to a marked + reduction of activity, in which she neither spoke + spontaneously nor answered questions. She “appeared to + sleep,” but was said to have talked to her people. When + interfered with, she was resistive and sometimes let + herself fall out of bed. On the other hand, she + occasionally wandered about at night. It should be added + that during the stupor an alveolar abscess developed which + discharged pus. It was washed out and healed. + + Then she was sent to the Manhattan State Hospital and + admitted to the service of the Psychiatric Institute. + + _Under Observation:_ 1. On the first day she lay in bed + with cyanotic extremities, weak pulse, grunting, moaning + and not responding in any way when examined. After this the + moaning and grunting ceased and she was essentially + indifferent, and for the most part kept her eyes closed. + Often she wet and soiled herself. She was resistive to any + care or examination. She would not eat, as a rule, but + again gulped down milk offered her. For a considerable time + she had to be tube-fed. During the early part of this + stupor she once took a paper from the doctor, examined it, + and then gave it back without saying anything, or again she + peered around silently, or asked to go home, or again, on a + few occasions, answered a question or two or spoke some + unintelligible words. Orientation could not be established. + + 2. After a few weeks she became more rigid, a condition + which continued for six months. She let saliva collect in + her mouth, and drooled. She had to be tube-fed. She lay + very rigid, with very pronounced general tension, with her + lips puckered, hands clenched, sometimes holding her eyes + tightly closed, and often with marked perspiration. For one + day she held her breath until she was blue in the face. On + the same day she was extremely rigid, so that she could be + raised by her head with only her heels resting on the bed. + Her eyes were tightly shut and she was in profuse + perspiration. Sometimes she interrupted this by a deep + breath, only again to resume the forcible holding of her + breath. On another day towards the end of the period, while + quite stiff, she kept grunting and screaming “murder.” The + soiling continued. She never spoke. + + _Physical condition during the stupor:_ At first she had a + coated tongue, foul breath and a fetid diarrhea. The latter + was treated with high colonic flushing and mild diet. Urine + normal--gynecologically normal. General neurological and + physical examination not possible. At the same time she had + for two weeks a temperature which often reached 100° or a + little above, a weak, irregular but not rapid pulse, a + leucocytosis of 17,500 and 80% hemoglobin. When she began + to refuse food and before she was tube-fed regularly, she + twice had syncopal attacks and lost considerable flesh + which was gradually regained under tube-feeding. After the + diarrhea she was habitually constipated. Cyanosis of the + extremities seemed to have been present only at first. + + 3. Six months after admission she began to make very free + facial movements--winking, raising the eyebrows--and soon + developed an excitement with marked elation. She had to be + kept in the continuous bath, talked continuously, whistled, + sang, was markedly erotic towards the physician, careless + in exposing herself and often obscene in her talk. Most of + her productions were determined by the environment. She was + therefore quite distractible, very alert; sometimes she was + meddlesome, again irritable, irascible. The following + illustrates her productions: “Send for my husband, S.--He + had one sister as big as that. She likes candy.... My + father is underneath and my mother is on top because she is + fat and he is skinny.... Wait till the sun shines, + Nellie--we will be happy, Nellie--don’t you sigh, + sweetheart, you and I--wait till the sun shines by and + by.... Come in (as noise is heard)--I bet that is my + husband--my name is Regina K. (mother’s name)--my mother’s + name is the same--I got a little sister named Regina--she + is my husband.” When she heard the word pain, she said, + “Who says paint, Pauline used paint, I used paint,” etc. + + Towards the end of August she had pneumonia, which did not + change her condition. + + By October she was well, having gradually settled down. She + had good insight. + + _Retrospectively:_ She laid very little stress on the false + report of the father’s death. She claimed to remember being + at the Observation Pavilion, but to recall very little of + the other hospital. Unfortunately an inquiry was not made + regarding her memory during the stupor period under + observation with the exception of the fact that she said + she wanted to die and therefore refused food. + + She was seen in March, 1913, appeared perfectly well, and + stated she had been well during the entire interval. + +If this forced holding of the breath had been the only anomaly, one +would, perhaps, not be justified in drawing any conclusions as to its +significance. But the deep stupor was interrupted again for a day by +grunting and screaming of “murder.” This is certainly indicative of a +compulsive death idea and retrospectively she spoke of having refused +food in order to die. The latter seems to indicate some connection +between her negativism and death. Consequently, even if we regard the +breath holding as resistiveness, it would still be related to her idea +of dissolution. Her negativism went beyond ordinary limits in that it +affected the expression of the face. + +When we consider these three cases together, we see that what would +otherwise have been deep stupors with profound inactivity, were modified +by activity in two directions: suicidal and resistive. Presuming that +the symptoms of stupor are all interrelated, we can see a reason why the +affect should also have been altered. When one is modified, this should +influence the other. When the activity is increased, the emotional +concomitants of impulsive acts tend to break through as well. Hence the +changes observed in these cases in facial expression and tone of voice. +It is noteworthy, too, that all three showed a tendency for laughter to +appear, as if, the emotions once stirred, it was possible for them to be +exhibited in other than unpleasant forms. So, too, it was possible for +ideas unrelated to the stupor picture, such as those of lovers, to occur +sporadically. Finally, since activity must imply some contact with +environment, the first of these cases at least showed less interference +with the intelligence than is usual. In general, one may conclude that +any aberration from the pure type of stupor tends to allow other +impurities to appear. + + + + +CHAPTER IV + +THE INTERFERENCES WITH THE INTELLECTUAL PROCESSES + + +This is one of the most interesting and important of the stupor +symptoms. We are accustomed to think of the functional psychoses having +symptoms to do with emotions and ideas in the main, and, conversely, +that disorientation, etc., observed in such cases is merely the result +of distraction, poor attention or coöperation. But in stupor the deficit +in understanding, incapacity to solve simple problems and failure of +memory seem deep-rooted and fundamental symptoms. So far is this true +that Bleuler[5] looks on “schizophrenic” cases with this symptom of +“Benommenheit” as organic in etiology. It may be said at the outset that +we do not share this view for many reasons. One at least may now be +stated as it seems to be final. In benign stupor purely mental stimuli +may change the whole clinical picture abruptly and with this produce a +change in the intellectual functioning such as we never see in organic +dementias or clouded states. We find it more satisfactory to attempt a +correlation of this with the other symptoms on a purely functional +basis, as will be explained later. + +For the study of the interferences with the intellectual processes +during stupor reaction, we have two sources of information: The first is +derived from the account which the patient is able to give in regard to +what he remembers as having taken place around him or in his mind during +the stupor period; the second is the direct observation of partial +stupor reactions. + + +1. Information Derived from the Patient’s Retrospective Account + +We will start with the cases of marked stupor mentioned in Chapter I. +Anna G.’s (Case 1) psychosis commenced at home, and under observation +lasted with great intensity for five months. She remembered only vaguely +the carriage going to the Observation Pavilion, had no recollection of +the latter, nor of her transfer to the Manhattan State Hospital and of +most of the stay at the Institute ward, including the tube- or +spoon-feeding which had to be carried on for four months. She also +claimed that she did not know where she was until four or five months +after admission. She was amnesic for her delusions and hallucinations. +Of Caroline DeS. (Case 2) we have no information. Of Mary F. (Case 3), +whose stupor began at home and under observation lasted two years, we +find that she had no recollection of coming to the hospital, what ward +she came to, who the doctor and nurses were (with whom she became +acquainted later), in fact she claimed that for about a year she did +not know where she was. But she remembered having been tube-fed (this +took place over a long period). Mary D.’s (Case 4) stupor also commenced +at home, and under observation lasted for three months. She had no +recollection of going to the Observation Pavilion, of the transfer to +Manhattan State Hospital, and of a considerable part of her stay here, +including such obtrusive facts as a presentation before a staff meeting, +an extensive physical and a blood examination, and she claimed not to +have known for a long time where she was. Annie K.’s (Case 5) stupor +commenced at home. Although she recalled the last days there and some +ideas and events at the Observation Pavilion, the memory of the journey +to Ward’s Island was vague, as was that of entrance to the ward, and she +claimed not to have known where she was for quite a while. Specific +occurrences, such as the taking of her picture (with open eyes two +months after admission), an examination in a special room, her own +mixed-up writing (end of second week) were not remembered. But it is +quite interesting that an angry outburst of another patient within this +same period, which was evidently not recorded, is clearly remembered. + +We shall later show that when the patient comes out of a stupor the +condition may be such that, for a time at least, retrospective accounts +are difficult to obtain. It must also be remembered that not +infrequently the more marked stupors may be followed by milder states, +and it is important, if we wish to determine how much is remembered, +not to confuse the two states or not to let the patient confuse them. +For example, Mary D. (Case 4), who showed two separate phases, while she +claimed not to know of many external facts, also added that she could +not understand the questions which were asked. From observation in other +cases it seems that in marked stupor any such recollection about the +patient’s own mental processes would be quite inconsistent. We have to +assume, therefore, that this remark referred in reality to the second +milder phase, for which, as we shall see, it is indeed quite +characteristic. It is not necessary to burden the reader with other +cases, all of which consistently gave such accounts. + +We see, then, that in the marked stupor the intellectual processes are +regularly interfered with, as evidenced by almost complete amnesia for +external events and internal thoughts. In other words, this would +indicate that the minds of these patients were blank. Inasmuch as direct +observation during the stupor adduces little proof of mentation, we may +assume that such mental processes as may exist in deepest stupor are of +a primitive, larval order. + +Before we examine more carefully the milder grades of stupor, it will be +necessary to say a few words about the retrospective account which the +patient gives of intellectual difficulties during the incubation period +of the psychosis. As a matter of fact, we find that these accounts are +remarkably uniform. While some patients, to be sure, speak of a more or +less sudden lack of interest or ambition which came over them, others of +them speak plainly of a sudden mental loss. Mary. C. (Case 7) claimed +she suddenly got mixed up and lost her memory. Laura A. spoke at any +rate of suddenly having felt dazed and stunned. Mary D. (Case 4) said +she felt she was losing her mind and that she could not understand what +she was reading. Maggie H. (Case 14) began to say that her head was +getting queer. We see from this that the interferences with the +intellectual processes may in the beginning be quite sudden. + +In some instances a more detailed retrospective account was taken, which +may throw some light upon the interferences with the intellectual +processes with which we are now concerned. Emma K., whose case need not +be taken up in detail, had a typical marked stupor which lasted for nine +months, preceded by a bewildered, restless, resistive state for five +days. She was in the Institute ward for the first four months, including +the five days above mentioned; later in another ward. When asked what +was the first ward which she remembered, she mentioned the one after the +Institute ward, and when asked who the first physician was, she +mentioned the one in charge of the second ward. However, when taken to +the Institute ward, she said it looked familiar, and was able to point +to the bed in which she lay, though somewhat tentatively. The same +rousing of memory occurred when the first physician, who saw her daily, +was pointed out to her. She remembered having seen him, and then even +recalled the fact that he had thrown a light into her eyes, but +remembered nothing else. This observation would seem to show that with +some often repeated or very marked mental stimuli (throwing electric +light into her eyes) a vague impression may be left, so that it may at +least be possible to bring about a recollection with assistance, whereas +spontaneous memory is impossible. In another instance, the patient was +confronted with a physician who had seen a good deal of her. She said +that he looked familiar to her, but she was unable to say where she had +seen him. Here then again evidence that a certain vague impression was +made by a repeated stimulus. + +Another feature should here be mentioned, namely, that isolated facts +may be remembered when the rest is blank. We have seen above that Annie +K. (Case 5), while very vague about most occurrences, recalled a sudden +angry outburst in detail. Another patient, though the period of the +stupor was a blank, recalled some visits of her mother. At these times, +as she claimed, she thought she was to be electrocuted and told her +mother so, “Then it would drop out of my mind again.” These facts are +very interesting. We can scarcely account for such phenomena in any +other way than by assuming that certain influences may temporarily lift +the patient out of the deepest stupor. In spite of the fact that stupors +often last for one or two years almost without change, a fact which +would argue that the stupor reaction is a remarkably set, stable state, +we see in sudden episodes of elation that this is not the case, and +other experiences point in the same direction. A similar observation was +made on a case of typical stupor with marked reduction of activity and +dullness. A rather cumbersome electrical apparatus (for the purpose of +getting a good light for pupil examination) was brought to her bedside. +Whereas before, she had been totally unresponsive, she suddenly wakened +up, asked whether “those things” would blow up the place, and whether +she was to be electrocuted. During this anxious state she responded +promptly to commands, but after a short time relapsed into her totally +inactive condition. We have, of course, similar experiences when we try +to get stuporous patients to eat, who, after much coaxing may, for a +short time, be made to feed themselves, only to relapse into the state +of inactivity. + +Such variations are paralleled, as we shall later show, by a suddenly +pronounced deepening of the thinking disorder. We have already seen that +the onset may be quite sudden. All this indicates that, in spite of a +certain stability, sudden changes are not uncommon. Finally, we know +that, in spite of the fact that stupor is an essentially affectless +reaction, certain influences may produce smiles or tears, or, above all, +angry outbursts, which again can hardly be interpreted otherwise than by +assuming that those influences have temporarily produced a change in the +clinical picture, in the sense of lifting the patient out of the depth +of the stupor. All these facts suggest that inconsistencies in +recollection are correlated with changes in the clinical picture. + +As is to be expected, the cases with partial stupors remember much more +of what externally and internally happened during their psychoses. Rose +Sch. (Case 6), who had a partial stupor during which she answered +questions but showed a great difficulty in thinking, said +retrospectively that she felt mixed up and could not remember. Although +she recalled with details the Observation Pavilion and her transfer, she +was not clear about their time relations (how long in the Observation +Pavilion, how long in the first ward). Mary C. (Case 7), whose activity +was not entirely interfered with and who showed some thinking disorder, +said retrospectively that she could not take in things. Henrietta H. +(Case 8), who had a partial stupor, claimed to have known all along +where she was, but that she felt mixed up, that her thoughts wandered +and that she felt confused about people. In the cases where a partial +stupor was preceded by a marked one, such as in phase 2 of Anna G. (Case +1) and phase 2 of Mary D. (Case 4), we have no retrospective account +regarding the partial stupor, because emphasis in the analysis was +naturally laid on the period comprising the most marked disorder. +However, we can gather from the few cases at our disposal that the +patients retrospectively lay stress chiefly on their inability to +understand the situation. + +We finally have to consider the group of suicidal cases. We have +information only in regard to two cases, namely, Margaret C. (Case 10) +and Pearl F. (Case 9). In both of these, we find that a good many things +that happened during the period under consideration were remembered, as +were also the patients’ own actions. In Rosie K. (Case 11) we have at +least the evidence that she remembered her own impulses, namely, that +she refused food because she wanted to die. In other words, in these +partial stupors with impulsive suicidal tendencies the interference with +the intellectual processes seems to be moderate, and memory for external +events not markedly affected. + + +2. Information Derived from Direct Observation + +The evidence can best be presented by considering the details of some +cases. + +Rose Sch. (Case 6) was remarkable, in connection with the present +problem, in her unusually poor answers. She either merely repeated the +questions, or made irrelevant superficial replies, or said she did not +know, this even with very simple questions. When better, too, though not +quite well, she showed striking discrepancies in time relations and +incapacity to correct them. It would seem that in this case there was +something more than an acute interference with the intellectual +processes, such as we are here discussing. As a matter of fact, we have +the statement in the history that the patient herself said she was slow +at learning in school and had not much of an education. A congenital +intellectual defect and the attitude which it creates may, however, as +my experience has repeatedly shown me, very greatly exaggerate an acute +thinking disorder. The case, therefore, while it shows us an +unquestionably acute interference with the intellectual processes, does +not give us useful information about its nature. More information can be +gathered from Mary D. (Case 4). Even toward the end of her marked stupor +some replies were obtained chiefly by making her write. When asked to +write Manhattan State Hospital, she wrote Manhatt Hhospshosh, and for +Ward’s Island, Ww. Iland. Again, instead of writing 90th Street, she +wrote 90theath Street. These are plainly reactions of the path of least +resistance or, in these instances, of perseveration. Of the same nature +are some of her other replies in writing or speaking. After she had been +asked to write her name, she was requested to add her address, or the +name of the hospital; she merely repeated the name. Similarly, when +asked whether she knew the examiner, she said “Yes,” but when urged to +give his name, she gave her own. In the partial stupor at a time when +she knew where she was, knew the names of some people about her, the +year and approximately the date, she made mistakes in calculation and +could not get the point of a test story. Moreover, she failed in +retention tests without there being any evidence of anything like a +marked fundamental retention disorder, such as we find in Korsakoff +psychosis. It seems that these results are best termed defects in +attention, which chiefly interfere with the apprehension of more +difficult tasks. As we shall see later, this seems to be rather +characteristic of these cases. Another point which should be mentioned +is the fact that her reaction to questions which she was unable to +answer (such as matters which referred to her amnesic periods) was +peculiar, inasmuch as she did not only not try to think them out, but +seemed indifferent to her incapacity, simply leaving the question +unanswered. This too, as we shall see later, is characteristic. Laura +A., at a time when she could be made to reply, merely repeated the +question, again a reaction of least resistance. The same patient +sometimes asked, “Where am I?” Mary C. (Case 7) made similar queries. +Although she was at times approximately oriented, she would say, “I +don’t know where I am,” or “I can’t realize where I am,” or more +pointedly, “I can’t take in my surroundings.” She often did not answer +and sometimes seemed bewildered by the questions. Henrietta H. (Case 8) +again showed some defect of orientation and mistakes in calculation, and +above all, marked mistakes in writing (for Manhattan State +Hospital--Manhaton Hotspal). A special feature here is that this +occurred immediately after she had been quite talkative, but suddenly +had relapsed into a dull state. Anna G. (Case 1), during the third phase +of her psychosis, showed the following: Although she was approximately +oriented and answered promptly simple questions; e.g., about orientation +or simple calculation, she, like these other patients, simply remained +silent when more difficult intellectual tasks were required of her +(more difficult calculations); or when she was asked how long she had +been here (which involved data that could not be available to her, owing +to her amnesia); or when questions were put to her regarding her +feelings or the condition she had passed through. On the other hand, she +sometimes gave appropriate replies in the words “yes” or “no,” but it +was difficult to say whether these answers did not also represent the +path of least resistance. + +We will finally take up the last phase of Margaret C. (Case 10). +Although she was entirely oriented, there was a certain vagueness about +her answers which is difficult to formulate. She was telling about the +onset of her sickness and said that at that time her mind was taken up +with prayers about the salvation of her relatives. She was asked exactly +when it was that she thought of this and she answered “Now?” (What +period are we talking about?) “The present.” (What did I ask you?) +“About this period of my sickness.” (Which one?) “What sickness?” She +said herself at this point, “I am rather stupid.” Again when asked how +her mind worked, she said, “Pretty quickly sometimes--I don’t know.” (As +good as it used to?) “No, I don’t think so.” (What is the difference?) +“There is no difference.” (What did I ask you?) “The difference.” (The +difference between what?) “You did not say.” In this the shallowness of +her comprehension and thinking is well shown, and it seems here again +perhaps justifiable to formulate the main defect as one of attention, +which prevents completion of a complicated process of comprehension. A +feature of further interest in this case is that automatic intellectual +processes, such as those necessary for the writing of a long poem from +memory, were not interfered with. + + +Summary + +In the most pronounced stupor we have evidently a more or less complete +standstill in thinking processes. Practically no impressions are +registered and consequently nothing is remembered except events that +occurred in some short periods when some affective stimulus, or a brief +burst of elation, lifts the patient temporarily out of the deep stupor. +It is impossible to say whether the statement of a complete standstill +has to be qualified. In some stupors repeated environmental stimuli +sometimes make at least a vague impression, so that while spontaneous +recollection is impossible a feeling of familiarity is present when the +patient is again confronted with this environment. This might be an +exception to the dictum of complete mental vacuity, or it may be that +there are somewhat less pronounced stupor reactions. When more is +perceived, there is often a retrospective statement of having felt mixed +up, being unable to take in things, or, directly under observation, the +patient may say, “I cannot realize where I am,” “I cannot take in my +surroundings.” In harmony with this is the fact that questions often +produce a certain bewilderment. In quite pronounced states in which +some replies can still be obtained, we find that the intellectual +processes may be interfered with to the extent of a paragraphia, i.e., a +remarkably mixed-up writing in which perseveration (one form of +following the path of least resistance) plays a prominent part. This +same principle is also seen in such reactions as the repetition of the +question or the senseless repetition of a former answer. These phenomena +remind us of what we see in epileptic confusions, in epileptic +deterioration and in arteriosclerotic dementia. + +In milder cases difficulties in orientation may be more or less marked; +or there may be incapacity to think out problems, although the +orientation is perfect. The more automatic mental processes may run +smoothly (memory and calculation may be excellent) and there may yet be +a certain shallowness in thinking, a defect of attention (a purely +descriptive term) which is most obvious in the patient’s inability to +grasp clearly the drift of what is going on or the meaning of +complicated questions. I am inclined to think that poor results in +retention tests are entirely due to this attention disorder, for we have +no evidence of any fundamental retention defect such as we find in the +totally different organic stupors. From a practical point of view it is +important at this place to call attention to the fact that such mild +changes are particularly seen in end stages. Even when pronounced +negativistic tendencies do not play a prominent rôle, the patient is +then apt to be silent chiefly as a result of the residual disorder in +the intellectual processes. Still more striking are the conditions which +are on a somewhat higher level and in which the shallowness of the +responses, due to the residual disorder of attention, together with the +last traces of the affectlessness, are apt to create the impression of a +dementia. In such cases the opinion is often held that the patient has +reached a defect stage from which recovery is impossible, whereas a +thorough knowledge of these end stages teaches us that they are not only +recoverable but quite typical for the terminal phases of stupor. + +Considering these data, especially those gathered in the end stages, it +would appear that there is no tendency in this intellectual disorder +associated with the stupor reaction for any special side of mental +activity to be most prominently affected. It looks rather as if it were +a question of a general diminution of the capacity to make a mental +effort which in its different intensities accounts for the symptoms. + + +FOOTNOTES: + +[5] See Chapter XV. + + + + +CHAPTER V + +THE IDEATIONAL CONTENT OF THE STUPOR + + +_Brief survey of the ideas associated with stupor:_ Having thus +described the formal manifestations of the various stupor reactions, it +will now be interesting to see what ideas seem to be associated with +these reactions. It is, of course, impossible to obtain during a +considerable part of the stupor any statement of the patients’ thoughts. +We therefore have to depend on their utterances during periods when the +inactivity temporarily ceases, or on the retrospective account which the +patient gives after the stupor has completely disappeared; and as we +shall see, we also may obtain considerable information by studying the +ideas which occur in the period preceding the stupor. These last may be +autogenous delusions or thoughts about actual events which precipitated +the psychosis. + +It is not likely that many observers have a very clear conception about +what sort of ideas to expect. We have, as a rule, not been in the habit +of paying much attention to the content of delusions, hallucinations, +and the like. So far as we could judge, therefore, the ideas expressed +might be expected to be fairly multiform, and it was distinctly +interesting to us when we found a marked tendency for the trends of +ideas to remain within a certain small compass.[6] It was possible, to +state this at once, to show that in by far the majority of cases the +same set of ideas returned, and that these ideas had among themselves a +definite inner relationship, being concerned with thoughts of “death.” +In isolated instances other ideas were found as well, and they will have +to be discussed later. For the present we shall take up more habitual +content. + +In addition to the eleven cases already described, it may be well to +cite four others which present material now of interest to us. + + + CASE 12.--_Charlotte W._ Age: 30. Admitted to the + Psychiatric Institute October 21, 1905. + + _F. H._ The father was alcoholic and quick-tempered; he + died when the patient was a child. The mother was alcoholic + and was insane at 40 (a state of excitement from which she + recovered). A brother had an attack of insanity in 1915. A + maternal uncle died insane. + + _P. H._ The patient was described as jolly, having many + friends. She got on well in school and was efficient at her + work. + + She was married at 23 and got on well with her husband. The + latter stated, however, that she masturbated during the + first year of her married life. The first child was born + without trouble. + + _First Attack at 25:_ Two or three days after giving birth + to a second child, her mother burst into the room + intoxicated. The patient immediately became much + frightened, nervous, and developed a depressive condition + with crying, slowness and inability to do things. During + this state she spoke of being bad and told her husband + that a man had tried to have intercourse with her before + marriage. This attack lasted six months and ended with + recovery. + + When 29, a year before her admission, she had an abortion + performed, and four months later another. Her husband was + against this, but she persisted in her intention. Seven + months before admission she went to the priest, confessed + and was reproved. It is not clear how she took this + reproof, but at any rate no symptoms appeared until three + weeks later, after burglars had broken into a nearby + church. Then she became unduly frightened, would not stay + at home, said she was afraid the burglars would come again + and kill “some one in the house.” The patient herself + stated later, during a faultfinding period, that at that + time she was afraid somebody would take her honor away, and + that she thought burglars had taken her “wedding dress.” + “Then,” she added, “I thought I would run away and lead a + bad life, but I did not want to bring disgrace to the + family.” + + The general condition which she presented at this time is + described as one of apprehensiveness when at home. For this + reason she was for five weeks (it is not clear exactly at + what period) sent to her sister, where she was better. + About a month before the patient was admitted, the husband + moved, whereupon she got depressed, complained of inability + to apply herself to work, became slow and inactive, and + blamed herself for having had the abortion performed. She + began to speak of suicide and was committed because she + bought carbolic acid. She later said that while in the + _Observation Pavilion_ she imagined her children were cut + up. + + _Under Observation_ the condition was as follows: + + 1. For the first three days the patient, though for the + most part not showing any marked mood reaction, was + inclined at times to cry, and at such times complained + essentially that this was a terrible place for a person who + was not insane. + + 2. On the fourth day the condition changed, and it will be + advisable to describe her state in the form of abstracts of + each day. + + On _October 24_ the patient began to be preoccupied and to + answer slowly. A few days later she became distinctly dull, + walked about in an indifferent way or lay in bed immobile. + Twice on _October 27_ she said in a low tone and with + slight distress, “Give me one more chance, let me go to + him.” But she would not answer questions. At times she + lapsed into complete immobility, lying on her back and + staring at the ceiling. When the husband came in the + afternoon, she clung to him and said: “Say good-by forever, + O my God, save me.” Again, very slowly with long pauses and + with moaning, she said: “You are going to put me in a big + hole where I will stay for the rest of my life.” _On + October 28_ she was found with depressed expression and + spoke in a rather low tone, but not with decided slowness + as had been the case on the day before. She pleaded about + having her soul saved; “Don’t kill me”; “Make me true to my + husband”; once, “I have confessed to the wrong man the + shame of my life.” Later she said she did not tell the + truth about her life before marriage. Again she wanted to + be saved from the electric chair. At times she showed a + tendency to stare into space and to leave questions + unanswered. + + 3. From now on a more definite stupor occurred, which is + also best described in summaries of the individual notes. + + _Oct. 29._ Lies in bed with fixed gaze, pointing upward + with her finger and is very resistive towards any + interference. She has to be catheterized. + + _Oct. 30._ Can be spoon-fed but is still catheterized. + During the morning she knelt by the bed and would not + answer. At the visit she was found in a rather natural + position, smiling as the physician approached, saying “I + don’t know how long I have been here.” Then she looked out + of the window fixedly. At first she did not answer, but, + when the physician asked whether she knew his name, she + laughed and said, “I know your name--I know my name.” Then + she would not answer any more questions but remained + immobile, with fixed gaze. When her going home was + mentioned, however, she flushed and tears ran down her + cheek, though no change in the fixedness of her attitude or + in her facial expression was seen. + + _Nov. 1._ Lies flat on her back with her hands elevated. + She is markedly resistive. + + _Nov. 2._ Free from muscular tension and more responsive. + When asked whether she felt like talking, she said in a + whining tone, “No, go away--I have to go through enough.” + Then she spoke of not knowing how long the nights and days + were, of not having known which way she was going. When + asked who the physician was she whimpered and said, “You + came to tell me what was right.” She called him “Christ” + and another physician “Jim” (husband’s name), though, later + in the interview, she gave their correct names. When asked + about the name of another physician, she said: “He looks + like my cousin, he was here, they all came the first night. + I did not take notice who it was till I went through these + spirits, then I knew it was right.”--She paused and added: + “My God--mother it was; she is here on Earth, somewhere in + a convent--Sister C. (who actually is in a convent) she was + here, too, I could hear her.” She said they all came to try + to save her. When asked whether she had been asleep, she + said: “No, I wasn’t asleep, I was mesmerized, but I am + awake now--sometimes I thought I was dead.” (When?) “The + time I was going to Heaven.” Again: “I went to Heaven in + spirit, I came back again--the wedding ring kept me on + Earth--I will have to be crucified now.” (Tell me about + it.) “Jim will have to pick my eyes out--I think it is him. + Oh, it is my little girl.” (Who told you?) “The spirits + told me.” Again: “Little birds my children--I can’t see + them any more--I must stay here till I die.” (Why?) “The + spirits told me--till I pick every one of my eyes out and + my brains too.” When asked what day it was, she said, “It + must be Good Friday.” (Why?) “Because God told me I must + die on the cross as he did.” When asked why she had not + spoken the day before, she said that “Jesus Christ in + Heaven” had told her she should not tell anything, “till + all of you had gone, then I could go home with him, because + that is the way we came in and it was Jim too all the + time.” Finally she said crossly, “Go away now, you are all + trying to keep me from Jim” (crying). + + _Nov. 3._ Knelt by bed during the night. This morning lies + in bed staring, resistive, again she is markedly + cataleptic. She has to be spoon-fed, and is totally + unresponsive. In the afternoon she was found staring and + resistive. Presently she said with tears: “I am waiting to + be put on the cross.” + + _Nov. 4._ Still has to be catheterized. She sits up, + staring, with expressionless face, but when asked how she + felt she responded and said feebly: “I don’t know how I + feel or how I look or how long I have been here or + anything.” (What is wrong?) “Oh, I only want to go to a + convent the rest of my days.” (Why?) “Oh, I have only said + wrong things, I thought I would be better dead, I could not + do anything right.” Later she again began to stare. + + _Nov. 5._ During the night she is said to have been + restless and wanted to go to church. To-day she is found + staring, but not resistive. When questioned she sometimes + does not answer. She said to the physician, “I should have + gone up to Heaven to you and not brought me down here.” She + called the physician “Uncle James.” Again she said, “I want + to go up to see Jim.” Sometimes she looks indifferent, + again somewhat bewildered. + + _Nov. 6._ She eats better, catheterizing is no longer + necessary. She is found lying in bed, rigid, staring, + resistive, does not answer at first, later appears somewhat + distressed, says “I want to go and see Jim.” (Where?) “In + Heaven.” She gave the name of the place and of the + physician, also the date. + + _Nov. 8._ In the forenoon, after she had presented a rather + immobile expression and had answered a few orientation + questions correctly, she suddenly beckoned into space, then + shook her fist in a threatening manner. When later asked + about this, she said: “Jim was down there and I wanted to + get him in.” (And?) “You was up here first.” (And?) “I + thought we was going down down, up up--the boat-- --you + came in here for--to lock Jim out so we wouldn’t let him + in.” Later she said, when asked whether anything worried + her, “Yes, you are taking Jim’s place.” + + _Nov. 9._ During the night she is reported to have varied + between stiffness with mutism and a more relaxed state. + Once, the nurse found her with tears, saying “I want to go + down the hall to my sister--to the river,” and a short time + later with fright: “Is that my mother?” Again she said: “Oh + dear, I wish this boat would stop--stop it--where are we + going?” In the forenoon she was quiet and unresponsive. In + the afternoon she said in a somewhat perplexed way, “We + were in a ship and we were ’most drowned.” (When was that?) + “Day before yesterday it must have been”--Again she said in + the same manner: “It was like water. I was going down. I + could hear a lot of things.” She claimed this happened + “to-day.” “I saw all the people in here, it was all full + of water,” “I have been lying here a long time--do you + remember the time I was under the ground and it seemed full + of water and every one got drowned and a sharp thing struck + me?” “I was out in a ship and I went down there in a + coffin.” When asked whether she had been frightened at such + times, she said: “No, I didn’t seem to be, I just lay + there.” She also said: “the water rushed in,” and when + asked why she put up her arms, she said, “I did it to save + the ship.” + + _Nov. 10._ She is still fairly free. She said that when she + was on the ship things looked changed, “the picture over + there looked like a saint, the beds looked queer.” (How do + things look now?) “All right.” (The picture too?) “The same + as when I was going down into a dark hole.” When asked + later in the day where she was, she said, “In the Pope’s + house, Uncle Edward is it?” but after a short time she + added, “It is Ward’s Island, isn’t it?” + + _Nov. 11._ Inactive, inaccessible, but for the most part + not rigid. + + _Nov. 14._ Varies between mutism with resistance and more + relaxed inactivity. To-day lies in a position repeatedly + assumed by her, namely, on her stomach with head raised, + resistive towards any interference, immobile face, totally + inaccessible. + + _Nov. 15._ Freer. She said: “One day I was in a coffin, + that’s the day I went to Heaven.” She also said she used to + see “the crucifix hanging there” (on the ceiling)--“not now + but when I was going to Heaven.” (When was that?) “Over in + that bed” (her former bed). Later she added, “The place + changed so ... things used to be coming up and down + (dreamily)--that was the day I was coming up on the ship or + going down.” She is quite oriented. + + _Nov. 17._ Usually stands about with immobile face, + preoccupied, but she eats voluntarily. + + _Nov. 24._ When the husband and sister came a few days ago + she said she was glad to see them, embraced them, cried and + is said to have spoken quite freely. To-day she speaks more + freely than usually. When asked why she had answered so + little, she said she could not bring herself to say + anything, though she added spontaneously, “I knew what was + said to me.” When shown a picture of her cataleptic + attitude with hands raised, she said dreamily, “I guess + that must have been the day I went to Heaven, everything + seemed strange, things seemed to be going up and down.” + (Did you know where you were?) “I guess that was the day I + thought I was on the ship.” When the sister spoke to her, + she seemed depressed and said, “If only I had not done + those things I might be saved, if I had only gone to church + more.” + + _Dec. 3._ Seems depressed. She weeps some, says she is sad, + “There seems to be something over my heart, so I can’t see + my little girls.” Again: “I should have told you about it + first--I should not have bought it”--(refers to buying + carbolic acid). She wrote a natural letter but very slowly. + + 4. There followed then a state lasting for six months, + during which the patient was rather inactive, preoccupied, + even a little tense at times. Sometimes she did not answer, + again at the same interview spoke quite promptly. For the + most part the affect was reduced, at other times she + appeared a little uneasy, bewildered, or again depressed. + She said that sometimes a mist seemed to be over her. Now + and then spoke of things looking queer and she asked, when + the room was cleaned, “Why do they move things about?” and + she added irrelevantly: “I thought the robbers broke into + my house and stole my wedding dress and my children’s + dresses” (refers to the condition during the onset of her + psychosis). In the beginning of this state, when asked + about the stupor, she spoke again of the “ship” and about + going “down, down,” but also said that on one occasion she + heard beautiful music, was waiting for the last trumpet and + was afraid to move. Moreover, she had some ideas referring + to the actual situation which were akin to those in the + more marked stupor period. Although she admitted she was + better, she said on December 8 that she still had queer + ideas at times, “I sometimes think the doctor is Uncle Jim” + (long dead). She also spoke of other patients looking like + dead relatives, and added, “Are all the spirits that are + dead over here?” “We never die here, the spirits are here.” + But after that date no such ideas recurred, in fact this + whole period seems to have been remarkably barren of + delusions. Exceptionally isolated ones were noted. Thus, on + January 28 it is mentioned that she stated she sometimes + felt so lonely, and as though people were against her; and + on February 13 she said she felt as though the chair knew + what she was talking about. It is also mentioned in January + that she wept at times, but this seems not to have been a + leading feature at all. In March, when asked why she was + not more active and cheerful, her lips began to quiver and + she said, “Oh, I thought my children would be cut up in + Bellevue.” “I don’t know why I feel that way about them.” + She sometimes cried when her friends left her. + + 5. Then followed a week of a rather faultfinding, + self-assertive state, during which she demanded to be + allowed to go home, saying indignantly that she was not a + wicked woman, had done nothing to be kept a prisoner here; + she wanted justice because another patient had called her + crazy. But in this period also she said that after the + robbery (at home) she felt afraid that her honor would be + taken away. When told that her husband had been with her, + she said “Yes, but I was afraid they would get into a + fight.” (You mean you were afraid the other man would kill + him?) “No, he is not dead.” She further talked of a + disagreement she had at that time with her husband, and + that she felt then like running away and leading a bad + life, but thought of the children. With tears she added: “I + would not do anything that is wrong. I have my children to + live for.” Quite remarkable was the fact that she then told + of various erotic experiences in her life, though with a + distinctly moral attitude and minimizing them. + + 6. On _June 16_ another state was initiated with peculiar + ideas, the setting of which is not known, as she told them + only to the nurses. She said that she was not Mrs. W. but + the Queen of England, again that she was an actress, or + again the wife of a wealthy Mr. B., and that she was going + to have a baby. But at night she is said to have been + agitated and afraid she was to be executed. She asked to be + allowed to go to bed again, then stopped talking, and + remained in this mute condition for about a week. She often + left her bed and went back again, remained much with a + perplexed expression. On one occasion she put tinsel in her + hair saying it was a golden crown. + + 7. At the end of that time she became freer and more + natural, and remained so for three weeks. She occupied + herself somewhat. When asked what had happened in the + condition preceding, said she thought she was a queen or + was to be a queen. + + 8. Towards the end of this period she had again three more + absorbed days, but when examined on the third of these days + got rather talkative and somewhat drifting in her talk on + superficial topics. + + 9. Two days later she began to sing at night, kissed + everybody, said it was the anniversary of her meeting her + husband, again cried a little, and on the following morning + began to sing love songs, with a rather ecstatic mood, and + at times stood in an attitude of adoration with her hands + raised. This passed over to a more elated state, during + which she smiled a good deal, often quite coquettishly; she + sang love songs softly; on one occasion put a mosquito + netting over her head like a bridal veil; or she held her + fingers in the shape of a ring over a flower pinned to her + breast. But even during this state she said little, only + once spoke of waiting for her wedding ring, and again, when + asked why she had been singing, said “I was singing to the + man I love.” (Why are you so happy?) “Because I am with + you” (coquettishly). + + This, however, represented the end of the psychosis. She + improved rapidly. At first she smiled rather readily, but + soon began to occupy herself and made a perfect recovery. + + She gave a rather shallow retrospective account about the + last phase: at first she said it was natural for people to + feel happy at times, and that she did not talk more because + the inclination was not there. The only point she added + later was that she held her fingers in the shape of a ring + because she was thinking of her wedding ring. + + She was discharged on _October 11_. + + The patient was seen again in _September, 1915_. She then + stated that she had been perfectly well until 1912, when + she had a breakdown after childbirth. (A childbirth in 1910 + had led to no disorder.) The attack lasted six months. She + slept poorly, lost weight, and felt weak, depressed, “my + strength seemed all gone.” In _July, 1915_, following again + a childbirth, she was for about six weeks “despondent, weak + and tired out.” + + At the interview she made a very natural, frank impression, + and displayed excellent insight. + + + CASE 13.--_Johanna S._ Age: 47. Admitted to the Psychiatric + Institute January 23, 1904. + + _F. H._ It was claimed that there was no insanity in the + family. + + _P. H._ The patient was said to have been bright and rather + quick-tempered. She came to the United States from Ireland + at the age of 20, worked as a servant, was well liked, and + retained her position well. + + She was married at 24. After a second confinement, at the + age of 26, the patient had her first attack of manic + excitement, from which she recovered in four months. She + had, subsequently, at the ages of 28, 30, 32, 35, 43, and + 45, other attacks of the same nature, each one lasting + about four months. No precipitating cause was known for any + of them. Only one of the attacks, the fifth, (none were + well observed) seems to have shown features different from + an elated excitement with irritability. At the end of this + attack she was said to have been “dull” for a month. + + Her husband died four years before the present admission, + evidently soon after her sixth attack. + + The present attack: + + About two months before admission the patient began, + without appreciable cause, to be sleepless, complained of + headaches and appeared downhearted and sad. She sat about. + + After a week she would not get out of bed and remained in + bed until she was sent to the Observation Pavilion, getting + up only to go to the closet. She said very little and would + not eat much. About a month before admission she began to + say that she did not want to live, begged her daughter to + throw her out of the window. About two weeks before + admission she began to insist that she heard the voice of + her brother (living in Ireland) calling her. She got out of + bed to look for him. + + At the _Observation Pavilion_ she was described as slow, + looking about in an apprehensive manner, bewildered, dazed, + saying “I am dead--there is poison in it (not clear in + what)--I am dead, you are dead.” + + _Under Observation:_ 1. On admission the patient had a + coated tongue, foul breath, constipation, lively knee-jerks + and a pulse of 110. She appeared dull, inactive, lay in bed + with her eyes closed. She would open them when urged but + appeared drowsy and her face was strikingly immobile. At + times she moaned a little. She could be made to respond in + various ways such as shaking her head, or making some + motions as though to indicate that she could not give any + explanations. All movements were slow. She also responded + to a few questions by “I don’t know.” + + Two days after admission the condition was not essentially + different except that she was a little uneasy when urged to + speak, corrugated her forehead, said “Everything is dark,” + again “I am very sick,” or she turned away her head. + + On the fourth day, i.e., January 26, the picture altered, + inasmuch as she was much more responsive. She was found + sitting up in bed and, at times, a little uneasy. She was + slow in her movements and answers, speaking in a whisper + and sometimes a little fretfully. The answers, though slow, + were, however, by no means given in the shortest possible + manner, but with variations, e.g., from “I don’t know,” to + “I could not tell you,” or “I can’t tell that either.” She + said herself that everything had “been so dark--it is light + now, but it gets so dark sometimes.” She denied knowing + where she was, even in what city, also denied knowing the + month, adding to the latter answer “the nurse can tell + you.” She could not tell where she had been before coming + to the hospital, or how she came. Finally, she also claimed + not to know her age, her birthday or the date of her + marriage; but she gave the current year correctly, the + place where she went to school, the names of some of her + teachers, and the year of her arrival in the United States. + She also stated in answer to questions that she came to the + hospital “to get well.” She repeatedly said “I am so sick,” + or “I am so stupid,” or “My mind is mixed up, twisted,” or + “My mind is not so good,” or “I am so tired.” What could be + obtained of a content was as follows: When she spoke of + being “twisted,” she said, “I got all kinds of medicine.” + (How does it affect you?) “Through my head and it made me + hot inside.” Again, when asked whether anybody had done + anything to her, she said “No, I have done wrong myself, by + speaking bad of my neighbors.” She claimed to hear voices + “all over,” but could not tell what they said. When, in the + evening of that day, the nurse asked her why she did not + talk more, she said, “God damn it, I am all twisted, my + brain is mixed up, my system is all upset, the doctor made + me stupid with questions, and the medicine I have taken + made me all stupid and I am inhaling gas now.” Then she + again settled into a dull state and was found by the + physician with immobile expression, slow motions and mute. + + 2. For about ten days, i.e., from January 27 to February 8, + her condition was of a more pronounced character. For the + most part she lay in bed with often quite immobile face and + with eyes closed, or she looked about in a bewildered + manner. She was very inactive, presented a marked + resistance in her arms and jaw when passive motions were + attempted, or, again, exhibited decided catalepsy. She had + to be tube-fed. Once on the 27th of January, when the nurse + tried to feed her, she pushed her away and said, “I am + dead--I am not home.” Sometimes she turned her hands about + with slow tremulous movements, looking at them in a + bewildered manner. + + She usually was mute, except on the few occasions to be + mentioned later, as well as on February 3, when she was + generally a little more responsive. At that time she could + be made to open her eyes, and then replied to a few + questions slowly and in a low tone; others were left + unanswered. (To the questions where she was and how long + she had been here, she replied with “I don’t know,” but to + questions about who the physician and the nurse were, by + saying “You are a doctor,” and “she is a nurse.”) + + In the general setting just described there occurred at + various times changes in behavior which were as follows: On + the evening of the 27th of January she got out of bed and + walked about with slow restlessness, saying: “They say I am + going to be cut up.” On February 1, she was seen for a time + making peculiar slow swimming motions with her hands. Again + on the 3d of February she got out of bed, walked about + slowly, with peculiar steps, as though avoiding stepping on + something. Next day (the 4th) she sat up in bed--again made + at times her peculiar slow swimming motions. She presented + at the same time a peculiar dazed bewildered uneasiness + and, when questioned what was the matter, said: “I am--I + am--at the bottom of the deep--deep water--oh--oh--the + deep--deep--dark water.” And when further urged she added + with the same manner, “I can’t swim--I don’t know--but the + place”--She did not finish but later again muttered “the + deep--deep--dark water.” (Do you really think you are in + the water?) “I don’t know--my head is so bad.” + + For the following five days this behavior was repeated + from time to time, when she would sit up and with + bewildered uneasiness make slow swimming motions and mutter + when questioned, “I am in the deep, dark water.” + + Some other emotional responses in reaction to external + events must still be mentioned. They were rare. On February + 1 the patient’s daughter came while she was lying + motionless in bed. She slowly extended her hands, tried to + speak, and then her eyes filled with tears. Again, at the + end of the interview of February 3, after she had made a + few replies, she settled down to her usual inactivity and, + when further urged to answer, her eyes filled with tears. + + 3. From about February 9 to February 24 the condition again + presented a different aspect, inasmuch as while there was + still a marked reduction of activity, she showed this to a + decidedly lesser degree. Moreover, there was no + bewilderment at any time. No resistance, but cataleptic + tendencies were still seen occasionally. There was at no + time the peculiar dazed uneasiness and slow restlessness + associated with the idea of being in the deep, dark water. + + She now dressed herself very slowly, ate slowly but of her + own accord, and spoke, though her voice was consistently + slow, in a low tone and her words were few. + + At the beginning of this period on February 9, when asked + how she was, she said “I--I am sick.” To the questions as + to where she was, how long she had been here and how she + had been taken sick, she replied by saying “I don’t know.” + But she knew she was in a hospital, had been here before + “many times.” (Correct.) She was then again asked for the + name of the hospital, but replied “I don’t know.” So the + physician pointed out of the window and asked her what it + was that she could see there (the East River). She replied, + “It is the dark water. Sometimes I go there and don’t come + back again--and--something throws me up and I come back.” + (What has been the matter with you?) “I have been sick all + this time.” Again, “I can’t tell--I am not a good woman--I + am very sick.” (Why do you say you are not a good woman?) + “Oh, I did not do things right.” + + At a later interview, during the same period, she knew the + doctor’s name, knew she had seen him at Ward’s Island, + knew she was in a hospital, but somehow could not connect + the present place with Ward’s Island. She said she didn’t + know, when asked where she was, and when questioned about + the season, said, after a pause “Summer” (February 15). + + We have seen above that she once spoke of not having been a + good woman. She repeated this on February 10, said “I have + done lots of harm, I have been a bad woman all my life.” + Again: “I had bad thoughts.” (What kind?) “I have forgotten + all about them.” It should be added that at this interview + she also said, “My mind is better now.” + + On February 25 there was a sudden change. She laughed when + a funny remark was made on the ward. Later, when the + physician came to her, she still lay in bed inactive and + had to be urged considerably at first, but presently began + to laugh good-naturedly and quite freely commented on the + funny remark she had heard earlier in the morning, and on + peculiarities of some patients. She spoke quite freely and + without constraint. But it was striking how little account + of the condition she had gone through could be obtained + from her. She either turned the questions off by flippant + remarks, or said she did not know. The only information + obtained was that she had been sick since Christmas, felt + like a dummy, that she had lost track of time, and did not + know how she had felt during that period. When asked why + she had not spoken, she said, “I couldn’t, I had a jumping + toothache,” or she said, “Ask the nurse, she put it down in + the book.” Or again she said, “Did you ever get drunk? That + is the way I felt. I felt like dead.” + + She soon developed a lobar pneumonia and died. + +The following typical case of partial stupor is quoted as an example of +delusions appearing only during the onset. + + + CASE 14.--_Maggie H._ Age: 26. Admitted to the Psychiatric + Institute February 8, 1905. + + _F. H._ The father died when 33. The mother was living. + Psychopathic tendencies were denied. + + _P. H._ The husband and brother stated that the patient + was natural, capable, rather jolly. She married about a + year before admission and shortly became pregnant. During + the pregnancy she was rather nervous and had various + forebodings, among which were that the child might be born + deformed, or that she would die in childbirth. + + The baby was born three weeks before admission. The patient + seemed much worried immediately after the childbirth, + fretted about not having enough milk, was quite concerned + about her husband and did not want him to leave her side. + The brother stated that about this time the patient heard + that the husband was out of work. She worried about this + and told her sister so. She also began to say that her head + was getting queer. On the fifth day after childbirth, a + change came over the patient. She cried and said she was + going to die. She also spoke of poison in the food and + accused the husband of unfaithfulness. The next day she + became silent, “did not seem to want to have anything to do + with anybody,” lay in bed, had a tendency to pull the + covers over her head and scarcely ever spoke. But during + this period she continued to look after the baby + faithfully. Sometimes she clung to her husband, saying she + was afraid he was going to die. + + After recovery the patient said that while she was at home + she thought she saw bodies lying about. + + At the _Observation Pavilion_ she was quiet and apathetic, + indifferent to environment and could not be induced to + speak. She soiled, refused food, and was resistive when + anything was done to her. + + _Under Observation:_ 1. On admission the patient was fairly + well nourished but looked rather anemic and weak. The + temperature was normal, the pulse a little irregular but of + normal frequency, the tongue coated. She lay inactive but + looked about, and the facial expression sometimes changed + as she did this. Any interference met with intense + resistance. There was no catalepsy. In contradistinction to + this inactivity and resistance, natural, free motions were + observed at times, as, for example, when she arranged her + pillows. She did not speak and could not be made to answer. + + For the rest of the first week she made no attempt to + speak, except once when she seemed to attempt to return a + “good morning,” or on another occasion, when the nurse + tried to feed her, she said, in quite a natural tone, “I + can feed myself.” The resistance to interference remained + in a variable degree, and was at times quite strong. It was + largely passive, though not infrequently associated with a + scowl, or she moved away when approached. She sometimes + looked dull and stared, again she looked determined, + “disdainful,” or scowled; or she looked about watching + others, sometimes only out of the corners of her eyes. She + had to be spoon-fed at times, again she ate naturally when + the food was brought. Repeatedly, when taken out of bed, + though she resisted at first, she dressed with natural free + motions. She always retracted promptly from pin pricks. + + Towards the end of the week she even complied at times with + a request to do some work, but on the same day she would + remain passive, with a look of disdain, or resist intensely + when interfered with, e.g., when an attempt was made to + make her sit down. She never soiled and never showed any + catalepsy. + + 2. Then the condition changed, inasmuch as the marked + resistance ceased entirely, and the mutism gave way first + to slow and low answers, and later to much freer speech, + though the inactivity improved only gradually. Thus at the + examination on February 19, though she was quite inactive, + she answered some questions, albeit in whispers and + briefly. This was the case when questioned about the year, + month and date, which she gave correctly, but she merely + shook her head when asked how long she had been here, why + she was here, what was the matter with her. Once she smiled + appropriately. Later she became freer in speech, with a + more natural tone, although her answers continued to be + short. Not infrequently, when asked to calculate or to + write, she would not coöperate, saying “This has nothing to + do with my getting well,” or (later) “What has that got to + do with my going home?” or she would simply say she did not + want to. Improvement in her listlessness and inactivity was + more gradual. + + The prevailing affective state was indefinite. She denied + repeatedly that she was depressed, though later she + admitted once being downhearted, yet it seems that even + then her mood was not so much one of sadness as of a slight + resentment. On one occasion, however, she showed some tears + when asked about the baby. She repeatedly expressed the + wish to go home, but not in a pleading, rather in a + resentful, way, saying she would never be better here, that + the questions which were asked had nothing to do with her + going home, that she would be all right if she went home. + She never admitted that she had ever been sick enough to be + taken to a hospital, though she quite appreciated that + there had been something the matter with her head at home + and in the hospital. She stated, in answer to questions, + that she had a peculiar feeling in the head which she could + not explain, that she could not remember so well as + formerly. Once she said, “I hear so much around here that + my head gets so full.” + + When towards the end she was questioned about her + condition, i.e., the reason for her resistance, her mutism, + and her refusal of food, she said that then she “wanted to + be left alone”; that she did not eat “because she did not + want food,” and she also spoke of not having had any + interest. + + She was discharged on April 29, i.e., about ten weeks after + admission before she had become entirely free. + +The last case is interesting in that a depressive onset to a deep stupor +was observed in the Institute. It was characterized by constant +repetitions of a request to be killed. + + + CASE 15.--_Meta S._ Age: 16. Admitted to the Psychiatric + Institute June 26, 1902. + + _F. H._ The father was dead, and the mother living abroad. + Not much could be learned about them and the immediate + family. + + _P. H._ An aunt who gave the anamnesis had known the + patient only since she came to the United States, a year + before admission. After her arrival the patient at once + went to work as a servant. It was claimed that her employer + liked her, but that she was rather slow about the work. The + only trouble known was that she sometimes complained of + indigestion. She went to see her aunt about once every two + weeks. + + Three weeks before admission, when the patient visited her + aunt, she seemed quieter than usual. Further, she spoke + about sending money home on the _Kaiser Wilhelm der + Grosse_, which was thought peculiar because she had no + money, and on a walk through a cemetery said “I would like + to be here too.” At the time this did not impress the aunt + as very peculiar. The patient continued to work until nine + days before admission. The employer then sent for the aunt + and said the patient had been very quiet for about two + weeks, and that she now had become more abnormal. She + suddenly had begun to cry, said the police had come, + claimed, without foundation, that she had “stolen,” and + kept repeating “I have done it, I will not do it again.” + The aunt took her home with her. There she was quite + dejected, cried, spoke of killing herself (wanted to jump + out of the window, wanted to get a knife). On the whole, + she said very little, but when the aunt pressed her to say + why she was so worried, she said she had allowed men to + kiss her and had taken money from them. It is claimed that + she never menstruated. + + After recovery the patient herself described the onset as + follows: Ever since she came to this country she had been + homesick, and felt especially lonesome for some months + before admission. She knew, however, of no precipitating + cause, in spite of what she had said to the aunt and what + she said at first under observation. She consistently + denied that anything had happened with young men. A short + time before she left her place (she left it nine days + before admission) she could not work, began to accuse + herself of being a bad girl and of having stolen. Then she + was taken to the aunt’s house. There she wanted to die. + + _Under Observation:_ 1. On admission the patient appeared + depressed, sat with downcast expression, looking up rarely. + She spoke in a low tone and slowly. But, in spite of delay, + she answered all questions, knew where she was and gave an + account of the place where she had worked. When questioned + about trouble with men, she claimed that a man who lived in + the same house where she worked had tried to make her “lie + on the bed,” but that she refused; that later a man had + assaulted her and had after that repeatedly come to her + room when she was alone. Yet when asked whether she worried + about this, she denied it. + + 2. For eight days her condition was sometimes one of marked + reduction of activity, with preoccupation. She sat in a + dejected attitude, and had to be urged to do anything. + Sometimes she was very slow in greeting and slow in + answering, and said very little. But whenever spoken to she + was apt to cry and this might lead to such distress that + the reduction of activity was no longer to be seen. Thus on + June 28, when greeted, she began to cry and say, “Oh, what + have I done!--Oh, just cut my head off--Oh, please what + have I done--I have given my hand.” (Tell me the whole + story.) Imploringly and with hands clasped: “No, I can’t do + it--just cut my head off, please, please.” (Why can you not + tell me?) “Oh, what have I done!” The imploring to cut her + head off was then several times repeated, and she could not + be made to answer orientation questions. On June 29 she + became agitated spontaneously and cried loudly, saying, + “Oh, let me go home and die with my father.” She was then + put to bed, and when seen she could not be made to answer + orientation questions. But when asked whether she had seen + the physician before, she said, “I saw you yesterday.” She + could not be made, however, to say how long she had been + here, “I think a”--not finishing the sentence. Although she + would not answer further, she presently began to say “Oh, + cut my head off--oh, where is my papa and mamma?” When told + that her people were in Germany and that she could go back + to them, she said “I haven’t any money to pay it.” Then she + wanted to know if she was to pay for her board and bed and + said she could not do it. + + Again, on July 1, although she had been quite preoccupied, + inactive and silent, she began to say when greeted, “Oh, + please cut my head off.” But she then answered some + questions, said she had not worked enough. On questioning, + she explained it was not that the work had been too much, + but that she had been nervous, had tried to work as much as + the servant next door, but could do only half as much, “Oh, + I ought to have worked.” + + Repeatedly on other occasions she begged, with distress, to + have her head cut off or to be killed. Frequently there + were statements of self-blame: she ought to have worked + more, was lazy or “I am not worthy”; or she said she had + lied and stolen; or again, “I have not paid for these beds + and I cannot,” or “I am a bad girl.” + + 3. For a month she presented a more marked reduction of + activity. She sat about with a dejected look, often gazed + in a preoccupied manner, or she stood or walked around + slowly. Sometimes she had to be spoon-fed. At other times + she ate slowly. Toward the latter part of this period, a + distinct tendency to catalepsy appeared. During this + period, too, as a rule (though not always), she would cry + when spoken to. A few times she would make some ineffectual + motions when questioned, but she scarcely ever spoke. + + 4. Then followed a period again lasting about one month in + which the picture was at times one of still greater + inactivity. She would retain uncomfortable positions, allow + flies to crawl over her face. She presented resistance in + the jaws, did not react to pin pricks. She sometimes sat + with eyes closed or, with an immobile face, the eyes stared + with little blinking. The catalepsy was more decided. She + often would not swallow solid food but swallowed fluid. + Again she held her saliva, sometimes drooled. Once she held + her urine and had to be catheterized. When spoken to she + once smiled at a joke, sometimes there was no response, but + as a rule there were tears or flushing of the face. On the + physical side, there were marked dermatographia and, for a + time, towards the end of the period, profuse sweating. + Throughout the stupor proper her temperature was between + 99° and 100° as a rule. + + 5. The period which followed and which lasted about two + months was characterized, like the one just described, by + marked stupor symptoms, associated, however, with more + resistance, while the crying practically disappeared. On + the other hand, a number of plainly angry reactions were + seen and, towards the end, smiling and laughing. She lay in + bed, on her back, staring, allowing the flies to crawl over + her face; retained uncomfortable positions without + correcting them, and her arms often showed a decided + tendency to catalepsy. Sometimes she soiled. She constantly + held saliva in her mouth, though she did not often drool. + She was totally mute, did not respond in any way except in + the manner to be presently indicated. She had to be + tube-fed a good part of the time, was quite resistive when + an attempt was made to open her mouth. When attended to by + the nurse, she was apt to make herself stiff. But as a + rule, she was not resistive to passive motions when tested. + On a few occasions she had, as was stated, marked angry + outbursts. Thus on one occasion when her temperature was + taken she angrily pushed the nurse away and then struggled + vigorously. On another occasion, when the bed-pan was put + under her, she threw it away angrily and struck the nurse; + once she did the same with the feeding tube. She struck a + patient, on another occasion, when the latter came to her + bed. On two occasions she suddenly threw herself headlong + on the floor. Towards the end of the period, when the + blood-pressure was taken, she smiled and then laughed out + loud. She could be made to smile again later. + + 6. The last period, before the more definite improvement, + lasted about a month. She was inactive and slow, ate slowly + (feeding no longer necessary), and was mute. But she did + not stare, was no longer resistive, no longer held saliva. + She appeared indifferent, but could be made to smile quite + readily when spoken to. On one occasion she laughed out + loud when a comical toy was shown her, again was amused at + a party. In the beginning of the period she was once seen + to cry a little when sitting by herself, and at the same + time wept a little when spoken to, but this was now + isolated. Towards the end of the period she spoke a little, + asked for paper and pencil and wrote: “Dear Mother.--I only + take up the pencil in order to write you a few lines. We + are all cheerful and in good health and hope that you are + the same and we congratulate you on your birthday 19th of + December that I have not written to you for a long time + were in the same ...” (Translated.) This was written very + slowly. + + On the day after this letter she was distinctly freer, + talked a little to the nurse and then improved rapidly. A + week after this, January 16, she is described as quite free + in her talk and activity, but when asked about the + psychosis she merely shrugged her shoulders. However, mere + extensive retrospective accounts were taken later. + + The retrospective accounts were obtained on January 24 and + March 13. As these two accounts do not seem to be + fundamentally different for the period of the psychosis, + they may here for the sake of brevity be combined. + + She remembered clearly going to the Observation Pavilion, + and feeling frightened, as she did not know where she was + going and what they were going to do with her. She knew + when she was in the Observation Pavilion and had a good + recollection of the place, also of the transfer to the + hospital, the ward she came to, who spoke to her, etc. She + did not know what the place was until the doctor told her a + day or two after admission. Unfortunately definite + incidents were inquired into only for the first part + (July). But she remembered those clearly. She also claimed + to remember all visits which were made to her by her + friends, but it was not specifically determined whether + there was a period of less clear recollection or not. + However, she remembered the tube-feeding, which occurred + only during the more marked stupor. Her desire to be + killed, to have her head cut off, she recalled but claimed + not to know why she wanted to be killed. However, she + remembered worrying about being bad, about the fact that + she could not “pay for the beds,” etc. + + Her mutism and refusal of food she was unable to account + for. She could not talk, her “tongue would not move.” As + regards ideas during the more stuporous period, she claimed + that (when quite inactive) she heard voices but did not + recall what they said. But she remembered having dreams at + that time “of fire,” “of her dead father and of home.” + +In a survey of thirty-six consecutive cases of definite stupor, literal +death ideas were found in all but one case. They seem to be commonest +during the period immediately preceding the stupor, as all but five of +these cases spoke of death while the psychosis was incubating. From this +we may deduce that the stupor reaction is consequent on ideas of death, +or, to put it more guardedly, that death ideas and stupor are +consecutive phenomena in the same fundamental process. Two-thirds of +these patients interrupted the stupor symptoms to speak of death or +attempt suicide, which would lead us to suppose that this intimate +relationship still continued. One-quarter gave a retrospective account +of delusions of being dead, being in Heaven, and so on. From this we may +suspect that in many cases there may be a thought content, although the +patient’s mind may seem to be a complete blank. It is important to note +that when a retrospective account is gained, the delusions are +practically always of death or something akin to it, such as being in +prison, feeling paralyzed, stiff, and so on. + +In the one case of the thirty-six who presented no literal death ideas, +the psychosis was characterized essentially by apathy and mild +confusion, a larval stupor reaction. It began with a fear of fire, +smelling smoke and a conviction that her house would burn down. It is +surely not straining interpretation to suggest that this phobia was +analogous to a death fear. When one considers the incompleteness of +anamneses not taken _ad hoc_ (for these are largely old cases) and that +the rule in stupor is silence, the consistence with which this content +appears is striking. + +To exemplify the form in which these delusional thoughts occur we may +cite the following: Henrietta H. (Case 8) said, retrospectively, that +she thought she was dead, that she saw shadows of dead friends laid out +for burial, that she saw scenes from Heaven and earth. Annie K. (Case 5) +claimed to have had the belief that she was going to die, and to have +had visions of her dead father and dead aunt, who were calling her. She +also thought that all the family were dead and that she was in a +cemetery. Rosie K. (Case 11) said she had the idea that she wanted to +die and that she refused food for that purpose, and during the stupor +she sometimes held her breath until she was cyanotic. Mary F. (Case 3), +before her stupor became profound, spoke of the hereafter, of being in +Calvary and in Heaven. In this case, as well as in the above-mentioned +Henrietta H., we find, therefore, associated with “death” the closely +related idea of Heaven. Whether Calvary merely referred to the cemetery +(Mt. Calvary Cemetery) or leads over to the motif of crucifixion, cannot +be decided. It is, however, clear that this latter motif may be +associated with that of death, as is shown in Charlotte W. (Case 12), +who, during intervals when the inactivity lifted, spoke of having been +dead, of spirits having told her that she must die, of having gone to +Heaven, of God having told her that she must die on the cross like +Christ. But this patient also showed in a second subperiod of her stupor +another content. She said: “It was like water. I was going down.” Or +again, she spoke of having gone “under the ground”; “I went down, down +in a coffin.” She spoke of having gone down “into a dark hole,” “down, +down, up, up”; again, of having been “on a ship.” We shall see in the +further course of our study that this type of content occurs not at all +infrequently. + +_The internal relationship among the different ideas associated with +stupor:_ Before we go any further it may be advisable to examine the +meaning of such ideas when they arise in other settings than those of +the psychoses. If we consider these ideas of death, Heaven, of going +under ground, being in water, in a boat, etc., we are impressed with the +similarity which they bear to certain mythological motifs. This is, of +course, not the place to enter into this topic more than briefly. We are +here concerned with a clinical study, and therefore, among other tasks, +with the interrelationship of symptoms, but for that purpose it is +necessary to point out how these ideas seen in stupor can be shown to +have, not only a connection amongst each other, when viewed as +deep-seated human strivings, but also are closely related to, or +identical with, ideas found in mythology. + +To one’s conscious mind death may be not only the dreaded enemy who ends +life, but also the friend who brings relief from all conflict, strife +and effort. Death may, therefore, well express a shrinking from +adaptation and reality, and as such may symbolize one of the most +deep-seated yearnings of the human soul. But from time immemorial man +has associated with this yearning another one, one which, without the +adaptation to reality being made, yet includes a certain attempt at +objectivation, the desire for rebirth. We need not enter further into +possible symbols for death _per se_, but it is quite necessary to speak +briefly of the symbolic forms in which the striving for rebirth has ever +found expression. The reader will find a large material collected in +various writings on mythology, for the psychological interpretation of +which reference may be made to Jung’s “Wandlungen und Symbole der +Libido” and Rank’s “Mythos von der Geburt des Helden.” From them it +appears how old are the symbols for rebirth, and how they deal chiefly +with water and earth, and the idea of being surrounded by and enclosed +in a small space. Thus we find a sinking into the water of the sea, +enclosure in something which swims on or in the water, such as a casket, +or a basket, or a fish, or a boat; again, we find descent into the +earth. The striving for rebirth might be assumed to have adopted these +expressions or symbols on account of the concrete way in which the human +mind knows birth to take place. The tendency for concrete expression of +abstract notions causes the desire for another existence to appear, +first as a rebirth fantasy and then as a return to the mother’s body. +One thinks of Job’s cry, “Naked came I from my mother’s womb and naked +shall I return thither,” as an example of the literal comparison of +death with birth. We need only refer to the myths of Moses and the older +one of Osiris, and the many myths of the birth of the hero, to call to +the mind of the reader the examples which mythology furnishes. There is +probably not one of the ideas expressed by these patients which cannot +be duplicated in myths. We have, therefore, a right to speak of these +ideas as “primitive,” and to see in them, not only deep-seated strivings +of the human soul, but to recognize in them an essential inner +relationship. It is especially this last fact to which at this point we +wish to call attention: that without any obvious connection the +fantasies of our forefathers recur in the delusions of our stupor cases. +We presume that in each case they represent a fulfillment of a primitive +human demand. In one of our cases a vision of Heaven and a conscious +longing to be there was followed by a stupor. On recovery the patient +compared her condition to that of a butterfly just hatched from a +cocoon. No clearer simile of mental rebirth could be given. + +_Brief survey of the ideas associated with the states preceding the +stupor:_ If we now return to the study of the further occurrence of such +ideas in the cases described, we find motifs, similar to those seen in +the stupor, in the period which immediately precedes the more definite +stupor reaction. Indeed we find the ideas there with greater regularity. +In Meta S. (Case 15) the stupor followed upon six days with reduced +activity and crying, with self-accusation, but also with entreaties to +be allowed to go home and die with her father. At the very onset of her +breakdown, the desire for death had also occurred. Anna G. (Case 1) +expressed a wish to be with her dead father, and, at the visit of a +cousin, she had a vision of the latter’s dead mother. A second attack of +this same patient began with the idea that the dead father was calling +her. Maggie H. (Case 14) saw dead bodies, and during outbursts of +greater anxiousness, she thought her husband was going to die. In +Caroline De S. (Case 2) the psychosis began with a coarse excitement, +with statements about being killed, with entreaties to be shot, with the +idea of going to Heaven, again with frequent calling out that she loved +her father (who was dead since her ninth year), while immediately before +the stupor the condition passed into a muttering state in which she +spoke of being killed. Mary D. (Case 4) began by worrying over the +father’s death (dead four years before), had visions of the latter +beckoning, and she heard voices saying, “You will be dead.” Mary F. +(Case 3) had a vision of “a person in white,” and thought she was going +to die. In Henrietta H. (Case 8) the stupor was preceded by nine days of +elation, with ideas of shooting and of war, but this had commenced with +hearing voices of dead friends, and with ideas that somebody wanted to +kill her family. In the case of Annie K. (Case 5) we find before the +stupor a state of worry, with reduction of activity, and then a vision +of the dead father coming for her. In Charlotte W. (Case 12) the stupor +was preceded by a state of preoccupation, with distress and entreaties +to be saved, partly from being put into a big hole, partly from the +electric chair. + +We see, therefore, in the introductory phase of the stupor in almost +every case ideas of death, and in one case an idea belonging to the +rebirth motif, namely, of being put into a dark hole. In well-observed +cases apparently we do not find the stupor reaction without either +coincident or preceding ideas of death. + +_Relation of death and rebirth ideas with affect:_ In order to +investigate the relation of these ideas to the affective condition +associated with them, it will be necessary to study not only the +abstract ideational content but the special formulation in which the +content appears. In looking over the enumeration of the ideas given +above, it is very clear that these formulations differed considerably +from each other. A priori we would say that it is, psychologically, a +very different matter whether a person expresses a desire to die, or has +the idea that he will die or is dead, or says he will be killed. We +associate the first with sadness, the last with fear, while our daily +experience does not give us so much information about the delusion of +being dead. A vivid expectation of death is usually accompanied by +either fear or resignation. + +In studying the ideas which we obtained from the patients by +retrospective account after the psychosis or from a retrospective +account during freer intervals, it is, of course, difficult, especially +in the former case, to say whether they have persisted for any length of +time. Probably in most instances this was not the case, and we must +remember in this connection that in a considerable number of cases the +patients recalled no ideas whatever. + +Of the five cases which we may consider as types, Henrietta H. (Case 8) +and Mary F. (Case 3) formulated their ideas simply as _accepted facts_ +during the stupor. The former thought she was dead, saw dead friends +laid out for burial, and scenes from Heaven and earth. The latter spoke, +during the stupor, of being in “Calvary,” “the hereafter,” or “Heaven.” +We have seen that these stupors were essentially affectless reactions +and we can therefore say that, so far as these two cases are concerned, +the ideas thus formulated were not associated with any affect. + +Annie K. (Case 5) was a little different. During the stupor she made a +few utterances about priests and “all being dead,” and retrospectively +she said that she had thought she was in the cemetery, was going to die, +that she had repeated visions of her dead father and once of a dead aunt +calling her; that she had thought her family were dead, again that the +baby (who was born just before the psychosis) was dead. The formulation +is therefore less one of fact than of something prospective, something +which is coming--the _going_ to die. Correlated, perhaps, with this +anticipation were slight modifications of the usual apathy. The patient +often had an expression of bewilderment. She was also more in contact +with her environment than many stuporous patients are, for, not +infrequently, she would look at what was going on about her. Her apathy +was also broken into in a marked degree by her active resistiveness, +which was sometimes accompanied by plain anger. It seems that a prospect +of death may occur in other instances in a totally affectless state. We +have recently seen it in a partial stupor during which the patient spoke +and had this persistent idea in a setting of complete apathy. We see +here also, as in one of the former cases, the idea of other members of +the family being dead. + +More difficult and deserving more discussion are the two remaining +cases, Rosie K. (Case 11) and Charlotte W. (Case 12). Rosie K. showed a +peculiar condition. She said, retrospectively, that during the stupor +she had the desire to die and that for this purpose she refused food. +Moreover, she was repeatedly seen to hold her breath with great +insistence, though without affect. This is worth noting. We are in the +habit in psychiatry to say in a case like this that “there is no +affect,” and yet there is evidently a considerable “push” behind the +action. We shall later have to mention in detail a patient whom we +regard as belonging in the group of stupor reactions, and who for a time +made insistent, impulsive and most determined suicidal attempts, yet +with a peculiar blank affectless facial expression and with shouting +which was more like that of a huckster than one in despair. Here also, +then, there was a great deal of “push,” yet not associated with that +which we call in psychiatry an affect. In both instances we see acts +which we are in the habit of calling for this very reason “impulsive.” +Evidently this is an important psychological problem which leads +directly into the psychology of affects and deserves further study. For +the present it is enough to say that with a different formulation--that +of wishing to die--there is here not, as in other psychoses, a definite +affect, such as sadness or despair, but no affect, though there may be a +good deal of “push” or impulsiveness. + +The case of Charlotte W. (Case 12) is a complicated one, for she had +short stupor periods with inactivity, catalepsy, resistiveness, etc., +which were interrupted with freer spells. A careful analysis of her +history has been instructive and justifies a detailed and lengthy +discussion. For the purpose in hand it is necessary to separate the +ideas which she expressed only in the freer periods (during which some +affect was at times seen) into those which referred retrospectively to +the stupor phase and those which referred to the freer periods +themselves. + +We find that the time during which more marked stupor symptoms appeared +may be divided into two subperiods. This is not possible in regard to +the manifestations belonging to the general reaction, which seem to have +undergone no decided change, but only in regard to the form of the +delusions. In this we find there was a first phase in which ideas of +death and Heaven (and crucifixion) occurred, and a second phase in which +ideas were present which belonged essentially to the motif of rebirth +but which were also associated with ideas of Heaven. + +About the first subperiod she said: “I was mesmerized,” or “I thought I +was dead,” or “God told me I must die on the cross as He did,” or “I +went to Heaven in spirit.” About the second subperiod she said +retrospectively: “We were on a ship and we were ’most drowned.” “It was +like water, I was going down, down.” She said she saw the people of the +hospital and “it was all full of water”; or again, “I went under the +ground and it was full of water and every one got drowned and a sharp +thing struck me”; or “I was out on a ship and I went down in a coffin.” +She claimed she put up her arms to save the ship. Again she spoke of +having gone into a dark hole. She also said: “One day I was in a +coffin--that was the day I went to Heaven.” “They used to be coming up +and down, that was the day I was coming up in a ship or going down.” And +when shown her picture in a cataleptic attitude, she said: “That must +have been when I went to Heaven--everything seemed strange, things +seemed to go up and down--I guess that was the day I thought I was on +the ship.” Finally she also said: “Once I heard beautiful music--I was +waiting for the last trumpet--I was afraid to move.” + +We see, therefore, that most of the ideas which she thus spoke of +retrospectively as having been in her mind during this stupor, and which +belonged both to the death and the rebirth motifs were formulated as +facts (as in the cases of Henrietta H. and Mary F. above mentioned). It +was, moreover, a condition which was accepted without protest. Here +again an affect was not associated with these ideas, and when the +patient was asked whether she had not been frightened, she said herself, +“No, I just lay there.” The idea that God told her she would have to die +on the cross like Christ, is, in the religious form, like the beckoning +of the father with Henrietta H. The only exception to the claim that the +ideas were formulated as facts and accepted as inevitable seems to be +the statement that she held up her arms to save the ship. This would +seem to be, in contradistinction to the rest, a formulation as a more +dangerous situation. However, this was isolated and we can do no more +than to determine main tendencies. We must expect, especially in such +variable conditions as we see in this patient, to find occasional +inconsistencies. + +In summing up we may say, therefore, that so far as the stupor itself +is concerned, the ideas are formulated as a rule:-- + + 1. As accepted facts (being dead, being in a ship, etc.). + + 2. As accepted prospects (going to die). + + 3. As the wish to die. + +In the first two types the ideas are not associated with affect; in the +third, though not associated with affect, they are combined with +“impulsive” suicidal attempts. + +In order not to tear apart the analysis of Charlotte W. (Case 12) too +much, we may begin our study of the intervals and the conditions +preceding the stupors with the ideas which this patient produced when +the stupor lifted somewhat. We shall see that the ideas are closely +related to those mentioned above but formulated differently. + +It will be remembered that Charlotte W. had freer intervals when she +responded and was less constrained generally, and that it was in these +that the ideas above mentioned were gathered. Since they were spoken of +in the past tense, we regarded them as not belonging to the actual +situation but to the more stuporous period. It seems tempting now to see +whether the ideas which are expressed in the present tense are different +in character, the general aim being to discover whether any tendencies +can be found in regard to the types and formulations of delusions +associated with different clinical pictures. We see that on November 2 +the patient, when speaking much more freely than before, said she had +felt that she was mesmerized, was dead, and that she had gone to Heaven, +ideas which we have taken up above as belonging to the stupor period. In +addition to speaking much more freely in these intervals, she showed at +times some affect. Thus to the physician whom she called Christ, she +said, with tears, “You came to tell me what was right,” or again with +tears, “I will have to be crucified,” or she spoke in a depressed manner +about her children, “I can’t see them any more,” “I must stay here till +I die,” and she spoke of having to stay here till she picked her eyes +and her brains out; or she claimed her husband or her children had to +pick them out. Once she exclaimed crossly and with tears, “You are +trying to keep me from Jim” (husband). Another idea was not plainly +associated with affect. She said she had come back from Heaven, “The +wedding ring kept me on Earth.” What strikes one about these +formulations is that they are, on the one hand, sometimes associated +with an affect, and that, on the other hand, they refer much more to her +actual life, her marriage, her husband, her children. At least this +seems to be a definite tendency. A similar tendency may be seen later: +On November 4, while generally stuporous, this suddenly lifted for a +short time, and with feeble voice she uttered some depressive ideas. She +said she wanted to go to a convent, that it would be better if she were +dead, that she could not do anything right. On November 5 and 6 she +said she wanted to go to Jim in Heaven (in contradistinction to the +retrospective statements that she had gone to Heaven), and on the 8th, +when she had the idea of being in a boat, she said with some anger that +she had wanted to get her husband into the boat, but that the doctor +kept him out and took his place. + +Later there were at times ideas expressed which referred to the actual +situation or essentially depressive ideas in a depressive setting. Thus +on December 3 she appeared sad, retarded, and spoke of not being able to +see her children and that she had done wrong in buying carbolic acid +(her suicidal attempt). So far as this case is concerned, therefore, we +do find a distinct tendency for the ideas which refer to the more +stuporous condition to differ from those which refer to the actual +situation in the freer intervals, a difference which we may formulate by +saying that, though primitive ideas are expressed, the tendency seems to +be to connect them more with actual life, or that the primitive +character is lost and the ideas take on a more depressive character with +a depressive affect. A few words should be added in regard to the +peculiar ideas that she or her husband or her child had to pick out her +eyes (or her brain). It is probable that this idea belongs to the motif +of sacrifice (the _Opfer motiv_ of Jung) into which we need not enter +further, except to say that in this instance it was plainly connected, +like some of the other ideas just spoken of, with the real situation of +her life (husband, children). + +It will now be necessary to examine the earlier state of Charlotte W. +The condition preceding the stupor set in with pre-occupation, slow talk +and slight distress. During the time she asked to be given one more +chance, she said to the husband she would not see him again. Then +followed a day when she was very slow and with moaning said she was +going to be put into a dark hole. Again on the next, when speaking more +freely, she begged to be saved from the electric chair, and also said, +“Don’t kill me, make me true to my husband,” etc. [Again the connection +with real life!] We see here the idea of death and especially an idea +pertaining to the rebirth motif in a setting of distress and slowness, +as an introduction to the stupor which had in it both of these motifs. +We must leave it undecided whether it is accidental or not that the +distress was associated with more slowness (i.e., more marked stupor +traits) when she spoke of the dark hole than when she spoke of the +electric chair or death. But what interests us is that distress and +reduction of activity (not sadness and reduction of activity, which +seems as a rule to have a different content) are here associated with +ideas seen in stupor but formulated as prospective dangers. We know from +experience that we often find associated with the fear of dying +considerable freedom of action, and we see at times in involution states +conditions with freedom of motion and marked anxiety, whereas the ideas +seem to belong to the motif of rebirth; e.g., the fear of being boiled +in a tank.[A] + +In this connection, however, two other cases should be taken up which +show a condition which reminds one somewhat of that we have just +discussed, but in which the rebirth motif appeared, not as prospective, +but, as in the stupor, as an actual situation. At the same time this +situation was not passively accepted but conceived as a dangerous +situation. The significant phenomenon in both these conditions was that +there was not anxiety with freedom of action but a bewildered uneasiness +with marked reduction of activity. + +The first case is that of Johanna S., whose history has been given in +this chapter. It will be observed that in the fourth period the patient +presented two days of typical stupor with the idea that she was dead. We +are familiar with this. But this was followed by several days of +bewildered uneasiness and slow restlessness, with ideas that she was at +the bottom of the deep, dark water and for a time she made attempts at +stepping out of the water or swimming motions. All of this was in a +general setting of reduction of activity with bewildered uneasiness. In +the ideas about being at the bottom of the deep, dark water, we +recognize again the rebirth motif, yet the situation is not accepted +but attempts are made by the patient to save herself, i.e., the attitude +is one in which the situation is taken to be one of danger. It is +interesting in this connection that immediately following this state +there was one day of ordinary retardation with sadness and ideas of +being bad and sick. That is, when the element of anxiety, the +uneasiness, disappeared and sadness supervened, the rebirth ideas were +no longer present. + +In Mary C. (See Chapter II, Case 7) we have, unfortunately, not a direct +observation, but we have, at any rate, a description from the +Observation Pavilion which seems so plain that we should be justified in +using it here. The condition we refer to is described as a dazed +uneasiness, with ideas of being shut up in a ship, of the ship being +closed up so that no one could get out, of the boat having gone down, of +the people turning up. We should add here that the condition was not +followed by a typical stupor. Essentially it was a retardation, in which +only on one occasion was a definite akinesis observed. During this phase +she soiled her bed. Perhaps the persistent complaint of inability to +take in the environment belonged also more to the retardation of stupor +than to that of depression. We have again, therefore, in this initial +phase, a similar situation, namely, ideas belonging essentially to the +rebirth motif, formulated as of a threatening character if not as +actually dangerous. + +We can say, therefore, that what characterizes these three cases, and +brings them together, is the fact that all three had ideas belonging to +the rebirth motif, but formulated as dangerous situations. Associated +with this there was not a typical anxiety with the relative freedom of +activity belonging to this state, but an anxiety or distress or +uneasiness with traits of stupor reaction, namely, slow movements, lack +of contact with the environment, and a dazed facial expression. It would +seem that these facts could scarcely be accidental but that they must +have a deeper significance. As a discussion of this belongs, however, +more into the psychological part of this study, we shall defer it for +the present, and be satisfied with pointing out here the clinical facts +of observation. + +In brief, then, our findings as to the ideational content of the benign +stupor are as follows: From the utterances during the incubation period +of the psychosis, from the ideas expressed in interruptions of the deep +stupor, as well as from the memories of recovered patients, we find an +extraordinary paucity and uniformity of autistic thoughts. They are +concerned with death, often as a plain delusion of being no longer +alive, or with the closely related fancy of rebirth. The rule is a +setting of apathy for these ideas, but when they are formulated so as to +connect them with the real life and problems of the patient, or when +rebirth is represented as a dangerous situation, some affect, usually +one of distress, may appear. + + +FOOTNOTES: + +[6] Kirby, _loc. cit._, pointed out that stupor showed resemblance to +feigned death in animals, that the reaction suggested a shrinking from +life and that ideas of death were common. + +[A] We may mention that since this study was made we risked a prediction +of stupor, which events justified, in the case of a patient who showed +expectation of death without affect. Such opportunities are rare, +however, since we usually do not see these cases till the stupor +symptoms are manifest. It would be unsafe to dogmatize on the basis of +such meager material. + + + + +CHAPTER VI + +AFFECT + + +The most constant and significant symptom in the stupor reaction is the +change in affect. This extends from mere quietness in the mildest phases +of the disease through the stage of indifference where apathy replaces +the normal reactions of the personality, to the final condition of +complete inactivity in the vegetative stupor where all mental life seems +to have ceased. It seems as though there were, as a pathognomonic sign +of the morbid process, a lack of energy and loss of the normal _élan +vital_. + +We may say, in fact, that the establishment of a specific type of +emotional change is justification for classifying all milder stupor +reactions with the deep stupors. In other words, our reason for the +enlargement of the stupor group to include all apathetic reactions +(except those of dementia præcox) is the belief that this dulling of the +emotional response is as specific a type of emotional change as is +anxiety, depression or elation. Perhaps it would be more accurate to say +that this clinical group is founded on the symptom complex which is +built around apathy. There is never any resemblance between apathy and +the mood of elation or anxiety. A discrimination from depression is the +only differentiation worth discussion. + +The first point that should be made is that there is a difference +between marked depression and the mood of stupor. In the former we get a +retardation with a feeling of blocking, rather than of an absence of +energy. The expression of the patient is one of dejection, not of +vacancy, which bespeaks a mood of sadness, even when the patient is so +retarded as to be mute and therefore incapable of describing his +emotions. Running through all the stages of stupor, however, there is an +emptiness, an indifference that is in striking contrast to the positive +pain that is felt or expressed by the depressed patient. It may be +objected, of course, that this apathy really represents the final stage +in the emotional blocking of the depressed individual, but the +development of stupor and recovery from it shows an entirely different +type of process. A deep depression recovers by changing the point of +view from a feeling of unworthiness and self-blame to one of normality. +The stuporous case, on the other hand, evidences merely less and less +indifference, and more and more interest in his environment and in +himself as he gets well. + +The associated symptoms are no less dissimilar. The difficulty in +thinking which troubles the depressed patient is slight in proportion to +his emotional gloom, and he feels himself to be much more incompetent +intellectually than examination proves him to be. On the other hand, in +the stupor reaction we find that the thinking disorder runs hand in +hand with the apathy and that the intellectual capacity of the patient +is really markedly interfered with, as can be shown by more or less +objective tests. A mere slowing of thought processes accompanied by +subjective feeling of effort is the limit reached in true depression, +while it is merely the beginning of the intellectual disorder in stupor, +for one meets with retardation symptoms only in the partial stupors. The +slowing in these cases seems to represent an early stage of the +intellectual disturbance which reaches its acme in the mental vacuity +and complete incompetence of the deep stupor, just as slow movements in +the partial stupors seem to represent a diluted inactivity reaction. +This actual thinking disorder is not present in those forms of +manic-depressive insanity which are characterized by elation, anxiety or +depression but is seen only in stupors, occasionally in absorbed manic +states (manic stupor) and sometimes in perplexity states. The +psychological mechanisms of this last group are probably analogous to +those of stupor, but this is not the place for a discussion of this +topic. + +Another associated symptom whose manifestations differ in depression and +stupor is that of unreality. In the former there is frequently a feeling +of unreality that is purely subjective, whereas the stupor case does not +usually complain of this but does exhibit a difficulty in grasping the +nature of his environment, which the typical depressive case never has. + +The occurrence of other mood reactions than apathy in the same patient +is also characteristic. Manic states (usually hypomanic) frequently +occur during the phase of recovery from the stupor. This is an unusual, +although not unknown, phenomenon in recovery from severe retarded +depressions. The circular cases who swing from depression to elation +usually show the milder types of depressive reaction which would never +be confused with stupor. On the other hand, deep stupors very frequently +are terminated by manic reactions, and if not by such means, recovery +seems to occur merely in virtue of a gradual attenuation of the stupor +symptoms. Rarely do we see a change to depression or anxiety heralding +improvement. This tendency of the stupor reaction to remain pure or +change to hypomania is a peculiarity which seems to put stupor in a +class by itself among the manic-depressive reactions, as all the other +mood reactions frequently change from one to the other. + +Although apathy is the central pathognomonic symptom of stupor +conditions, there are other mood anomalies to be noted. One of these is +the tendency for inconsistency in, as well as reduction of, the +expression of emotion. For instance, in the states where one would +expect anxiety during the onset of stupor or in its interruptions, +manifestation of this anxiety is often reduced to an expression of dazed +bewilderment. In the anxiety states associated with stupor one does not +meet with the restlessness and expressions of fear which would be +expected. Quite similarly, when a manic tendency is present, it occurs +either in little bursts of isolated symptoms of elation (such as smiling +or episodic pranks), or some of the evidences of elation which we would +expect are missing. For instance, Johanna S. (Case 13) terminated her +stupor with a hypomanic state which was natural except for her always +wearing an expressionless face. Sometimes laughter occurs alone and +gives the impression of a shallow affect, raising a suspicion of +dementia præcox. In fact, such evidences of affect as do appear in the +course of the stupor are apt to be isolated, queer and “dissociated.” It +does not seem as if the whole personality reacted in the emotion as it +does in the other forms of manic-depressive insanity. For example, we +may think of the resistiveness which is so frequently present when the +patient seems in other respects to be psychically dead. One may recall +the case of Meta S. (Case 15), who, otherwise inert, was occasionally +seen with tears or smiles. Anna G. (Case 1), too, was often seen smiling +or weeping. It was noted once of Charlotte W. (Case 12) that she ceased +answering questions and remained immobile with fixed gaze, but when some +mention was made of her going home she flushed and tears ran down her +cheeks, although no change in the fixedness of her attitude or facial +expression was seen. When Johanna S. was visited by her daughter and was +lying motionless in bed, she slowly extended her hands, apparently tried +to speak, and then her eyes filled with tears. Two days later, at the +end of an interview when she had made a few replies, she settled down +into her usual inactivity and, when further urged to answer, her eyes +filled with tears. Similarly, too, in fairly deep stupor pin pricking +may result in flushing, in tears or an increased pulse rate without the +patient giving any other evidence of the stimulus being felt. These +examples seem to show a larval effort at normal human response which, +failing of complete expression, appeared as single isolated features of +emotion suggesting true dissociation. We should also in this connection +bear in mind the impulsive suicidal acts which occur either as +unexpectedly as the impulsiveness in a true dementia præcox patient, or +in a setting of coarse animal-like excitement that seems quite unrelated +to the personality. One is reminded of the patient who made suicidal +attempts during the period when she shouted like a huckster, giving no +evidence whatever by her expression or the tone of her voice of feeling +anxiety, sorrow or any other normal emotion. + +All these queer and larval affective reactions remind one strongly of +dementia præcox. The resemblance of the benign stupor to certain +dementia præcox types is not merely a matter of identity with catatonic +features (catalepsy, negativism). In these anomalous mood reactions it +seems as if there were a definite dissociation of affect, and so there +is. How then can we differentiate these emotional symptoms from the +“dissociation of affect” which is regarded as a cardinal symptom of +dementia præcox? The answer is that this term is used too loosely as +applied to the latter psychosis. It is a particular type of dissociation +which is significant of the schizophrenic reaction, for in it there is +an acceptance of what should be painful ideas evidenced either by +incomplete manifestations of anxiety or depression or actually by +smiling. We never see in dementia præcox the reverse--a painful +interpretation of what would normally be pleasant. It is the pleasurable +interpretation of what is really unpleasant that gives the impression of +queerness in the mood of these deteriorating or chronic cases. In +stupor, on the other hand, although this dissociation takes place, the +mood is never inappropriate, merely incomplete in that all the +components or the full expression of the normal reaction are not seen. + +Our description of the mood reactions in stupor would be incomplete if +we omitted to mention the occasional appearance of an emotional attitude +not unlike that seen in many cases of involution melancholia, which +reminds one in turn of the reactions of a spoiled child. The commonest +of these manifestations is resistiveness that may occur when an +examination is attempted, feeding is suggested, or a sanitary routine +insisted upon. One also meets with resentfulness. One patient, who +frequently showed this reaction, explained it retrospectively by saying +that she wanted to be left alone. Quite analogous to this is sulkiness +that occasionally appears. Then we have, particularly as recovery +begins, other childish tricks, such as flippancy in answering questions +or the playing of pranks. Such tendencies naturally lead over to frank +hypomanic behavior. + +Finally, a peculiar characteristic of the stupor apathy must be +mentioned. This is its tendency to interruptions, when the patient may +return to life, as it were, for a few moments and then relapse. Such +episodes occur mainly in milder cases or towards the end of long, deep +stupors. It is interesting that the occasion for such reappearance of +affect is frequently obvious. We usually observe them in response to +some special stimulus, particularly something that seems to revive a +normal interest. Visits of relatives are particularly common as such +stimuli, in fact recovery can often be traced to the appearance of a +husband, mother or daughter. It is also important to recognize that with +this revived interest, other clinical changes may be manifest, that the +thinking disorder may, for instance, be temporarily lifted. Helen M., +for example, when visited by her mother was so far awakened as to take +note of her environment, and remembered these visits after recovery like +oases in the blank emptiness of her stupor. She further remembered that +definite ideas were at such a time in her mind that ordinarily was +vacant. She then had delusions of being electrocuted. + +In summary, then, we may say that the _sine qua non_ of the stupor +reaction is apathy in all gradations, and that this apathy is as +distinct a mood change as is elation, sorrow or anxiety. Incidental to +this loss of affect there is a dissociation of emotional response +whereby isolated expressions of mood appear without the harmonious +coöperation of the whole personality which seems to be dead. Thirdly, +there tends to be associated with the stupor reaction a tendency to +childish behavior. Finally, the apathy and accompanying stupor symptoms +may be suddenly and momentarily interrupted. An explanation of these +apparently anomalous phenomena will be attempted in the chapter on +Psychology of the Stupor Reaction. + + + + +CHAPTER VII + +INACTIVITY, NEGATIVISM AND CATALEPSY + + +1. INACTIVITY. We must now turn our attention to the other cardinal +symptoms of the stupor reaction, and quite the most important one of +these is the inactivity. It is convenient to include under this heading +both the reduction of bodily movement and the diminution or absence of +speech. This inactivity is, of course, related to the apathy which we +have just been discussing, in fact it is one of the evidences of the +loss of emotion. We presume that a patient is apathetic when there is no +expression in the face and when he does not respond to external stimuli, +whether these be physical or verbal, by movement or by word. + +Bodily inactivity is present in all degrees, and in some forty +consecutive cases was recognizable in every one. In its most extreme +form there is complete flaccidity of all the voluntary muscles, and +relaxation of some sphincters. As a result of the latter we see wetting, +soiling and drooling. Even those reflexes which are only partially under +voluntary control, like those of blinking and swallowing, may be in +abeyance; for instance, saliva may collect in the mouth because it is +not swallowed, and tube-feeding is frequently necessary on account of +the failure of the patient to swallow anything that is put into his +mouth. The eyes may remain open for such long periods of time that the +conjunctiva and sclera may become quite dry and ulcerate. In these +extreme cases there is, of course, no response to verbal commands. What +is more striking, no reaction appears to pin pricks, so that it seems as +if consciousness of pain were lost. + +This deep torpor does not usually persist indefinitely. The commonest +evidence of some form of consciousness persisting is probably to be seen +in blinking when the eye is threatened or the sclera or cornea actually +touched. A very large number of patients, when otherwise quite inactive, +showed considerable response in their muscular resistiveness, the +phenomena of which will be discussed shortly. The relaxation of the +sphincters is apt to persist even after control of the rest of the body +is exercised to the point of permitting the patient to stand or walk +about. + +The first phase of obvious conscious control is seen in those patients +who will retain a sitting posture in bed or in a chair. The next stage +is reached where the stuporous case can be stood upon his feet but +cannot be induced to walk. The next degree is that of walking only when +pushed or commanded. Finally spontaneous movement is observed in which +the inactivity is evidenced merely by a great slowness. + +No correlation can be established between restrictions of speech and +motion other than that present in the extremes. With complete inactivity +there is almost always consistent mutism, and perfect freedom of speech +does not, as a rule, appear until the movements are free. In between +these extremes all variations are possible, even the deepest stupors are +occasionally interrupted by one or two words; for instance, a patient +may remain comatose, as it were, and absolutely mute for six months, +then to every one’s surprise say one or two words and relapse into a +year of silence. Again one sees cases where movements have become fairly +free and yet the patient says nothing. This is another example of that +inconsistency in reaction which we have already noted in connection with +the mood or affect. + +In so far as inactivity is merely an expression of apathy, its causation +will be considered in connection with the psychology of the stupor +reaction as a whole. In so far as there may be specific factors, +however, it may be of interest to consider what information the patients +themselves give us from time to time as to what determined their +inactivity. It is really surprising how frequently something can be +gained either from careful notes taken during the stupor or from the +retrospective accounts of the psychotic experiences. Of course when one +considers the degree of amnesia which is usually present and the extent +of the intellectual defect in general, it becomes obvious that one +cannot think of getting anything like a complete explanation of the +behavior of any given case. Nevertheless this material is quite +suggestive in the mass; it gives one some idea of the mental state as a +whole. + +Among 40 cases, 27 offered some explanation either during or following +the psychosis. Of these, 20 spoke of feeling dead, numb or drugged, or +feeling as if paralyzed or having lockjaw. This group, just half of all +the cases, apparently ascribed their disability to something which +seemed physical. One might call them somatopsychic cases. The other 7 +gave more allopsychic explanations: 3 attributed their inactivity to +outside influence; 3 more said they were afraid (one of these because +she imagined herself to be in prison), which is analogous to the outside +influence; the 7th case thought she would injure people if she moved. + +The following are some examples of the statements of the somatopsychic +group: Laura A.: “I can’t move,” and retrospectively, “My arms were +stiff.” Bridget B. claimed retrospectively that she felt dead or +drugged, that her limbs were lifeless, she felt as if she had lockjaw. +Johanna B. remembered being pricked with a pin on several occasions but +claimed that she did not feel the pain at any time. This suggests a +definitely hysterical mechanism. Anna L. (Case 16) said retrospectively +that she felt as if she were dead, although walking around, and also +that she thought she was a ghost and not supposed to speak. Anna M. said +she had tried to speak but everything stuck in her throat. Alice R. said +that she had no energy, did not want to talk. Meta S. (Case 15) claimed +that while stuporous her tongue would not move. Isabella M. in +intervals claimed that during the stuporous periods she felt as if dead +and said retrospectively when the whole psychosis was over that it was +“an effort to speak.” Johanna S. (Case 13), while stuporous when pressed +with questions would say: “I can’t think,” “I don’t know,” “I am +twisted.” When food was offered her she protested, “I am dead.” +Charlotte W. (Case 12), in reviewing her case, said: “I was mesmerized,” +“I thought I was dead.” Anna G. (Case 1), in retrospect said: “I don’t +think I could speak,” again “I made no effort,” or “I did not care to +speak.” Henrietta H. (Case 8) said, “I lost speech.” She claimed that +she did not move because she was tired and had a numb feeling. Mary C. +(Case 7) said that her tongue had been thick and that she felt dull. +Rose Sch. (Case 6) said during the psychosis that her head was upside +down and retrospectively that she had been mixed up, could not remember +well, did not feel like talking. Mary D. (Case 4) said that she had been +dazed, that she had not felt like talking, and that her limbs “were +stiff like.” We should probably also include here as a delusion of death +the statement of Annie K. (Case 5) who wanted to die and thought she +would do so if she kept still enough. + +It is rather striking that among all the forty cases only one spoke of +being sick--“I am so sick.” Only one evaded questions with “that was my +illness.” One would expect a priori that these patients would offer some +vague explanations or make complaints of weakness. If these stupors +were purely physical in origin, one would expect such explanations as +weakness or illness to be offered in accounting for the inactivity. That +there is a rather definite type of explanation offered is, we think, +distinctly suggestive. If one tries to correlate and group the death +ideas, one sees that they are all delusions of death or of loss of +energy or complaints of hysterical symptoms that look like sham death. +If the lack of energy complained of be looked upon as lifelessness, one +can conceive of these explanations being variations of one theme, +namely, that of death. In the last chapter it has been shown that a +delusion of dying, being dead, or having been dead is extremely frequent +in the stupor group. It would seem only natural then to regard the +inactivity, in so far as it may be specifically determined, as an +expression of some such delusion. + +Psychiatrists are more or less aware of there being typical ideational +contents in the different manic-depressive psychoses. For instance, +every one is familiar with ideas of wickedness and inadequacy in +depression, ideas of violence in anxiety, or expansive and erotic +fancies in manic states. Quite similarly we have seen that death is a +dominant topic in a stupor. Now in addition to these typical ideas we +often hear expressed what we might term non-specific delusions, ideas +that seem to have nothing to do with a peculiar type of reaction which +the patient presents. It is therefore not surprising to find that +inactivity is not consistently ascribed to death or a related delusion. + +For instance, Henrietta B. had much talk of higher powers that were +controlling her, also said that it was fear which kept her quiet. +Josephine G. said retrospectively that she had thought she would injure +people if she moved and that if she opened her eyes she would murder the +people around her. Johanna B. was afraid to talk because she fancied she +was in prison. Laura A.: During her stupor was more vague, saying, “I +can’t move, they won’t let me be,” without betraying any suggestion of +whom “they” might be. Finally Mary C. (Case 7) was still more +indefinite, ascribing her immobility merely to fear. When one considers, +however, that these five were the only ones who gave any atypical +explanation of their inactivity among the thirty-seven cases, the +preponderance of the death idea becomes striking. + +2. NEGATIVISM. The next of the cardinal symptoms to be considered is +negativism. This term, which is often loosely used, we would define as +perversity of behavior which seems to express antagonism to the +environment or to the wishes of those about the patient. Naturally it is +only in the minor stupors that we see it in well-developed form as +active opposition and cantankerousness. For example, Harriett C., who +stood about until her feet became edematous, would spit out food when it +was placed in her mouth but would eat if she were left alone with the +food. Josephine G., in a milder state, would turn her back on people. +When more inactive once rolled out of bed and lay on the floor. At this +time also she tried to keep people out of her room. Rarely, patients may +have angry outbursts, as did Annie K. (Case 5) who would strike at the +nurses. + +Very often the failure to swallow and anomalous habits of excretion seem +to be negativistic in their nature. One thinks at once of the necessity +for tube-feeding, which is so common even when patients seem otherwise +fairly active. Naturally this form of treatment is necessary only when +the patient refuses to swallow. Quite frequently a refusal to urinate is +met with so that catheterization is necessary, or a patient may never +use the toilet when led to it, but will defecate or urinate so soon as +he leaves it. These latter, like some other perversities, suggest +reactions of a petulant, spoiled child. + +By far the commonest manifestation is muscular resistiveness, often +spoken of as “resistiveness.” It was present in thirty-two out of +thirty-seven of our cases. Usually it takes the form of a contraction of +the whole system of voluntary muscles when the patient is touched or the +bed approached. Often it appears only when any passive movement of the +limb is attempted. All muscles of the limb then stiffen, making the +member rigid. Sometimes the negativism is expressed by quite isolated +symptoms, such as stiffness in the jaw muscles alone. One patient showed +no opposition except by holding her urine for two days. Another kept her +eyes constantly directed to the floor. The reaction of another showed +no irregularity except for stiffness in the neck and arms and wetting +herself once after she had been taken to the toilet. One displayed +merely a slight stiffness in her arms. An interesting case was that of +Annie G. (Case 1) who kept one leg sticking out of bed. If this were +pushed in, she would protrude the other. Mary F. (Case 3) sometimes +expressed her antagonism to the environment by slapping other patients. +She spoke only twice in a year and a half, and each time it was when +interfered with. By far the commonest cause of muscular movement in +these inactive cases is resistiveness, and as a rule the inactivity is +interrupted only by negativistic symptoms. + +If we look for some explanation or correlation of these symptoms, we +find that chance references to conduct seem to point in the same +direction, namely, to the desire to be left alone. This resentment +against interference again reminds us of the reactions of a spoiled +child. For instance, Laura A., in manic spells during which she was +still constrained and drooled, said, “I don’t want to have my face +washed.” In the intervals she showed an intense muscular resistiveness. +Mary G. used to say, “Leave me alone,” and covered her head or buried it +in the pillows. Maggie H. (Case 14) said in retrospect that she had +wanted to be left alone. Similarly Alice R. thought she did not want to +talk. Emma K. thought that she was in prison and apparently resented +this. Henrietta B. combined in her behavior tendencies both to +compliance and opposition. When her arms were raised they retained the +new position for a minute. Then she dropped them and said, “Stop +mesmerizing me.” But then she put them up again of her own accord, and +when she had done this presented intense resistiveness to any movement. +Later she extended her arms in front of her and said, “I am all right,” +in a theatrical manner, and then added, “Why don’t you go away?” + +There seems to be some correlation between inaccessibility and muscular +resistiveness. For example, Charlotte W. (Case 12), whose condition +varied a great deal, always lost the resistiveness when she became +accessible, during which periods she also showed some facial expression. +The resistiveness would invariably return when the inaccessibility +reappeared. Caroline DeS. (Case 2) lost her resistiveness as she became +more accessible, although the inactivity and apathy persisted. This +tendency, which is quite common, suggests that muscular resistiveness +represents a lower level of expression of opposition which patients put +into words or purposeful actions when there is other evidence of some +contact with the environment. Sometimes one observes both general +resistiveness and specific acts. For instance, Mary G., who said, “Leave +me alone,” and covered her head or buried it in the pillows, accompanied +her muscular resistiveness with laughter. This shows the affective +nature of the apparently purposeless muscular tension. The case of Annie +K. (Case 5) is more instructive. In the stage of deeper stupor she had +the automatic type of resistiveness but also outbursts of anger, +particularly toward the nurses, striking one of them she said, “You are +the cause of it all.” When food was offered her, she said, “I wonder +people would not leave me alone sometimes.” Again, when her bed was +approached, she would clutch and hold the bed clothes in an apparently +aimless way as if the impulse to resist never reached its goal. +Retrospectively she could not account for her muscular rigidity on the +basis of definite ideas, and could recall only that she felt stubborn. +In a later period when more accessible, she felt cross and did not want +to be bothered. This emotional attitude was quite conscious with her, +whereas the acts and speech of the earlier period, when her stupor was +more profound, seemed more automatic and impulsive. In other words, the +resistiveness looks like a larval attempt to express an idea which is +probably not fully conscious and therefore gives the appearance of being +aimless. As another example of this we may cite the case of Pearl F. +(Case 9), who said when she recovered, “I was stubborn.” In addition to +the muscular resistiveness she had shown, she would often bite the bed +clothes or scratch herself when she was approached. Mary F. (Case 3), +while in a stupor, slapped at nearby patients quite aimlessly. When +somewhat better, this conduct appeared in a more conscious form, as +sullenness, indifference and smearing of feces (again the behavior of a +naughty child). Here one might quote Laura A. once more, whose +resistiveness when stuporous was intense but who in her manic spells +expressed her negativism in a definite idea, “I don’t want my face +washed.” + +To summarize, then, we may say that negativism is apparently the result +of a desire to be left alone, and that muscular resistiveness is a +larval exhibition of the same tendency. But the appearance of this +attitude in such aimless, impulsive acts or habits reminds us strongly +of the dissociation of affect, which was commented on in the previous +chapter. It would seem to be another example of this rather fundamental +tendency of the stupor reaction, not merely to diminish conative +reactions in general, but to reduce their appearance to that of +isolated, partial and therefore rather meaningless expression. + +3. CATALEPSY. The last of the cardinal symptoms to be considered is +catalepsy. It occurred in thirteen of thirty-seven cases, although it +was present only as a tendency in three of these. If we define it as the +maintenance of position in which a part of the body is placed regardless +of comfort, we can see that sometimes it is difficult to differentiate +from the phenomenon of resistiveness with its rigidity. It is most +frequently observed in the hands and arms, perhaps because it is, as a +rule, most convenient to demonstrate the retention of awkward positions +in the upward extremities. But any part or even the whole body may be +involved; for example, Charles O. retained standing positions even where +balance was difficult. This phenomenon is often accompanied by “waxy +flexibility,” where the joints move stiffly but retain whatever bend is +given them, like a doll with stiff joints. + +The significance of catalepsy is best studied by considering its +relationship to other symptoms and by noting remarks made by the +patients in reference to it. The most important observations which we +have made seem to indicate that it never occurs with that degree of deep +inactivity which suggests a complete lack of mentation on the part of +the patient. One is therefore forced to conclude that back of this +phenomenon there must be some purpose, some kind of an ideational +content, although this may be of a primitive order. This is demonstrably +true in some cases, at least such as that of Isabella M., who left her +arm sticking up in the air but took it down to scratch herself and then +put it back. Somewhat similarly, Charlotte W. (Case 12), when she was +shown during convalescence a photograph of herself in a cataleptic +state, said that that was when she was waiting to go to Heaven and was +afraid to move. Again she remarked, “I was mesmerized.” Josephine G., +who showed only a tendency to catalepsy, said that she feared the devil +would get control of those about her if she moved. Sometimes there is a +development of this symptom from others which seem to be ideational in +their origin. For instance, Charles O. began making flail-like +movements. These passed over into slow circular motions which finally +subsided into the maintenance of fixed position. + +References to hypnotism are not infrequent, and in many cases there is +evidence of a delusion that the posture is desired by those in charge of +the patient. Annie G. (Case 1) said so directly. In retrospect she +explained the holding of her arms in the air by saying, “I thought you +wanted me to have them up.” Henrietta B. at one examination kept her +arms raised in the position in which they had been put for a minute and +then dropped them, saying, “Stop mesmerizing me.” But she then put them +up again of her own accord and now presented intense resistance to any +motion. Later she extended her arms in front of her and said, “I am all +right,” in a theatrical manner. Some patients give evidence in other +symptoms of larval efforts at coöperation with the actual or supposed +wishes of the physician and in such cases it is not impossible that +passive movements are interpreted as orders. One must remember in this +connection that the more primitive are the mental operations of any +individual, the more important do signs, rather than speech, come to be +a medium of communication with other people. As an example of this type +we might mention Rose Sch. (Case 6), who flinched from pin pricks +(showing that she felt them) but made no effort to get away. When +somewhat clearer she said that she was “here to be cured.” Similarly +Mary D. (Case 4), who showed no catalepsy from ordinary tests, kept her +head off the pillow for a long time after it was raised to have her hair +dressed. She showed such perseveration in many constrained positions. +She too flinched from pin pricks but not only made no effort to prevent +them but would even stick out her tongue to have a pin stuck in it. + +The relationship of catalepsy to resistiveness is interesting but +unfortunately complicated and unclear. In only one of our cases was +catalepsy definitely present without resistiveness, and in one other a +“tendency to catalepsy” was noted without muscular rigidity being +observed. In this latter case, when the catalepsy became unquestionable, +resistiveness also appeared. It is one thing to note this coexistence +and another to explain it adequately. All that we can offer are mere +speculations as to the real meaning of the association of these +phenomena. It may be that the tension of muscles that occurs when +resistiveness is present gives the idea to the patient of holding the +position. There would be two possible explanations for this. We might +think there is a dissociation of consciousness, like that of hysteria, +where the feeling of tenseness in the muscles that comes from the +resistance to gravity is not discriminated from the resistance to the +movements made by the examiner. On the other hand, there might be a +similar dissociation where the perception of contraction in the +antagonistic muscles is interpreted as the action of the examiner in +placing the limb in a given position. This latter view would seem, on +the face of it, ridiculous, inasmuch as its presumes the existence of +two directly opposed tendencies, namely, those of opposition to the will +of the physician and compliance with it. But ambivalent tendencies are +frequently present in psychopathic states, and moreover we find +occasionally some evidence in the behavior of the patient to +substantiate this view. For example, at one stage of the stupor of Annie +G. (Case 1), her arm could be moved without resistance. Then the elbow +would catch and at this moment the position would be maintained. Such +observation is highly suggestive of the resistance being signal for the +catalepsy. In Isabella M. the catalepsy appeared when resistance to +passive movements also developed. On the other hand, when the resistance +became extreme, the catalepsy was reduced, and vice versa. This makes +one think of two tendencies: suggestibility on the one hand, and +opposition on the other. We might presume that when both are present and +equally strong, stiffness with passive movements results as a kind of +compromise, but when there is a greater development of one, the other is +inhibited. + +Such speculations remind one strongly of the psychology of conversion +hysteria and of hypnotism. In some cases of stupor hysterical symptoms +are quite definitely present. For instance, Celia G. began her psychosis +with hysterical convulsions which would terminate with short periods of +stupor. Later the stupor became persistent and during this stage she had +catalepsy (and restiveness as well) in her left arm only. On recovery +from her stupor she complained of stiffness in her hands, which +examination proved to be a purely hysterical difficulty. + +This whole subject is without question obscure and many more and very +careful observations are needed before really satisfactory explanations +can be given for these phenomena. That it is a reaction which is related +to the primitiveness of the mental content and the intellectual deficit +in stupor would seem to be a reasonable view, inasmuch as quite similar +phenomena have been observed in a large number of animals, even among +crustaceans. As a result of our own observations the only thing we feel +at liberty to state with real confidence is that catalepsy is presumably +a phenomenon mental in origin rather than somatic, because it always +occurs in conditions which show other evidence of mentation. + +Whatever may be the origin of the idea of the posture assumed, there can +be little doubt that its indefinite maintenance is a phenomenon of +perseveration. The conception of the position being in the patient’s +mind, it is easier to hold it than elaborate another idea. This, of +course, is part of the intellectual disorder in stupor. In fact, it is +difficult to imagine any one whose critical faculty was functioning +coöperating in a test for catalepsy. + + + + +CHAPTER VIII + +SPECIAL CASES: RELATIONSHIP OF STUPOR TO OTHER REACTIONS + + +We have described typical cases of benign stupor and isolated certain +interrelated symptoms which, when they dominate the clinical picture, we +believe establish the diagnosis of stupor, regardless of the severity of +the reaction. These symptoms are apathy, inactivity, a thinking disorder +and, quite as important as these, an absorbing interest in death. It is +typical that the patient contemplates his dissolution with indifference +or, at most, with mild or sporadic anxiety. There seems little reason to +doubt that when these four symptoms occur alone, we are justified in +making a diagnosis of stupor. The next problem is to consider the +meaning and classification of cases where these symptoms occur in +conjunction with others. This naturally introduces the subject of +relationship of stupor to other manic-depressive reactions. + +It is probably best to begin with presentation of three such cases. + + + CASE 16.--_Anna L._ Age: 24. Admitted to the Psychiatric + Institute August 21, 1916. + + _F. H._ Maternal grandmother temporarily insane during + illegitimate pregnancy, thereafter a little odd. Mother + high strung and emotional. Father high strung, impulsive + and irritable. + + _P. H._ As a child she was quick tempered, quite a spitfire + and given to tantrums. At the age of 14 she became a + vaudeville actress in Cleveland, which was the home of her + childhood. When 17 she married a Jew, although she was + herself a Catholic. Her husband noted that she was fretful, + sensitive, resentful and quick tempered, although apt to + recover quickly from her rages. Previously healthy, + neurotic symptoms began with marriage, taking the form of + stomach trouble and a tendency to fatigue. Shortly after + marriage an abortion was induced. After being married for + two years she had a quarrel and separated from her husband. + They were reconciled later, but in the meantime she had + been having relations with another man. When 20 an + abdominal operation was performed in the hope of relieving + her gastric symptoms, but no improvement occurred. The + patient after recovery stated that she continued to be + nervous, shaky and dizzy, at times trembling when going to + bed at night. Two years later, however, she took up + Christian Science and showed objectively some improvement + in her health, although according to her later accounts she + continued to feel somewhat nervous and fatigable. Her + husband stated that at this time she also began to ponder + much about such questions as the difference between life + and death, what “matter” was, and also studied “grammar” + and “etiquette.” According to the patient some five or six + months before admission she began to have peculiar + sensations following intercourse--a feeling of bulging in + the arms, legs and back of the neck. One evening after an + automobile ride there were peculiar sensations on her right + side like “electricity” or as if she were inhaling an + anesthetic. She gasped and thought she was dying. Two + months before her admission she went with her husband and + his family to a summer resort where she felt increasingly + what had always been a trouble to her, namely, the nagging + of this family. + + Just before her breakdown, because she went daily to the + Christian Science rooms in order to avoid the family, they + suspected her of immorality and accused her of going to + meet other men. Even her husband began to question her + motive. Retrospectively the patient herself said that she + now felt she was losing her mind and did not wish to talk + to any one. At the time she told her husband that she felt + confused and as if she were guilty of something and being + condemned. Repeatedly she said she knew she was going to + get the family into a lot of trouble. Once she spoke of + suicide, and for a while felt as if she were dying. Finally + she became excited and shouted so much that she was taken + to the _Observation Pavilion_, where she was described as + being restless and noisy, thinking that she was to be + burned up and that she had been in a fire and was afraid to + go back. + + _On admission_ she looked weary and seemed drowsy. + Questions had to be repeated impressively before replies + could be obtained, when she would rouse herself out of this + drowsy state. She seemed placid and apathetic. She said + that nothing was the matter, but soon admitted that she had + not been well, first saying that her trouble was physical + and then agreeing that it had been mental. When asked + whether she was happy or sad, she said “happy,” but gave + objectively no evidence of elation. Her orientation was + defective. She spoke of being in New York and on + Blackwell’s Island, but could not describe what sort of + place she was in, saying merely that it was “a good place,” + or “a nice country place,” again “a good city.” Once when + immediately after her name L. had been spoken and she was + asked what the place was, she said “The L.” She knew that + she had arrived in the hospital that day but said that she + had come from Cleveland, and to further questions, that she + had come by train, but she could not tell how she reached + the Island. She claimed not to know what the month was and + guessed that the season was either spring or autumn + (August). She gave the year as 1917, called the doctor “a + mentalist,” and the stenographer “a tapper,” or “a mental + tapper.” She twice said she was single. When asked directly + who took care of her, said “Mr. Marconi,” who she claimed + at another time had brought her to the hospital. To the + question, who is he? she replied, “Wireless,” and could not + be made to explain further. That night she urinated in her + bed, and later lay quite limp, again held her legs very + tense. + + For five days she remained lying quietly in bed for the + most part, although once she called out “Come in, I am + here,” “Jimmie, Jimmie” (husband’s name). Several times she + threw her bed clothes off. Otherwise she made no attempt to + speak and took insufficient food unless spoon-fed. At one + examination she looked up rather dreamily but did not + answer. When shaken she breathed more quickly and seemed + about to cry but made no effort to speak. When left to + herself she closed her eyes and did not stir when told she + could go back to the ward. She was then lifted out of her + chair and took a step or two and stopped. Such urging had + to be repeated, as she would continue to remain standing, + looking about dreamily, although finally when taken hold of + she whimpered. When she got to the dining-table she put her + hand in the soup and then looked at it. So far there is + nothing in this case atypical of what we would call a + partial stupor. The cardinal symptoms of apathy, + inactivity, with a thinking disorder, are all present and + dominate the clinical picture. There is, further, the + history of a delusion of death during the onset of the + psychosis. Had her condition remained like this, there + would be no difficulty in classifying the case, but other + symptoms appeared. + + Five days after admission she was restless, somewhat + distressed, and announced that she wanted to talk to the + physician. When examined, the distress, with some + whimpering, continued. She asked the doctor not to be harsh + to her, frequently said there was something wrong and began + to cry. A normal interest appeared only once, when she + spontaneously said she wanted to see her relatives. A most + interesting feature, however, was a certain perplexity that + now appeared. She spoke of this directly: “I do not know + what it is all about. I know you are a doctor, that is all. + I don’t know whether I passed out and came back again or + what--I don’t know what to make of it.” She also felt + confused about her marriage--“There is where all the mixup + is. I was married when I was 16.” She was reminded that she + had said she was single, and replied “I am single.” Then + where is your husband? she was asked. “He must be dead.” + She recalled the examination on admission and remembered + some of the questions that she was asked then, also knew + that she had been at the Observation Pavilion and that she + had reached this hospital by boat. On the other hand she + still claimed that the year was 1917, and in connection + with the delusion of having died was quite unclear as to + the time. She said that it seemed as if she had died many + years ago and that she had come to the hospital years ago. + She also spoke of having died at a summer resort the year + before. When asked for her age, she said that she must be + very old, but on the other hand claimed that she was + supposed to die and to come to the hospital when she was 26 + (two years more than her actual age). + + Her psychosis continued from then on for about ten weeks. + She soon began to feed herself, but otherwise for most of + this period remained quietly in bed, looking about a good + deal, although showing no particular mood reaction until + questioned, when she was apt to make repeated statements + about her perplexity--that she did not know what it was all + about, every one had mixed her up, everything was so + strange, “my head is mixed up, I am trying to straighten + things up.” She frequently when interviewed became + lachrymose and often with her subjective confusion there + was considerable anxiety. Another unusual phenomenon for a + stupor patient was that she was frightened at a thunder + storm. On the whole, however, her apathy and indifference + were quite marked. For instance, during the latest phase of + her psychosis, when the nurses would sometimes make her + dance with them, she did so but without showing any + interest and not until immediately before her recovery did + she begin to speak spontaneously to any extent whatever. A + marked difference from the ordinary stupor was that this + apathy was invariably broken into when she was questioned + and ideas came to her mind, the nature of which seemed to + be essentially connected with her perplexity. + + Not only did ideas appear more frequently than one meets + them in stupor cases, but they were present in greater + variety. The dominant stupor death idea was, it is true, + almost constantly present, but it did not come to the + direct and unequivocal expression which we are accustomed + to see in typical stupor. She did not say “I am dead,” or + “I was dead,” but it was always “It seems as if I were + dead,” or “I think I must have died,” or some such dubious + statement. Other ideas were that her mother was dead and + had been put into a box. She frequently gave her maiden + name and said that she lived in Cleveland with her mother + and that this was Cleveland. At times she thought she was + engaged and was going to be married to her husband shortly. + Again there were notions that her husband had married + somebody else or that some harm was going to come to him. + Sometimes she thought that her mother’s name was her own, + that is, Mrs. L. The hospital once seemed like a convent to + her. + + Her subjective and objective confusion seemed quite + definitely to be connected with the insecurity and + changeability of these ideas. It appeared as if insight and + delusion were struggling for mastery in her mind, so that + reality and fancy were alternately, even simultaneously, + possessing her, and that this gave her the feeling of + perplexity from which she suffered. Once when she remarked + “It seems as if I had been dead all the time,” she was + questioned more about this and replied, “Well, sometimes I + thought I was dead, at other times it seemed as if I + wasn’t.” In answer to a direct question about her feeling + of confusion she said “I don’t know. I know I have lots of + good friends, they all want to help me and it seems as if + everything got mixed up between the L.’s (her married name) + and the G.’s (her maiden name).” This was apparently an + elaboration of the wavering ideas she had about her + singleness or her married state. Once after referring to + her husband as her sweetheart whom she was to marry, and + immediately thinking that perhaps he had married somebody + else, she added, with a sigh, “The more this goes on, the + more mixup.” In short, any question, even on some + apparently neutral topic, seemed to start up conflicting + ideas in her mind, the inconsistency of which she + recognized without being able to control their appearance. + Hence, whenever she was spoken to, she became perplexed and + distressed. + + Her orientation gradually improved so that, although it + remained vague, it was no longer glaringly inaccurate. Then + quite suddenly she one day came to a nurse and asked how + long she had been in the hospital. When told, she remarked + that it seemed as if she had spent the whole winter there. + She was examined at once and found to be quite clear and at + first in good control of her faculties. She remembered a + good many of her ideas, in fact was able to elaborate a + little from memory on what had already been reported from + her utterances during the psychosis. The recovery was not + immediately complete, however, for at this examination, + when told that she had constantly given her maiden name, + she became distressed and said the physician was trying to + mix her up and was reluctant for this reason to discuss her + ideas. This soon passed, however, and within a few days + she was quite normal and had remained so for some months + after her discharge from the hospital, when last seen. In + fact, according to the husband, she was in better mental + and physical health following the psychosis than she had + been for years. + +Essentially, then, this case shows what was at first a typical partial +stupor, but soon became complicated by a tendency for questioning to +provoke rather a free flow of ideas and a distressed perplexity. This +symptom of perplexity soon grew to dominate the clinical picture, so +that the psychosis was really a perplexity ushered in by a brief stupor +reaction with a background of stupor symptoms running through it. The +second case shows similar tendencies but different from the one whose +history has just been cited in that the perplexity was never complained +of by the patient herself and that her emotional reactions were more +marked and varied. + + + CASE 17.--_Celia C._ Age: 18. Admitted to the Psychiatric + Institute May 2, 1914. + + _F. H._ Four years after this attack her mother was a + patient in the hospital with an atypical manic-depressive + psychosis from which she apparently recovered. + + _P. H._ The patient herself was described by superficial + observers as being bright, sociable, well-informed and very + ambitious. + + When 18 years of age she was working very hard preparing + for some examinations, and worried lest she should fail in + them. Some years later the patient accounted for her + psychosis by saying she had a quarrel with her sister, + immediately after which she began to feel depressed. The + anamnesis states that she was slow, complained of not being + able to think and feeling as if she had no brain. She was + sent to a general hospital, where she was apprehensive, + wanted her mother to stay with her and one night called out + “Mother.” + + The case being recognized after a few days as a psychosis, + she was sent to the _Observation Pavilion_, where she was + described as jumping about in bed in a jerky, purposeless + manner, resistive when anything was done for her, and mute. + Her sister reported that when she visited her the patient + said “Go away, I am dead.” + + _On admission_ she looked dazed, stared vacantly and had a + tendency to draw the sheet over her. When put on her feet + she let herself fall limply. At times she became agitated, + sobbed and cried loudly, especially when attempts were made + to examine her physically, or, when she was asked + questions, she scarcely spoke. + + Her psychosis lasted but a little more than three months + under observation and was characterized by the following + symptoms: She was usually in bed, staring blankly or + appearing otherwise quite indifferent and apathetic, but + not infrequently, especially during the first few weeks, + she was quite restless, resistive, whined and suddenly + appeared startled or distressed with no occasion for this + reaction in the environment. Rarely she was suddenly + assaultive. When attempts were made to examine her, she was + frequently mute or would repeat the question with a rising + inflection, not getting anywhere, or would say, “What shall + I say,” or “I, I----” never finishing her sentence. After + orientation questions she might say “This is--this is--this + is----” all this, together with a rather perplexed + appearance, gave the impression of considerable + bewilderment, but at no time did she complain of + autopsychic perplexity. It was difficult to judge of her + orientation on account of her failure to answer questions, + but it soon appeared that she knew the names of the nurses, + for she sometimes called them spontaneously by name. She + always ate reluctantly. + + During these examinations, however, other symptoms often + appeared. When she was talked to, she was apt to indulge in + depressive statements and show considerable distress. Such + remarks were: “I must confess my guilt,” “I am a bad girl + and I have to face my guilt,” or “I have sinned,” or, + standing up with a dramatic air, “I must stand up and tell + the truth.” Once she said, “It is too late to live now.” + She spoke of having lied and usually would not say what + about, but once on questioning replied “I said I would not + tell what happened here.” She was asked, What do you mean? + and answered “I took my oath not to tell anything.” Pressed + further she said that the nurses poisoned her. Another time + she said she was in prison. To her aunt who visited her she + said, “I am a prostitute,” and once she remarked to the + doctor, “I have killed my honor,” and on another occasion + in the middle of the night she called out, “Chinatown + Charlie, come here.” She thought the doctor was her + brother. + + Most of these statements were associated with painful + emotion, but there were a few occasions when an element of + elation cropped out. Thus on one occasion she laughed, + another time gripped the doctor’s pad and tried to read it. + When the nurse laughed, she made a funny grimace at her and + said “Why do you laugh?” Again she once sang two songs, but + after the first verse got stuck and kept repeating one + word. + + At the end of three months she improved rather rapidly and + was in a condition for discharge as “recovered” a month + later. Retrospectively she said that she recalled feeling + guilty, thinking that her mother was dead, having been + killed by the patient as a result of worrying over the + latter’s failure in her examinations and refusal to eat. + She remembered, too, that at times she thought the building + was burning. Some things like “Chinatown Charlie” she + denied remembering, although she had a good recollection + for the external facts throughout the psychosis. Her + insight was superficially good, but she was reluctant to + discuss her psychosis, in fact claimed that she had been + made more of a lunatic by coming to the hospital than she + was on admission. + + Some five years later she had another somewhat similar + attack, again following a quarrel, this time with a fellow + employee. In this second psychosis, however, manic elements + were much more prominent. + +Here again, then, we have the symptoms of apparent apathy, inactivity, +and similar ideas of death, but the thinking disorder was possibly not +very profound, inasmuch as she had a good memory for external events. +Her ideas, too, are much more florid than those which we customarily +meet with in stupor cases, but the most marked peculiarity was that +this “stupor” was liable to constant interruption, either spontaneously +or as a result of questioning, which always produced a mood reaction. +She was apathetic only so long as she was left alone. In other words, +whenever an effort was made to test what seemed to be apathy, the +evidences of it disappeared. + +The third case to be considered is somewhat like that of the first, Anna +L. (Case 16), in that with the inactivity and apathy there was a +coincident subjective perplexity. The apathy, however, was less marked +than in the case of Annie L. + + + CASE 18.--_Catherine M._ Age: 24. Admitted to the + Psychiatric Institute November 10, 1913. + + _F. H._ Information as to the family is confined to the two + parents. The mother, who was frequently seen, seemed to be + a natural, sensible woman. The father, on the other hand, + had been alcoholic all his life, had had two convulsions + while drinking, and had little respect from any member of + the family, including the patient. + + _P. H._ The patient was said always to have been healthy, + from a physical standpoint, although never robust. She got + on well at school, and then worked first as a stock girl + and later as clerk in a department store, where her work + was efficient and she advanced steadily. As a child she + played freely with other girls but little with boys. As she + grew older she moved about socially a little more, made the + acquaintance of men as well as of girls, but never cared + much for the former and had no love affairs until she met + her husband. She was never demonstrative but always rather + quiet and modest. Occasionally she spoke of thinking that + people talked about her, but the informant doubted if she + brooded over this, because she was not of a worrying + disposition. Considering the ideas which appeared in her + psychosis, it is striking that in her normal life she was + rather antagonistic towards her father on account of his + alcoholism and the crudity of his speech and manners. + + When she met her husband she liked him from the first, + although she at no time became really demonstrative. They + were engaged for a year, during which time she agreed to a + postponement of three months for the marriage, which was + suggested by her mother. For some time before this event + she was working harder than usual and seemed a bit worn + out. She ceased working a month before marriage and + improved physically, although she became rather nervous, + that is, she was more easily startled, an accentuation of + what had been a characteristic for some years. Her husband + stated that at this time she became fearful of the + approaching marriage relations and asked him to be kind to + her in this respect. She was married a year before + admission. For two and a half months she refused + intercourse and visited her mother’s home a great deal. She + finally submitted. She was quite frigid but became pregnant + at once. Her abnormality then became apparent. She kept the + fact of her pregnancy to herself for several months and + then when she told her mother wanted to have an abortion + performed. Neurotic symptoms appeared. She became sensitive + with her husband, correcting his grammar, and cried easily. + She also began to be anxious about the approaching + childbirth, and with this became more religious. + + For the first few days after the delivery, she was fussy + with the nurse so that two in succession had to be + discharged. On the fifth day she woke up and seeing a nurse + lying on the couch beside her bed thought the latter was + colored. On the seventh day she had a dream in which she + thought she “nearly died in childbirth.” Then she began to + talk of dying for her baby or of having two babies, of + dying herself and rising again after Easter Sunday. She + became antagonistic to her husband and with this excited + and confused so that she was taken to the Observation + Pavilion. + + On _admission_ she looked pale and exhausted, had a slight + temporary fever and a coated tongue. Her orientation was + usually vague but sometimes she gave fair answers. Her + verbal productions were rather fragmentary and with the + exception of some repetitions there did not seem to be any + special topics which dominated her train of thought. + + For some days the great weakness and the slight fever + continued, and then, as it gradually cleared up, there came + a change in her mental condition that settled into the + state which characterized the rest of her psychosis. She + talked less and was often quite inactive, frequently lying + with her eyes closed for long periods, or sat or stood + about. Such movements as she made were slow and languid. + Her expression was either blank, absorbed, or gave the + appearance of peculiar appealing perplexity. This last was + not infrequently associated with a rather sheepish smile. + She was never resistive and always ate and slept well. With + the exception of a few times she did not soil herself. The + most interesting feature of her mood reaction was that in a + general setting of a slight perplexity there appeared at + times and evidently associated with definite ideas, changes + in her emotional state. Sometimes this was a matter of + distress or of mild ecstasy, sometimes she became markedly + blocked. There was at no time any frank elation, but often + an appropriate smile, that is, appropriate to the situation + and to the thought to which she was giving expression at + the time. Then, rarely, there were sudden bursts of + peculiar conduct, such as throwing herself on the floor or + running down the hall. When questioned as to her motive for + these acts, she would flush, look perplexed and apparently + be unable to explain them. + + Her verbal productions dealt with a rather limited range of + topics which can be briefly summarized. As in the other + cases, the reader will notice that the bulk of these ideas + are of a kind not usually prominent in the typical stupor + cases. Many of her thoughts seemed centered around her + husband. She always knew him when he visited her, but in + her thoughts there was a constant change as to his + personality. She persistently confused him with the + physicians, with her father, and with God, and one remark + is typical, “I thought he was God, priest, doctor, + lawyer--well, I wanted to go to Heaven; I thought he would + still be my husband; I always hoped that I would be home in + Heaven.” Not unnaturally with this confusion there were + doubts about her marriage. People said her marriage was + wrong and her husband bad. Frequently she thought he was + dead, or voices informed her that she was not married to + him, or that he was the devil in Hell. In this connection + she also said that people called her a whore, or it seemed + as if she were accused of not being married. + + As prominently as appeared the ideas of the invalidity or + impossibility of her marriage, to the same extent did her + father assume an important rôle for her. As a rule he + appeared in religious guise as God, but often he was the + doctor--“I knew my father at home and my father in Heaven; + which God do you mean? did you say God or father?” At times + she spoke of being in Heaven and that God seemed to be God, + doctor or priest. In this connection there were ideas of + being under the power of some one, God, devil or father. + + As is usually the case where strong interest is expressed + in the father, ideas of the mother being dead occurred, + although in the frankest form she reported them as dreams; + for instance, one night she woke up screaming, said that + she had dreamed that her mother was dead and her sister + dying. That, in the psychoanalytic sense, this represented + a removal of a rival, making union with her father easy, + appeared in the statement that her father was dead but that + she had dreamed he had come to life again for some one + else. When asked what she meant, the question had to be + repeated several times, then she said “My mother died, my + father and mother had a quarrel.” There is more than a + suggestion here of a difference in the significance of + death, in so far as it concerned the two parents. The + mother dies and remains dead, that is, she is gotten rid + of. The father dies but takes on a spiritual existence and + comes to life again, a frequent method in psychoses for + legitimizing the idea of union with the parent by + elimination of the grossly physical. + + There were strikingly few allusions to the plainly sexual. + She spoke of being married to the doctor, and even went so + far as to say that they belonged together in bed. On + another occasion she called him “darling.” Once she + reported that it was said that she was going to have babies + and babies and babies. These references were, however, + quite isolated, so that the erotic formed a very small part + of her productions. + + Delusions of death, we have seen, are the most constant + content of true stupors. In this case they were present but + distinctly in the background. She spoke quite frequently of + being in Heaven. She also talked of being crucified. Once + she said “I died but I came back again.” This last + utterance was rather significant in that frankly accepted + ideas of death were unusual; for instance, she would say + sometimes, “I think I am in Heaven, again not. It confuses + me, but I know I am in Heaven.” + + In general, then, her ideas were, on the whole, not at all + typical of stupor but much more like those met with in + other manic-depressive conditions. Correlated with this was + an unusual mood picture. Quietness and apparent apathy of + the patient were interrupted by little bursts of emotion, + and throughout the psychosis there was a coloring of + perplexity. Not only was this last objectively noticeable, + but she spoke very frequently of it and always in + connection with the inconsistency of the ideas in her mind + which puzzled her. For instance, in speaking to the doctor + she said “I think of you as Bill (her husband’s name) + sometimes--I get confused thinking of Bill as God, doctor, + lawyer, priest.” Again, referring to her husband, she made + these curious statements: “They seemed to speak of him as + being in the wrong--the right--it seems that the right + devil is the wrong one for me--they say he is not the right + one for me; they say he went wrong from the time we were + married.” Again, she said that she did not know who her + father was, and went on: “It puzzles me, this father + business, I knew my father at home and my father in + Heaven.” Again, “Which God do you mean? Did you say God or + father?” A hint as to how this subjective confusion made + the environment seem uncertain comes from the statement, + “You looked like the devil and yet you were God.” + + Distress and anxiety appeared not infrequently and always + appropriately. The distress was usually occasioned by an + idea of injury to others, as when she cried over the + fancied accusation of drowning her husband and mother; or + in connection with accusations of herself, such as when she + reported “They called me a whore.” As has been stated, + there was never any frank elation, but an element of + pleasurable expansive emotion was frequently present in + connection with her religious utterances. This came + particularly when she spoke of union with her father as + God. She seemed to swell with ecstatic emotion. It was + especially well marked once when she threw herself on the + floor and when asked what she was trying to do replied, “I + want to do what God wants me to do, drop dead or anything + at all.” Perhaps the most unusual affective reaction was a + blocking which occurred when certain topics appeared. This + is a phenomenon quite unusual for stupor, where speech + seems to stimulate and arouse the patient as a rule. One + got the impression that ideas tended to come into this + patient’s mind which were painful enough to disturb her + capacity for connected thought. A good example of this + reaction was when she was speaking of her father having + died and coming to life again. On being asked what she + meant, she became quite blocked and the question had to be + repeated several times, when finally the apparently + unrelated statements appeared: “I dreamed my mother + died--they had a quarrel.” Who had a quarrel? she was + asked, and replied “My mother and father.” Apparently her + thinking about her father coming to life for some one not + her mother stimulated deeply unconscious ideas concerning + the separation of her mother and father, and her taking the + mother’s place, and these ideas were sufficiently + revolutionary to upset her capacity of speech for the time + being. + + She recovered completely about six and a half months after + her admission. + +If we consider together the common features of these three cases, we see +that they resemble stupors only in the presence of inactivity and +apparent apathy. It is true that death appears in the ideational content +but not with that prominence, bordering on exclusiveness, which +characterizes such delusions in the true stupors. These three patients +give one the impression of being absorbed in thoughts that have many +variations. It seems as if they had difficulty in grasping the facts of +the environment, while feeling at the same time the vividness of the +changing internal thoughts, hence a confusion develops which is either +subjective, objective, or both. It is probably the introversion of +attention which gives rise to the apparent apathy, because normal +emotions emerge as part of our contact with reality around us. This lack +of contact with the environment leads also to inactivity. If one’s +attention and interest is turned inwards, there can be no evidence of +mental energy exhibited until the patient is roused to contact with the +people or things about him. It is noteworthy that in these cases +emotional expression emerged when the patients were stimulated to some +productiveness in speech. + +These conditions really constitute a different psychosis in the +manic-depressive group, essentially they are perplexity states such as +have recently been described by Hoch and Kirby.[7] Not infrequently we +see exhibitions of this tendency in what are otherwise typical stupors. +For example, Mary F. (Case 3) (the third case to be described in the +first chapter), showed for a few days after admission a condition when +she was essentially somewhat restless in a deliberate aimless way. At +the same time she looked dazed or dreamy. With this restlessness she +appeared at times “a little apprehensive.” Although she spoke slowly, +with initial difficulty she answered quite a number of questions. Her +larval perplexity was evidenced by the doubt expressed in a good many of +her utterances, such as, “Have I done something?” “Do people want +something?” “I have done damage to the city, didn’t I?” When asked what +she had done, she said, “I don’t know.” She asked the physician, “Are +you my brother?” and when questioned for her orientation said, “Is not +this a hospital?” The atmosphere of perplexity also colored the +information which she did recall correctly; for instance, when asked her +address, she said, “Didn’t I live at ----?” then giving the address +correctly. + +As stated in Chapter V dealing with the ideational content of stupor, +one has to look on the delusions of patients as symptoms subject to +analysis and classification just as truly as the variations in mood or +intellectual processes, in fact they should be subject to the same +correlation as are the mental anomalies which are usually studied, +particularly if we are to understand these psychoses as a whole. Let us, +therefore, consider the death ideas in the three cases studied in this +chapter. We find that, as in the ordinary stupors, there are delusions +of death, also of mutual death (with the father), but there is a +tendency to elaboration so that the death is only part of a larger +Œdipus drama, the rest of which is usually lacking in stupors. Here +it is present. So we have thoughts of the death of the mother or +husband, another rival, considerable preoccupation with Heaven, and also +erotic fancies. + +We find in manic-depressive insanity a tendency for more or less +specific ideational contents with different types of the psychoses.[8] +For example, there are religious and erotic fancies or ambitious schemes +dominating the thoughts of manic patients, fears of aggression and +injury met with in anxiety cases, and so on. In stupors, death seems to +be a state of non-existence with other meanings lacking or only hinted +at occasionally. When it tends to be elaborated, it leads over to +formulations suggesting personal attachments and emotional outlet, and +then we are apt to find interruptions of the pure stupor picture. For +example, Charlotte W. (Case 12), whose case has been described, thought +much about being in Heaven and ended with a hypomanic state. Atypical +symptoms appear just as constantly in these cases, as do the atypical +ideas. In other words, the thought content is definitely correlated with +the clinical picture. + +As the clinical pictures show the relationship of stupor to other +psychoses, so there is also a correlation with varying formulations of +the death fancy. We are now in a position to define more narrowly what +death means in stupor. It is an accepted fact, a Nirvana state. When +death means union with God or appears in other religious guise, manic +symptoms tend to develop. When it is unwelcome and appears as “being +killed,” we find anxiety symptoms. A patient can conceive of death +variously and have various clinical pictures. A knowledge of the +metamorphoses of ideas and their relationship to other symptoms enables +us to understand such cases, that, without this key, seem confused and +lawless jumbles of symptoms. Such theories tend to justify the view of +essential unity of the manic-depressive group. + +It would be instructive at this point to consider another case which +illustrates beautifully how a stupor reaction may crystallize out of +other manic-depressive states when attention has become focused on +personal death. This patient went through four phases while under +observation. First, while showing a perplexed expression but with fair +orientation, she gave utterance to erotic and expansive fancies. She was +restless, somewhat intractable and gave the impression of brooding over +her imaginations rather than luxuriating in them. In other words, her +condition seemed to be more that of absorbed than active mania. Second, +these same ideas, somewhat reduced, continued in an apathetic state +while impulsive symptoms developed: She began to shout like a huckster +to be taken to Heaven and made numerous affectless, suicidal attempts. +Third, came a true stupor and, fourth, a period of recovery when the +stupor symptoms all disappeared but insight into the falsity of her +ideas was lacking. + + + CASE 19.--_Celia H._ Age: 19. Admitted to the Psychiatric + Institute October 22, 1913. + + _F. H._ The father was living; he always drank, and + especially in later years contributed little to the support + of the family. The mother was living and said to be + normal, while a brother was coincidentally insane, with a + recoverable psychosis. + + _P. H._ The mother stated that the patient was bright at + school, enjoyed company and going out, had a droll wit, was + not at all seclusive, no dreamer, helped to support the + family and was efficient. She was very much attached to her + brother and once said that if anything should ever happen + to him she thought she would die. She also cared much for + her older sister, with whom she worked, and for her mother. + + Three months before the patient’s admission her brother + became depressed, mute, seemed worried, cried at times. He + was sent to the country. Two months before admission, when + the mother and the patient went to bring the brother to + town, and while they were at the station, he suddenly tried + to throw himself under a train but was restrained just in + time. The patient appeared intensely frightened, but did + not talk. In fact, she seemed somewhat bewildered and at + once became dull. “Her movement and manner were much as at + present.” + + When the patient was able later to give a retrospective + account of the onset, she claimed that for some months + before this incident she saw that her brother was losing + his mind. She worried about this as well as about her work, + and felt worn out. She said that when the brother tried to + throw himself under the train she was terrified and could + not speak or move, and that her mind got upset at once, “I + lost my memory.” The others forgot her and left her alone + on the platform. Strangers put her on another train and she + knew nothing until she arrived at home. + + The mother added that at the time when the incident with + the brother happened, the patient was menstruating and that + this ceased at once. + + At home she sat about inactive and did not seem even to + worry. Whenever any one asked her about her brother she + replied that he was dead. For two weeks before admission + she said she was rich, that she owned all the property + around. She also said she was married to Mattie S. In this + connection the mother says that a foolish neighborwoman, + the mother of Mattie S., told the patient since her + sickness, by way of encouragement, that she should marry + her son (the man mentioned). Finally, the patient also + expressed the idea that her mother was a stranger, that her + real mother was dead. + + At the _Observation Pavilion_ she was described as + wandering about in a perplexed manner, restless, resistive, + answering few questions and in a low tone. She said things + were “changed,” also that she was married to S. + + _Under Observation:_ 1. For about ten days the patient’s + condition may be described as follows: The most striking + feature was a certain restlessness with insistence on going + out, with complaints that this and that had been done to + her and with senseless struggling when interfered with. But + all the motions were slow, the whole restlessness aimless + and impulsive. Although the facial expression was somewhat + perplexed, it changed remarkably little, and whenever asked + whether she felt worried or anxious she denied it, and, + indeed, there was only a suggestion of perplexity in her + face. + + The ideas which she expressed during this time referred to + a few topics only, namely, marriage, wealth, and State + prison. The remarkable fact was that all the ideas about + marriage and wealth were spoken of, often immediately, + again after some interval, now in the positive and again in + the negative sense. Thus she said she was “Mrs. S.,” again + “You kept me from marrying Mattie S.,” or “I am not + supposed to be here--I am a married person,” but also “You + kept me from getting married.” Or, “Take off that black + dress, I am a bride,” again “You have taken my bridal crown + off my head,” “The steamboats (seen from the window) are + mine--I own the ships, the oceans, the land and + everything,” or again, she said she owned a kingdom, was + Sh.’s wife, a wealthy woman, had millions. Sometimes she + connected the millions with Sh. “Sh. has millions.” On the + other hand, she said: “I owned all this before I came. I + have nothing now,” or “You have taken the regal crown from + me,” “You have made a pauper of me,” “They did it again, + they took my millions away,” or “Let me out, they are + taking my millions.” + + Other ideas throughout this period were that this was a + State prison, that “bums” were around. On one occasion she + said “You can’t put down all these things and make me out a + lunatic.” At another time she pulled a patient’s hair and + then said without fun: “I fixed the leading lady of the + dump--she knows a lot, but she does not know enough to + keep her soup cool.” When questioned about this woman (who + at the time while cleaning had moved the furniture), she + said: “I don’t know where I am at.” + + The orientation during these days was not markedly + disordered, when one got down to it. Although she spoke of + State prison, it was always found she knew the name and the + location of the hospital, the names of people around her, + even the date approximately, though she was apt to say it + was February 19, 1492, or October 19, 1492, or when the + year was not given as 1492 she said it was “1900 or 1901, + or 1911 or 1912.” Frequently, however, it was hard to hold + her attention. + + Finally, it should be mentioned that she very often wet + herself in bed or when standing, even when standing in the + examining room. + + 2. The period following and lasting for two months may be + given in the form of abstracts of each note. + + _November 7:_ Yesterday quiet, though struggling. Says + without change of expression, “I saw four people killed--my + mother, my brother, a priest, and my dear sister--we were + all killed.” Again, “I don’t know where I am,” “I am an + orphan, my people died” (without affect). + + _November 20:_ More quiet recently, says little, but tries + to get out when brought to the examining room, but when not + prevented walks slowly about as before, says she wants to + go home. Looks peculiarly blank. + + _November 23:_ Has remained quiet, says she is Dr. M.’s + wife. But when told she is not married, she agrees. Her + attitude towards the doctor is not changed, but when the + nurses talk to him, she has tried to prevent it. + + _December 6:_ Has remained quietly in bed, gazing about. + Slow in motion. She has spoken of being Dr. M.’s wife, + again President Wilson’s wife, again “Vincent (brother) is + the ruler of the world.” + + At interview says little, seems abstracted, answers briefly + in low tone. (Does anything bother you?) “No.” (Are you + natural?) “Yes.” (Who are you?) “C. H.” (correct). (You + said you were the President’s wife?) “No.” (Are you + married?) “No.” (You talked about the kingdom?) “I own the + kingdom” (affectlessly). (Where is Vincent?) “Here.” (Have + you heard him?) “Yes.” (What did he say?) “Nothing.” (Is + he all right?) “Yes.” (Where is your mother?) “Home.” (Why + don’t you go home?) “I can’t.” (Why not?) “I can’t.” (Why + not?) “The family tree is broken, the Cardinal.” (What + about him?) “Nothing.” (Retrospectively she said later she + thought her brother was a cardinal.) + + _December 8:_ When her mother visited her she said “It is + about time you come--I thought you were dead.” Has walked + down the hall “looking” for her dead cousin. When asked if + she wanted to see her brother, said, “Ain’t he dead?” + + _December 12:_ Cries out in an affectless tone like a + huckster, “Father MacN., take me to Heaven,” repeating this + over and over. + + _December 15:_ Quiet as a rule, then for a time at the + door, pulling at it and with whining voice but affectlessly + saying “Give me the key--I want to go to the river--you + can’t keep me from Heaven--it is either Heaven or the + river, give me the keys, give me the keys, open the door,” + “The niggers are taking possession.” To the physician to + whom she had claimed to be married, often repeats “You + don’t belong to me, I don’t belong to you.” (What about the + niggers?) “A band of niggers, that is all they are.” (Are + the nurses niggers?) “That is all they are.” Asked about + her people, she says “They are in Heaven.” (Where are you?) + “I am in Heaven” (without change of expression). Again, + when asked where her people are, says “At home.” Then she + went willingly back to bed and was quiet. In the afternoon + she again went to the door and tried to get out. When + questioned, she said “I don’t want to be an animal,” + “Everybody is making an animal of me” (pointing to an + animal picture). Then again, while trying the door, repeats + in the same affectless manner that she wants to go “to the + river,” “to the bottom of the river,” “to Heaven to see my + mother.” This last was said in a whining tone, with some + tears. She kept turning the knob, tried to get the keys, + and struggled impulsively when prevented. + + _December 23:_ Though quiet on the whole, when a visitor + came yesterday, she ran after this woman saying “I want my + generations,” and clung to her, and to-day at intervals + keeps talking about wanting to see her generations but is + often quiet. (Retrospectively she said she wanted to see + all her ancestors from the beginning of time.) + + _December 27:_ Of late often talks affectlessly about + wanting to die or wanting to go to Heaven, struggling + impulsively to get medicine away from the nurses, asking + for poison, trying to drink her own urine, or even the + fluid in the bed pan after she had been given an enema, all + evidently with suicidal intent. + + _December 28:_ Still constant, impulsive and apparently + affectless attempts at suicide, tries to get medicine away + from nurses, to get the fire extinguisher bottles, a bottle + of ink, etc., struggling when prevented. + + But when examined quiet, even smiles at a joke. When + questioned, denies feeling either worried or depressed. She + said she wanted to go home. She gave poor attention to the + questions. Later she threw a wet sheet over a patient and + laughed (this is rare). Later she slapped another patient. + Again she began to talk about wishing to go to the grave. + Calls Dr. M. “Uncle John.” + + _December 30:_ Talks either about wanting to die, or + wanting to go to Heaven, or wanting to go to Ireland, all + this as usual in an affectless way. Calls Dr. M. “Uncle + John.” Keeps shouting “Take me to Ireland.” + + _January 9, 1914:_ Often quiet in bed, again goes to door, + talks about wanting to go “to Heaven” or “to Ireland.” On + the whole, says little. + + It seems, then, that the transition was not abrupt, that + many traits of the first period remained, but that she was + on the whole much quieter, with the exception of some + spells when she insisted on going out or killing herself. + At such times she showed an affectless, impulsive + excitement. Whether there was an element of perplexity then + is not clear from the notes. The topics of which she spoke + also changed. The idea of wealth was rarely expressed, also + the idea of marriage was much in the background, but + prominent ideas were those of death, Heaven, killing + herself, going to Ireland--all of which she produced in an + affectless way. It should be added that she persistently + wet and soiled during this, as well as in the first period. + + 3. Then followed three months of greater inactivity. She + lay in bed gazing, moving very little, not even when her + meals were brought. She answered but little and + consistently wet and soiled. This state lasted from about + the middle of February until the beginning of April. + + 4. From this stuporous state she emerged during the next + four weeks, the awakening being associated with persistent + efforts to arouse her. She then was, for six or seven + weeks, nearly normal, so far as her mood went, but had a + tendency to cling to some of her ideas and was + overtalkative. Her memory for the earlier phases of the + psychosis was good, as she recalled not only many external + events but most of her false ideas. She said, however, that + her mind had been a blank for the third stage and she + remembered nothing of it. At the end of this time she + cleared up entirely and was discharged as “recovered.” She + continued well for some months, during which she was + occasionally examined. + +This case gives an excellent example of the relationship of stupor to +other manic-depressive reactions. She begins with an absorbed state, +showing elements of perplexity and mania. With this there are expansive +ideas but, also, statements about losing everything and being in prison, +which suggest abandonment of life. Next, with increasing apathy, she +begins to speak of death and soon makes impulsive suicidal attempts. +Evidently her mind was becoming more and more focused on death and with +this there was an appropriate emotional change. She was either apathetic +or the affect exhibited itself in pure impulsiveness. Then comes the +stupor, when all ideas disappear and mentation is reduced or absent. +When the stupor lifts, the original ideas appear not only in memory but +occasion a wavering insight. It is appropriate that she recalled all of +her psychosis fairly well with the exception of the pure stupor, which +she remembered only as a time when her mind was a blank. + +FOOTNOTES: + +[7] Hoch, August, and Kirby, George H.: “A Clinical Study of Psychoses +Characterized by Distressed Perplexity.” _Archives of Neurology and +Psychiatry_, April, 1919, Vol. I, pp. 415-458. + +[8] Hoch, August: “A Study of the Benign Psychoses.” _Johns Hopkins +Hospital Bulletin_, May, 1915, XXVI, 165. + +A book on “the psychology of manic-depressive insanity” will shortly +appear by the editor. + + + + +CHAPTER IX + +THE PHYSICAL MANIFESTATIONS OF STUPOR + + +We must now discuss the most difficult of all the aspects of the stupor +problem. The subject is so involved and the evidence so inconclusive +that observers will probably interpret the phenomena here reported +according to their individual preconceptions. What we have to say is +therefore published not so much to convince as to stimulate further +work. The problem is wider than that of the mere etiology of the stupors +we are considering. Their relationship to manic-depressive insanity is +so intimate that we must tentatively consider this affectless reaction +as belonging to that larger group. A discussion of the basic pathology +of manic-depressive insanity is outside the sphere of this book. The +author, therefore, thinks it advisable to state somewhat dogmatically +his view, as to the etiology of these affective reactions, merely as a +starting point for the argument concerning stupors specifically. + +It is our view that the manic-depressive psychoses may be, and probably +are, determined remotely but fundamentally by an inherent neuropsychic +defect, but this physical and constitutional blemish is non-specific. +The actual psychosis is determined by functional, that is, +psychological factors. A predisposed individual exposed to a certain +psychic stress develops a manic-depressive psychosis. Naturally any +physical disease reduces the capacity for normal response to mental +difficulties; hence physical illness may facilitate the production of a +psychosis. But this intercurrent factor is also non-specific. + +Such is our view of the etiology of manic-depressive insanity as a +whole. When we approach the study of benign stupors, however, difficult +problems appear. As will be discussed in a later chapter on the +literature, reactions resembling benign stupors occur as a result of +toxins, particularly following acute rheumatism. Recently the medical +profession has been called on to treat many cases of encephalitis +lethargica where similar symptoms are observed. If the resemblance +amounted to identity, we would have to admit that a specific toxin may +produce a specific mental reaction which we have concluded on other +grounds to be psychogenic. As a matter of fact, in two particulars these +reactions show relationship to organic delirium. Knauer reports that in +post-rheumatic stupors illusions are frequent--an ice bag thought to be +a cannon, or a child, etc.--and there are bizarre misinterpretations of +the physical condition, such as lying on glass splinters, animals +crawling on the body, and so on. Such illusions are, in our experience, +not found in stupor, and, on the other hand, are cardinal symptoms of +delirium. Further, Knauer reports that even at the height of +post-rheumatic stupor, external stimuli make some impression, in that a +thoughtful facial expression appears. In deep stupors, such as occurred +in our series, this response is not seen. The same phenomenon of +“rousing,” larval in Knauer’s cases, is often well marked in +encephalitis lethargica and is, of course, a pathognomonic symptom of +delirium. We might therefore think that these conditions are mixtures of +two organic tendencies, namely, delirium and coma. It is not impossible +that resemblances to benign stupor are due to functional elements +appearing in the reduced physical state as additions to the organic +symptoms. The prominence of pain might be taken as a likely cause for an +instinctive reaction of withdrawal, which would account for the +emotional palsy of these conditions on psychogenic grounds. [This +argument can be better understood when the chapter on Psychological +Explanation of Stupor has been read.] We therefore feel justified in +holding that the resemblance of the symptoms of certain plainly organic +reactions to those of benign stupor do not necessitate a splitting of +these stupors from the manic-depressive group. + +When we consider certain bodily manifestations of these typical stupors, +however, fresh difficulties are encountered. Unlike depressions, +elations and anxieties, certain physical symptoms appear with frequency, +even regularity. This would seem to indicate the presence of physical +disease. Inasmuch as the most constant of them is fever, the natural +conclusion would be that we are dealing with an infection which +produces a mental state called stupor. If we were not faced with an +obvious relationship to manic-depressive insanity, where such symptoms +are usually accidental and intercurrent, we would accept this +explanation, but this quandary necessitates further analysis. + +Let us first consider the fever. In 35 cases, on whom data of +temperature could be found from the records extant, 28 showed fever +usually running between 99° and 100°, often up to 101° or slightly over +this point. When these cases were analyzed, however, it was found that +27 were typical and 8 atypical, showing pictures resembling those +described in the last chapter. Of the latter only one had a rise of +temperature, while of the typical group only one was afebrile. +Therefore, since out of 27 typical cases 26 had the typical slight +fever, we must conclude it to be a highly specific symptom. Of these 28 +cases the incidence of the fever was as follows: 8 showed it only on +admission; in 7 it was highest on admission but continued at a low rate +throughout the rest of the psychosis; in 5 it extended without much +variation throughout the psychosis; in 4 it appeared intermittently, +while in 2 it was accentuated during periods when the mental symptoms +were most pronounced. We see, then, that there is a distinct tendency +for the fever to be associated with the onset of the disease. + +When we look for other data from which we might discover causes for the +fever, we find less than we would like. The records are of observations +made, some of them, twenty years ago. Although the mental examinations +were careful, the records of the physical symptoms either were not made +or were lost in many cases. Consequently our description must be +tentative and is published merely to stimulate further research as cases +come to the attention of psychiatrists. + +One looks, first, for other evidence of infection. Some of the cases +were thoroughly examined with modern methods and nothing whatever found. +Blood examinations were made in five cases; three of these had rather +high temperature with the following blood pictures: Charles O., 103°, +leucocytosis of 23,000, with 91.5% polymorphonuclears; Annie G. (Case +1), 103°, leucocytosis of 12,000 to 15,000, and 89% polymorphonuclears; +Caroline DeS. (Case 2), 104°, 15,000 leucocytes, no differential made, +Widal and diazo reaction negative. These three cases, then, had marked +febrile reactions and leucocytosis. It is quite possible that they had +infections which were not discovered. Of the other two Rosie K. (Case +11) had a temperature of 100° and 17,500 leucocytes associated with a +fetid diarrhea, an unquestioned infection, while Mary C. (Case 7), with +a temperature of only 100°, had no rise in number of total white cells +but 41% of lymphocytes. This last might be due to an internal secretion +or an involuntary nervous system anomaly. The possibility of the three +high temperatures with leucocytosis being due to intercurrent infections +must be considered. Charles O. had high fever only for ten days during +a psychosis of several months. Annie G.’s high fever was of about the +same duration. Caroline DeS. had short periods of marked pyrexia in the +first and seventh months of her long psychosis. Except for these +episodes, these three patients had the typical slight elevation of +temperature. Three cases out of thirty-five, in which high fever and +leucocytosis appeared episodically, are hardly enough to justify the +view that stupors are the result of a specific infection. We must +remember, too, that no focal neurological symptoms are ever observed, +which makes the possibility of a central nervous system infection highly +unlikely. + +An alternative view might be that the slight rise of fever is somehow +the result of stupor, not the cause of it. The editor consulted +Professor Charles R. Stockard, of Cornell Medical College, as to this +possibility. The following argument is the result of his suggestions: + +What we call a normal temperature is, of course, the result of a balance +maintained between heat production and heat loss. Either an increase in +the former or a decrease in the latter must produce fever. It is +possible that heat production may be increased in many stupors as a +result of the muscular rigidity. Some cases showed higher temperature +when this was more marked, but this was not sufficiently constant to +justify any conclusions being drawn. + +Heat loss occurs preponderantly as a result of radiation from the skin +and by sweating with consequent evaporation of the secretion. These +processes are functions of the skin and surface circulation. Are they +disturbed in our stupors? We find considerable evidence that they are. +Flushing or dermatographia occurred in six cases, cold or blue +extremities in four cases, greasy skin in four, marked sweating in +three, the hair fell out in two cases, while the skin was pathologically +dry in one case, in fact there were few patients who showed normal skin +function. Circulatory anomalies were also observed. The pulse was very +rapid in eleven cases, weak or irregular in two, and slow in one case. +All these symptoms are expressions of imbalance in the involuntary +nervous system, further evidence of which is found in the rapid +respiration of six cases and the shallow breathing of one patient. These +pulse and respiration findings are the more striking in that individuals +in stupor are, by the very nature of their disease, free from emotional +excitement. + +This imbalance could result from a poverty of circulating adrenalin +which is necessary for the activation of the sympathetic nerves. A cause +for low suprarenal function is to be found in the apathy of the stupor +case. As Cannon and his associates have so conclusively demonstrated, +any emotion which was open to investigation resulted in an increase of +adrenalin output. As our emotions are constantly operating during the +day--and often enough during sleep as well in connection with dreams--we +must presume that emotional stimulus is a normal excitant for the +production of adrenalin. It is therefore inconceivable that the blood +could receive its normal supply of adrenalin with an apathy of the +degree seen in stupor unless some purely hypothetically substitutive +excitant were found. + +We may therefore tentatively assume that the fever which marks the onset +and frequently the course of these benign stupors is the result of a +failure of the heat loss function, this being due to an imbalance in the +involuntary nervous system that is occasioned, in turn, by insufficient +circulating adrenalin, and the final cause for the poor suprarenal +function is to be traced to the most consistent symptom of the stupor, +namely, apathy. This hypothesis is welcome, not only because it would +account adequately for the fever, but it also tends to accentuate the +relationship with other forms of manic-depressive insanity, all of which +are marked fundamentally by a pathological emotion. Naturally enough, +one turns to the records again to see if the blood-pressure of these +patients was low, as would be expected with a poor adrenalin supply. +Unfortunately record was made of the blood-pressure in only two cases, +in both of which the reading was 110 m.m. Two such isolated observations +mean, of course, nothing whatever. It is possible that the drooling +which so many stupor cases show is not merely the result of the failure +of the swallowing reflex, but represents as well a compensation for +anhydrosis by excessive salivary secretion. + +Another symptom suggestive of involuntary nervous system or endocrine +disorder is the highly frequent suppression of the menstrual function. +At times this may occur as a sequel to mental shock, as it did in the +case of Celia H. (Case 19), who was menstruating when, frightened by the +suicidal attempt of her brother, the flow ceased abruptly. That purely +psychic factors can produce marked changes in such functions has been +demonstrated by Forel and other hypnotists time and again; presumably +the effect is produced by way of alteration in the endocrine or +involuntary nervous system influence. In such cases, however, we can +trace the menstrual suppression directly to an emotional cause. On the +other hand, most women in stupor fail to menstruate during the bulk of +the psychosis at a time when we believe emotions to be absent or greatly +reduced in their intensity. The recent work of Papanicolaou and +Stockard[9] offers a simple explanation for this phenomenon. They have +shown that in the guinea pig the œstrous cycle can be delayed by +starvation, while in weaker animals a period may be suppressed +completely. When one considers that even with the greatest care the +nutrition of tube-fed patients is bound to be poor, it would be only +natural to suppose that this malnutrition would cause such a disturbance +in the œstrous cycle and was evidenced objectively by a failure to +menstruate. Even in patients who are not tube-fed, under-nutrition is +to be expected and, as a matter of fact, is usually observed. The work +of Pawlow and Cannon has shown how essential psychic stimulus is for +gastric digestion. Any condition of apathy would therefore tend to +retard digestion and indirectly affect nutrition. + +Finally, under the heading of Physical Manifestations of Stupor, we must +consider epileptoid attacks, of which there was a history in two of our +cases, both of which have already been described in the first chapter of +this book. Anna G. (Case 1), in her second attack, was treated at +another hospital, and from the account which they sent it appears that +the stupor was immediately preceded by a seizure in which the whole body +jerked. This is, of course, rather thin evidence of the existence of a +definite convulsion, but in the case of Mary F. (Case 3) we have a +fuller description. During the two days when the stupor was incubating, +she had repeated seizures of the following nature. She sometimes said +that prior to the attacks it became dark before her eyes and that her +face felt funny or that she had a pain in the stomach which worked +toward her right shoulder. The attack would begin when sitting in a +chair, with the closing of her eyes, clenching her fists and pounding +the side of the chair. She would then get stiff and slide on to the +floor, where she would thrash her arms and legs about and move her head +to and fro. The warning of the pain working from the stomach to the +right shoulder is highly suggestive of an epileptic aura, although the +other symptoms mentioned so far could have been considered hysterical or +poorly described epileptic phenomena. The rest of the description +indicates an epileptic seizure more strongly. She frothed at the mouth +and once wet herself during an attack. They lasted only for a few +minutes and she would breathe heavily after them. At the end of one +attack she wiped the froth from her mouth with her handkerchief and gave +it to her aunt, saying, “Burn that, it is poison.” This is perhaps a +little less like epilepsy. It is plainly impossible for us to say with +any positiveness that either these were or were not genuine convulsions, +but it is nevertheless important to record them, because such phenomena +are observed fairly frequently in dementia præcox cases but are +practically unknown in manic-depressive insanity. This, then, would be +another example of the resemblance to dementia præcox in these stupors +which are unquestionably benign.[10] + +We see, then, in reviewing all the physical manifestations of the +benign stupors, that none occurred which cannot be explained as +secondary to the mental changes, and therefore, until such time as +physical symptoms are reported which cannot be so explained, we see no +reason for changing our view that the benign stupor is to be regarded as +one of the manic-depressive reactions. + + +FOOTNOTES: + +[9] Papanicolaou, G. N., and Stockard, C. R., “Effect of Under-feeding +on Ovulation and the Œstrous Rhythm in Guinea-pigs.” _Proceedings of +the Society of Experimental Biology and Medicine_, Vol. XVII, No. 7, +Apr. 21, 1920. + +[10] As a matter of fact, if the views of Clark and MacCurdy[B] be +accepted, some reason for these epileptic-like attacks may be imagined. +According to them, epilepsy is a disease characterized by a lack of the +natural instinctive interest in the environment which is expressed +chronically in the deterioration, and episodically in the attacks, the +most consistent feature of which is loss of consciousness. Now, in +stupor we have an analogous reaction where, although consciousness is +not disturbed in the sense in which it is in epilepsy, it is +nevertheless considerably affected, inasmuch as contact with the +environment is practically non-existent. The coincident thinking +disorder is quite similar, both in epileptic dementia and the torpor +following seizures and in these benign stupors. MacCurdy has suggested +tentatively that the epileptic convulsion may be secondary to a very +sudden loss of consciousness which removes a normal inhibition on the +muscles, liberating the muscular contractions which constitute the +convulsion. If this view were correct, it would not be hard to imagine +that during the onset of these stupors the tendency to part company with +the environment, which ordinarily comes on slowly, might occur with +epileptic suddenness and hence liberate convulsive movements. This is, +however, a pure speculation but not fruitless if it serves to draw +attention to the analogies existing between the stupor reaction and some +of the mental symptoms of epilepsy. These analogies are strong; aside +from the obvious clinical differences, the stupor and epileptic +reactions are dynamically unlike in that they are the product of +different temperaments and precipitated by different situations. + + +FOOTNOTES: + +[B] Clark, L. Pierce. “Is Essential Epilepsy a Life Reaction Disorder?” +_Am. Jour. of the Medical Sciences_, November, 1910, Vol. CLVIII, No. 5, +p. 703. This paper gives a summary of Dr. Clark’s theories. + +MacCurdy, John T., “A Clinical Study of Epileptic Deterioration.” +_Psychiatric Bulletin_, April, 1916. + + + + +CHAPTER X + +PSYCHOLOGICAL EXPLANATION OF THE STUPOR REACTION + + +In the previous chapter mention has been made of our view that +manic-depressive insanity is a disease fundamentally based on some +constitutional defect, presumably physical, but that its symptoms are +determined by psychological mechanisms. In accordance with this +hypothesis we seek, when studying the different forms of insanity +presented in this group, to differentiate between the different types of +mental mechanisms observed, and by this analysis to account for the +manifestations of the disease on purely psychological lines. If benign +stupors belong to this group, then we should be able to find some +specific psychology for this type of reaction. + +All speech and all conduct, except simple reflex behavior, are +presumably determined by ideas. When an individual is not aware of the +purpose governing his action, we assume, in psychological study, that an +unconscious motive is present, so that in either case the first step in +psychological understanding of any normal or abnormal condition is to +discover, if possible, what the ideas are that lead to the actions or +utterances observed. In the case of stupors the situation is fairly +simple, in that the ideational content is extremely limited. As has been +seen, it is confined to death and rebirth fancies, other ideas being +correlated with secondary symptoms, such as belong to mechanisms of +other manic-depressive psychoses. It is not necessary to repeat the +catalogue of the typical stupor ideas, as they have been given in an +earlier chapter. Our task is now to consider the significance of these +death and rebirth delusions and their meaning for the stupor reaction. + +Thoughts concerned with future and new activities require energy for +their completion in action and are therefore naturally accompanied by a +sense of effort which gives pleasure to an active mind. When the sum of +energy is reduced, one observes a reverse tendency called “regression.” +It is easier to go back over the way we know than to go forward, so the +weakened individual tends to direct his attention to earlier actions or +situations. To meet a new experience one must think logically and keep +his attention on things as they are, rather than imagine things as one +would like to have them. + +Progressive thinking is therefore adaptive, while regressive thinking is +fantastic in type, as well as concerned with the past--a past which in +fancy takes on the luster of the Golden Age. Sanity and insanity are, +roughly speaking, states where progressive or regressive thinking rule. +The essence of a functional psychosis is a flight from reality to a +retreat of easeful unreality. + +Carried to the extreme, regression leads one in type of thinking and in +ideas back to childhood and earliest infancy. The final goal is a state +of mental vacuity such as probably characterizes the infant at the time +of birth and during the first days of extra-uterine life. In this state +what interest there is, is directed entirely to the physical comfort of +the individual himself, and contact with the environment is so +undeveloped that efforts to obtain from it the primitive wants of warmth +and nutrition are confined to vague instinctive cries. Evolution to true +contact with the world around implies effort, the exercise of +self-control, and also self-sacrifice, since the child soon learns that +some kind of _quid pro quo_ must be given. Viewed from the adult +standpoint, the emptiness of this early mental state must seem like the +Nirvana of death. At least death is the only simple term we can use to +represent such a complete loss of our habitual mental functions. When +life is difficult, we naturally tend to seek death. Were it not for the +powerful instinct of self-preservation, suicide would probably be the +universal mode of solving our problems. As it is, we reach a compromise, +such as that of sleep, in which contact with reality is temporarily +abandoned. In so far as sleep is psychologically determined, it is a +regressive phenomenon. It is interesting that the most frequent +euphemism or metaphor for death is sleep. Sleep is a normal regression. +It does not always give the unstable individual sufficient relaxation +from the demands of adaptation and so pathological regressions take +place, one of which we believe stupor to be. It is important to note +that objectively the resemblance between sleep and stupor is striking. +So far as mental activity in either state can be discovered by the +observer, either the sleeper or the patient in stupor might be dead. +Briefly stated, then, our hypothesis of the psychological determination +of stupor is that the abnormal individual turns to it as a release from +mental anguish, just as the normal human being seeks relief in his bed +from physical and mental fatigue. When this desire for refuge takes the +shape of a formulated idea, there are delusions of death. + +The problem of sleep is, of course, bound up with the physiology of +rest, and as recuperation, in a physical sense, necessitates temporary +cessation of function, so in the mental sphere we see that relaxation is +necessary if our mental operations are to be carried on with continued +success. This is probably the teleological meaning of sleep in its +psychological aspects, for in it we abandon diurnal adaptive thinking +and retire to a world of fancy, very often solving our problems by +“sleeping over them.” The innate desire for rest and a fresh start is +almost as fundamental a human craving as is the tendency to seek release +in death. In fact the two are closely associated both in literature and +in daily speech, for in many phases we correlate death with new life. If +one is to visualize or incorporate the conception of new life in one +term, rebirth is the only one which will do it, just as death is the +only word which epitomizes the idea of complete cessation of effort. +Not unnaturally, therefore, we find in the mythology of our race, in our +dreams and in the speech of our insane patients, a frequent correlation +of these two ideas, whether it comes in the crude imagery of physical +rebirth or projected in fantasies of destruction and rebuilding of the +world. Many of our psychotic patients achieve in fancy that for which +the Persian poet yearned: + + “Ah Love! could you and I with Him conspire + To grasp this Sorry Scheme of Things entire, + Would we not shatter it to bits--and then + Re-mold it nearer to the Heart’s Desire!” + +A vision of a new world is a content occurring not infrequently in manic +states, but before the universe can be remolded it must be destroyed. +Before the individual can enjoy new life, a new birth, he must die, and +stupor often marks this death phase of a dominant rebirth fantasy. In +this connection it was not without significance to note that stupors +almost universally recover by way of attenuation of the stupor symptoms, +or in a hypomanic phase where there seems to be an abnormal supply of +energy. Antæus-like, they rise with fresh vigor from the Earth. They do +not pass into depressions or anxieties. + +Rebirth fancies unquestionably, then, contain constructive and +progressive elements, but, as has been stated above, any thinking which +implies a lapse of contact with the environment is, in so far as that +lapse is concerned, regressive, and in consequence rebirth fancies, as +dramatized by the stupor patients, are regressive, just as are the +delusions of death itself. + +It is obvious that an acceptance of death implies rather thorough mental +disintegration. Before that takes place there may be some mental +conflict. The instinct of self-preservation may prevent the individual +from welcoming the notion of dissolution, so that this latter idea, +though insistent, is not accepted but reacted to with anxiety; hence we +often meet with onsets of stupor characterized by emotional distress. It +has already been suggested that death may foreshadow another existence. +Often in the psychoses we meet with the idea of eternal union in death +with some loved one whom the vicissitudes and restrictions of this life +prevent from becoming an earthly partner. This fancy is frequently the +basis of elation. Similarly, new life in a religious sense as expressed +in the delusion of translation to Heaven, is a common occasion for +ecstasy. These formulations of the death idea may occur as tentative +solutions of the patient’s problems leading to temporary manic episodes +while the psychosis is incubating. It seems that stupor as such appears +only when death and nullity are accepted. + +The above are more or less a priori reasons for regarding the stupor as +a regressive reaction. We must now consider the clinical evidence to +support this view. In the first place, we always find that stupor occurs +in an individual who is unhappy and who has found no other solution +than regression for the predicament in which he is. There is nothing +specific in the cause of this unhappiness. At times the factors +producing it are mainly environmental; at others, the problem is +essentially of the patient’s own making. Of course almost any type of +functional psychosis may emerge from such a state of dissatisfaction, +but it is important to note that unlike manic states, for instance, +stupors invariably develop from a situation of unhappiness. Quite +frequently the choice of the stupor regression is determined by some +definitely environmental event which suggests death. This often comes as +the actual death of the patient’s father (in the case of a woman) or +employer, events which inflate the already existing, although perhaps +unconscious, desire for mutual death. Again, the precipitating factor +may be a situation which adds still another problem and makes the burden +of adaptation intolerable, forcing on him the desire for death. In these +cases the actual psychosis is sometimes ushered in dramatically with a +vision of some dead person (often a woman’s father) who beckons, or +there are dream-like experiences of burial, drowning, and so on. + +A few cases taken at random from our material exemplify these features +of the unhappiness in which the psychosis appears as a solution with its +development of the death fancy. + +Alice R., at the age of 25, was much troubled by worrying over her +financial difficulties and the shame of an illegitimate child. +Retrospectively she stated, “I was so disgusted I went to bed--I just +gave up hope.” Shortly before admission she said she was lost and +damned, and to the nurse in the Observation Pavilion she pleaded, “Don’t +let me murder myself and the baby.” + +Caroline DeS. (Case 2) for some time was worried over the engagement of +her favorite brother to a Protestant (herself a Catholic) and the +threatened change of his religion. At his engagement dinner she had a +sudden excitement, crying out, “I hate her--I love you--papa, don’t kill +me.” This excitement lasted for three weeks, during two of which she was +observed, when she spoke frequently of being killed and going to Heaven. +The conflict was frankly stated in the words, “I love my father but +don’t want to die.” Then for two weeks she had some fever, was tube-fed, +muttered about being killed or showed some elation, there being +apparently interrupted stuporous, manic and, possibly, anxiety episodes. +Finally she settled down to a year of deep stupor. + +Laura A. had for three months poor sleep with depression over her +failure in study. Another cause for worry was that her father was home +and out of work. She reached a point where she did not care what +happened but continued working. Ten days before admission she was not +feeling well. The next morning she woke up confused and frightened, +speedily became dazed, stunned, could not bring anything to her memory. +This rather sudden stupor onset was not accompanied by any false ideas, +at least none which the family remembered. + +Mary C. (Case 7) was an immigrant who felt lonely in the new country. +Two weeks before admission her uncle with whom she was living died. She +thought she had brought bad luck, complained of weakness and dizziness, +then suddenly felt mixed up, her “memory got bad,” and she thought she +was going to die. Next she was frightened, heard voices, thought there +was shooting and a fire. For a short time she was inactive and later +began shouting “Fire!” When taken to the Observation Pavilion, she was +dazed, uneasy, thought she was on a boat or shut up in a boat which had +gone down; all were drowned. Then came a mild stupor. + +Maggie H. (Case 14), while pregnant, fancied that her baby would be +deformed and that she would die in childbirth. Three weeks before +admission this event took place. For five days she worried about not +having enough milk, about her husband losing his job (he did lose it) +and thought her head was getting queer. On the fifth day she cried, said +she was going to die, that there was poison in the food, that her +husband was untrue to her. She became mute but continued to attend to +her baby. She saw dead bodies lying around, and by the time she was +taken to the Observation Pavilion was in a marked stupor. + +Turning now to the symptoms of the stupor proper, we note, first, the +effects of the loss of energy which regression implies. The inactivity +and apathy which these patients show is too obviously evidence of this +to require further comment. Another proof of the withdrawal of the +libido or interest is found in the thinking disorder. Directed, accurate +thinking requires effort, as we all know from the experience of our +laborious mistakes when fatigued. So in stupor there is an inability to +perform simple arithmetical problems, poor orientation is observed, and +so on. Similarly what we remember seems to be that which we associate +with the impressions received by an active consciousness. Actual events +persist in memory better than those of fancy, in proof of which one +thinks at once of the vanishing of dreams on waking, with its +reëstablishment of extroverted consciousness. This registration of +impressions requires interest and active attention. Without interest +there is no attention and no registration. The patient in stupor +presents just the memory defect which we would expect. Indifference to +his environment leads to a poor memory of external events, while on +recovery there may be such a divorce between consciousness of normal and +abnormal states that the past delusions are wiped from the record of +conscious memory. Withdrawal of energy then produces not only inactivity +and apathy but grave defects in intellectual capacity. + +The natural flow of interest in regression is to earlier types of +ambition and activity. This is betrayed not merely by the thought +content dealing with the youth and childhood of the patient, but also is +manifested in behavior. Excluding involution melancholia there is +probably no psychosis in which the patients exhibit such infantile +reactions as in stupor. Except for the stature and obvious age of these +patients, one could easily imagine that he was dealing with a spoiled +and fractious infant. One thinks at once of the negativism which is so +like that of a perverse child and of the unconventional, personal habits +to which these patients cling so stubbornly. Masturbation, for instance, +is quite frequent, while willful wetting and soiling is still more +common. We sometimes meet with childishness, both in vocabulary and mode +of expression. In one case there was evidently a delusion of a return to +actual childhood, for she kept insisting that she was “in papa’s house.” + +The frequency with which the delusion of mutual death occurs in stupor +is another evidence of its regressive psychology. The partner in the +spiritual marriage is rarely, if ever, the natural object of adult +affection, but rather a parent or other relative to whose memory the +patient has unconsciously clung for many years, reawakening in the +psychosis an ambition of childhood for an exclusive possession that +reaches its fulfillment in this delusion. Closely allied with this is +another delusion, that of being actually dead, which the patients +sometimes express in action, even when not in words. The anesthesia to +pin pricks, the immobility and the refusal to recognize the existence of +the world around, in patients who give evidence of some intellectual +operations still persisting, are probably all part of a feigned death, +with the delusion expressing itself in corpse-like behavior. + +Finally we must consider the meaning of the deep stupor where no +mentation of any kind can be proven and where none but vegetative +functions seem to be operating. This state is either one of organic +coma, in which case it marks the appearance of a physical factor not +evidenced in the milder stages, or else it is the acme of this +regression by withdrawal of interest. As has been stated, back of the +period of primitive childish ideas there lies a hypothetical state of +mental nothingness. If we accept the principle of regression we find +historically an analogue to what is apparently the mental state of deep +stupor in the earliest phases of infancy. This view receives +justification from the study of the phenomenon of variations in +symptoms. Mental faculties at birth are larval, and if such condition be +artificially produced mental activity must be potentially present (as it +would not be if we were dealing with coma). In Chapter IV phenomena of +interruption of stupor symptoms were detailed. One case that was +mentioned is now of particular importance as demonstrating that an +appropriate stimulus may dispel the vacuity of complete stupor by +raising mental functions to a point where delusions are entertained. +This patient retrospectively recalled only certain periods of her +deepest stupor, occasions when she was visited by her mother. At these +times, as she claimed, she thought she was to be electrocuted and told +her mother so, adding, “Then it would drop out of my mind again.” +Otherwise her memory for this state was a complete blank. Here we see a +normal stimulus producing not normality but something on the way towards +it, that is, a condition less profound than the state out of which the +patient was temporarily lifted. + +This case exemplifies the principle of levels in the stupor reaction +which we have found to be of great value in our study. These levels are +correlated with degrees of regression, as a review of the symptoms +discussed above may show. In the first place, the dissatisfaction with +life, the first phase of regression, leads to the quietness--the +inactivity and apathy, which are the most fundamental symptoms of the +stupor reaction as a whole. Initiative is lost and with this comes a +tendency for the acceptance of other people’s ideas. That is the +probable basis for the suggestiveness which we concluded was a prominent +factor in catalepsy. Indifference and stolidity may exist with those +milder degrees of regression which do not conflict with one’s critical +sense, and hence may be present without any false ideas. The next stage +in regression is that where the idea of death appears. Although not +accepted placidly by the subject, its non-acceptance is demonstrated by +the idea being projected--by its appearance as a belief that the patient +will be killed. This notion of death coming from without has again two +phases, one with anxiety where normality is so far retained that the +patient’s instinct of self-preservation produces fear, and a second +phase where this instinct lapses and the patient so far accepts the +idea of being killed as to speak of it with indifference. The next step +in regression is marked by the spoiled-child conduct, interest being so +self-centered as to lead to autoerotic habits and the perverse reactions +which we call negativism. When death is accepted but mental function has +not ceased, the latter is confined to a dramatization of death in +physical symptoms or to such speech and movements as indicate a belief +that the patient is dead, under the water, or in some such unreal +situation. Finally, when all evidence of mentation in any form is +lacking, we see clinically the condition which we know as deep stupor +and which we must regard psychologically as the profoundest regression +known to psychopathology, a condition almost as close to physiological +unconsciousness as that of the epileptic. + +Naturally we do not see individual cases in which all these stages +appear successively, each sharply defined from its predecessor. To +expect this would be as reasonable as to look for a man whose behavior +was determined wholly by his most recent experience. Any psychologist +knows that every human being behaves in accordance with influences whose +history is recent or represents the habit of a lifetime. At any given +minute our behavior is not simply determined by the immediate situation, +but is the product of many stages in our development. Quite similarly we +should not expect in the psychoses to find evidences of regression to a +given period of the individual’s life appearing exclusively, but rather +we should look for reactions at any given time being determined +preponderantly by the type of mentation characteristic for a given stage +of his development. As a matter of fact, we see in psychoses, +particularly in stupor, more sharply defined regressions to different +levels than we ever see in normal life. + +Our psychological hypothesis would be incomplete and probably unsound if +it could not offer as valid explanations for the atypical features in +our stupor reactions as for the typical. The unusual features which one +meets in the benign stupors are ideas or mood reactions occurring +apparently as interruptions to the settled quietude or in more +protracted mild mood reactions, such as vague distress, depression or +incomplete manic symptoms, which have been described in the chapter on +affect. The interruptions are easily explained by the theory of +regression. If stupor represents a complete return to the state of +nothingness, then the descent to the Nirvana or the re-ascent from it +should be characterized by the type of thinking with the appropriate +mood which belongs to less primitive stages of development. A review of +our material seems to indicate that there is a definite relationship +between the type of onset and the character of the succeeding stupor. +For instance, in the cases so far quoted in this book, the onsets +characterized by mere worry and unhappiness and gradual withdrawal of +interest had all of them typical clinical pictures. On the other hand, +of those who began with reactions of definite excitement, anxiety or +psychotic depression, there were interruptions which looked like +miniature manic-depressive psychoses in all but one case. This would +lead one to think that these patients retraced their steps on recovery +or with every lifting of the stupor process, moved slightly upward on +the same path on which they had traveled in the first regression. The +case of Charlotte W. (Case 12), which is fully discussed in the chapter +on Ideational Content, offers excellent examples of these principles. + +The next atypical feature is the phenomenon of reduction or dissociation +of affect, the frequency of which is mentioned in Chapter V. As the law +of stupor is apathy, normal emotions should be reduced to indifference +and no abnormal moods, such as elation, anxiety or depression, should +occur. What often happens is that these psychotic affects appear but +incompletely, often in dissociated manifestations. This looks like a +combination of two psychotic tendencies, the stupor reduction process +which inhibits emotional response and the tendency to develop abnormal +affects which characterize other manic-depressive psychoses. There is no +general psychological law which makes this view unlikely. One cannot be +anxious and happy at the same instant, although one can alternate in his +feelings; but one can fail to react adequately to a given stimulus when +inhibited by general indifference. In fact it is because apathy is, +properly speaking, not a mood but an absence of it, that it can be +combined with a true affect. It is possible, therefore, to have a +combination of stupor and another manic-depressive reaction, while the +others cannot combine but only alternate.[11] + +Finally we must discuss the psychological meaning of cases, such as +those described in Chapter VIII, where we concluded that there were +psychoses resembling stupors superficially. It seemed likely that these +patients were absorbed in their own thoughts, rather than being in a +condition of mental vacuity. It is not difficult to explain the +objective resemblance. All evidence of emotion (apart from subjective +feeling tone which the subject may or may not report) is an expression +of contact with the outer world. There must be externalization of +attention to environment before a mood becomes evident. A moment’s +reflection will show this to be true, for no further proof is needed +than the phenomena of dreaming. The attention being given wholly to +fantasies, the subject lies motionless, mute and placid, although +passing through varied autistic experiences. Only when the dream becomes +too vivid, disturbs sleep and re-directs attention to the +environment--only then is emotion objectively betrayed. There is an +appearance of apathy and mental vacuity which the dreamer can soon +declare to be false. He was feeling and thinking intensely. In any +condition, therefore, such as that of perplexity or of an absorbed manic +state, the patient may be objectively in the same condition as a typical +stupor. The histories of the two psychoses differentiate the two +reactions which may be indistinguishable at one interview. The keynote +of one reaction is _indifference_, while that of absorption is +_distraction_, a perversion of attention to an inner, unreal world. + +In summary we may recapitulate our hypotheses. Stupor represents, +psychologically speaking, the simplest and completest regression. +Adaptation to the actual environment being abandoned, attention reverts +to earlier interests, giving symptoms of other manic-depressive +reactions in the onset or interruptions, and finally dwindles to +complete indifference. The disappearance of affective impulse leads to +objective apathy and inactivity, while the intellectual functions fail +for lack of emotional power to keep them going. The complicated mental +machine lies idle for lack of steam or electricity. The typical +ideational content and many of the symptoms of stupor are to be +explained as expressions of death, for a regression to a Nirvana-like +state can be most easily formulated in such a delusion. Other clinical +conditions may temporarily and superficially resemble stupor on account +of the attention being misdirected and applied to unproductive +imaginations. To employ our metaphor again, in these false stupors the +current is switched to another, invisible machine but not cut off as in +true stupor. + + +FOOTNOTES: + +[11] The reader will note that this view is opposed to that of +Kraepelin, who has written largely on so-called “_mixed conditions_” in +manic-depressive insanity. We believe that careful clinical studies +confirm our opinion and that his classification is based on less +thorough observation and analysis. This subject will be discussed at +greater length in a forthcoming book on “The Psychology of Morbid and +Normal Emotions,” by Dr. MacCurdy. + + + + +CHAPTER XI + +MALIGNANT STUPORS + + +As we have seen, the benign stupors are characterized by apathy, +inactivity, mutism, a thinking disorder, catalepsy and negativism. All +these symptoms are also found in the stupors occurring in dementia +præcox. In fact this symptom complex has usually been regarded as +occurring only in a malignant setting. There can be no question about +the resemblance of benign to dementia præcox stupors. Even such symptoms +as poverty and dissociation of affect, usually regarded as pathognomonic +of dementia præcox, have been described in the foregoing chapters. +Either recovery in our cases was accidental or there is a distinct +clinical group with a good prognosis. If the latter be true, the +symptoms must follow definite laws; if they did not, we would have to +abandon our principles of psychiatric classification. Naturally, then, +we seek to find the differences between the cases that recover and those +that do not. There is never any difficulty in diagnosis where a stupor +appears as an incident in the course of a recognized case of catatonic +dementia præcox. We shall therefore consider only such clinical pictures +as resemble those described in this book, in that the symptoms on +admission to a hospital or shortly after are those of stupor. It should +be our ambition to make a positive diagnosis before failure to recover +in a reasonable time leads to a conclusion of chronicity. + +It is probably safe to assume, on the basis of as large a series as +ours, that the symptoms of stupor _per se_ imply no bad prognosis. +Further, it has been noted that a relatively pure type of reaction is +seen, the symptoms appearing with tolerable consistency. In analyzing +the histories of dementia præcox patients, therefore, one looks for +inconsistencies among, or additions to, the stupor symptoms. We may say +at the outset that we have been able to find no case of malignant stupor +that showed what we regard as a typical benign stupor reaction, and it +is questionable whether partial stupor as we have described it, ever +occurs with a bad prognosis. Usually the discrepant symptoms in the +dementia præcox cases are sufficiently marked to enable one to make a +positive diagnosis quite soon after the case comes under observation. + +The law of benign stupor is a limitation of energy, emotion and +ideational content. In dementia præcox we have a re-direction of +attention and interest to primitive fantastic thoughts and a consequent +perversion of energy and emotion. In many malignant stupors one can +detect evidence of this second type of reaction in symptoms that are +anomalous for stupor. For instance, one meets with frequent silly and +inexplicable giggling. Then, too, smiling, tears or outbursts of rage, +the occasions for which are not manifest, are much more frequent than in +typical stupor. Similarly, delusional ideas (not concerned with death at +all) may appear or the patient may indulge in speech that is quite +scattered, not merely fragmentary. Two cases may be cited briefly to +illustrate these dementia præcox symptoms superadded to those of stupor. + + + CASE 20.--_Winifred O’M._ Age: 19. Single. Admitted to the + Psychiatric Institute May 6, 1911. + + _F. H._ The occurrence of other nervous or mental disease + in the family was denied. + + _P. H._ The patient seems to have been rather shy and + goody-goody in disposition. According to her mother this + seclusiveness did not begin to be markedly noticeable until + the winter before her psychosis, when there was some + trouble about getting work. She had previously been to a + business school. Then she held a position as stenographer + temporarily. When this job was over she had a number of + positions that did not last long and was once idle for two + months. In February (three months before admission) her + father was out of work, which added to her worry. + + _Onset of Psychosis:_ Nine days before admission a young + man died in the house where they lived. The next day her + mother insisted on the patient and her sister going to the + funeral. On coming home the patient complained of being + afraid and having a funny feeling. She woke up at 2:30 that + night and lit all the gas, for which she could give no + explanation. The day following, or a week before admission, + she was slow, confused, could not get her clothes together. + The next day she was restless and worried, giving a + superficial explanation for the latter. She played the + piano a great deal. The following day she was fidgety and + cried. At 4 p.m. she was put to bed and appeared to fall + asleep. At midnight when a priest called she said to him + privately that she was all over the world, that she went to + the 12th floor of the Metropolitan Building, that she sat + down and took the man’s money, $7, and came right away. She + recognized the priest. Three days before admission she + wanted to stay in bed, kept her eyes closed. When spoken to + she would smile but did not open her eyes. She did not pass + her urine all day. Her mother then gave her some medicine + which the doctor had left. The patient immediately had a + peculiar attack in which she heaved her breast, drew her + head back, clenched her fists and worked her feet. Saliva + escaped from the side of her mouth. This attack lasted some + three to five minutes. + + Her mother then called an ambulance and she was taken to + the _Observation Pavilion_. She thought that the ambulance + doctor was an uncle, a soldier in the Philippines, of whom + she was very fond. There she remained in bed, with all her + muscles relaxed, her mouth constantly open, saying nothing + and indeed resisting efforts which were made to get her to + open her eyes. + + _Under Observation:_ She sat or lay down with her eyes + closed and usually limp, although occasionally resistive. + There was practically no reaction to pin pricks. Sometimes + she opened her mouth as if to speak but rarely did so + except in a very low tone and after repeated questioning. + Her answers were rarely relevant. To the usual orientation + questions she gave no answers that would indicate that she + knew where she was. Sometimes she said “Jimmy” when asked + her name, and replied to another question, “Jimmy big smile + on.” Once she said, “I don’t know myself--what I am talking + for--what I am doing.” In general her speech seemed to + indicate that her thought was directed entirely inward and + that she paid no attention whatever to the questions. In + most benign cases such a condition is accompanied by + perplexity or a dreamy, dazed expression. This the patient + had not. On the other hand, she was sometimes definitely + scattered. For example, when asked, How do you feel? she + replied, “Large all name.” Again to the command, Tell me + your trouble, her answer was, “I couldn’t tell my mother + last night and I can’t tell her this night and I can’t tell + my _proud_.” She referred in a fragmentary way to being + crazy and to having been dead. She admitted hearing voices + but may not have understood the question. + + A week after admission, when visited by her mother, the + latter asked her to kiss her. The patient opened her mouth + widely and put out her tongue. This is a type of response + which we have never seen in our benign cases. + + Two days later repeated questioning made it evident that + the patient knew more about her environment than would be + expected, judging from her other symptoms. She gave the + month correctly knew that she was in a hospital and told of + having recently been visited by her father. At the same + interview she spoke of masturbation, of wanting to marry + her uncle, and of having been in bed with her father. The + last she referred to as a “fall.” Such frank incest ideas + are never found in benign psychosis in our experience. + Other dementia præcox ideas appeared quite soon, for within + three days, when she was talking slightly more freely, she + spoke of having often imagined she was having sexual + experiences as a result of the influence of a man who lived + upstairs, and that even when sitting with her family at the + table she felt sexual sensations. + + Her condition then remained essentially the same for some + time. Then about six weeks after admission she became + somewhat less resistive, was frequently seen sitting up in + bed, moving her lips considerably (without speech) and + regarding the surroundings with a bright interested + expression and occasionally smiles. About this time she + began exposing herself and chewing her finger nails. + + Four months after admission she was noted as being very + resistive and negativistic, allowing saliva to accumulate + in her mouth and making no attempt to keep the flies off + her. At the same time she would keep in her mouth food that + had been put there without chewing it. + + Two months later she seemed to laugh occasionally when + other patients did so, but at the same time she showed a + cataleptic tendency and was quite mute. + + Six months after admission she began to feed herself but + rather sloppily. When one would speak to her, she would + occasionally smile, but if shaken she would weep silently. + About this time she began to do a little work in the ward, + pushing a floor polisher. + + For the next couple of months her condition was about the + same. She would stand around the ward, doing a little work + if urged, might even dance if forced to. She was + consistently mute. She was dirty but often decorated + herself. Rarely she was assaultive. + + Then ten months after admission she one day suddenly + became talkative, distractible and emotional, laughing and + crying. There was with this, however, no open elation. Her + talk was obscene, at times flighty, at times definitely + scattered. All her habits were filthy. + + This pseudomanic episode lasted for a couple of months, and + then she settled down to a fairly consistent deterioration + with indifference, silly laughter, occasional + assaultiveness, destructiveness and untidiness. + + Nearly two years after admission she had another period of + excitement lasting about a couple of months. Shortly after + this she began to fail physically, and in November, 1913, + two years and five months after her admission, she died of + pulmonary tuberculosis. + +In summary, then, we see that this patient exhibited symptoms of +dementia præcox from the outset of her stupor, with scattering, genital +sensations and incest ideas. The stupor symptoms gradually gave way to +the typical indifference, negativism, obscenity, filthiness and +inexplicable conduct of dementia præcox. At the beginning, however, the +condition was superficially similar to that of a benign stupor, it being +only on careful observation that other symptoms were noted. + + + CASE 21.--_Rose S._ Age: 23. Admitted to the Psychiatric + Institute April 5, 1905. + + _F. H._ The mother was living, the father dead. Otherwise + no pertinent information was secured. + + _P. H._ The patient was said always to have been somewhat + seclusive, mingling little with other people; this tendency + was so strong that she would leave the room when visitors + came. She always slept a great deal. It was stated that she + was able to do heavy housework quite well, but never + learned cooking. + + At 16 she hired out as a servant for a year and a half, and + then did laundry work. When 18 she had an illegitimate + child by a co-worker. + + _History of Psychosis:_ About a year before admission the + patient’s sister was burned to death. When the patient + heard of this she said that something had come up in her + throat. Henceforth she often complained of a lump in her + throat, and often bit her nails. Two months before + admission she suddenly left the laundry, again spoke of the + lump in her throat, and claimed to have seen the dead + sister. Two weeks later when the family had an anniversary + mass for the sister the patient appeared sad, but the + following day laughed, said she had seen her “sister + beckoning her to come.” She also thought she saw her + picture “and Heaven was behind it.” She also talked of + “dead relatives and friends.” A reaction of levity in + connection with a sister’s death is highly suggestive of a + malignant psychosis. + + Two weeks before admission her mother found her in a + stupor, immovable, with her eyes closed. In 24 hours she + woke up, began to sing “Rest for the Weary,” prayed, then + was stuporous again for six hours. When she came out of + this, she said she was “going to die,” God had told her so + and talked of her own funeral arrangements. She again went + into a stupor, in which she was sent to the Observation + Pavilion. + + At the _Observation Pavilion_ she was described as happy, + laughing, singing, saying she felt happy, but adding, “I + like to be sad too, I am going to Heaven Easter Sunday.” + She claimed that her sister frequently stood in front of + her, and that she knew she wanted her to go with her. + + _Under Observation:_ For about three weeks the patient + showed a variable stupor. She would lie with a mask-like + face inaccessible, cataleptic, drooling saliva, often with + her mouth open. When taken up, she was usually perfectly + flaccid, but once she let herself slide on the floor after + she had stood immobile at the window. Sometimes there was + marked resistance to passive motions, especially when + attempts were made to open her mouth or eyes, or on one + occasion when the examiner tried to open her hand in which + she held her handkerchief. Yet when one persisted in urging + her to respond there frequently could be elicited more or + less marked reactions. Thus repeatedly she could be made to + obey some commands, as showing the tongue, etc., even when + she would not answer. Once when her eyes were opened, tears + rolled down her cheeks--again, she usually reacted to pin + pricks by slight flushing, once she said, “Stop! it + hurts.” Again, she said, “Leave me alone, I want to sleep.” + + So far the description of this reaction is that of a benign + stupor. There were, however, other symptoms. In the first + place, she could sometimes be made to open her eyes and + write, although she would not speak. In spite of the + penmanship being careless, there were no mistakes. This + exhibition of an unhabitual and more difficult intellectual + effort when the patient was mute is suggestive of an + inconsistency. So was her habit of sometimes singing a + hymn, “Rest for the Weary,” when no other sign of mental + life was given. But, more important than these, she could + not infrequently be induced to answer questions and at such + times she spoke promptly and with natural affective + response. + + A number of her replies were of the type to be expected in + a benign stupor. In the first place, she spoke of her + condition as “going off to sleep” and also as “death,” “I + was dead all day.” “I died three times yesterday,” or she + merely described it by saying “I go off into states when I + lie with my mouth open and eyes closed, and cannot speak or + open my eyes.” When asked how she got into this condition, + she said “My sister died and I think it was on my mind.” + Again she said she became sad at the anniversary mass of + the sister and had been sad ever since. On the other hand, + she also stated that when she came home from the mass she + first was silly and danced. Spontaneously she spoke of + having frequently had visions of her dead sister; once she + saw her with wings. In explanation of her singing “Rest for + the Weary,” she said it was the hymn sung at her father’s + funeral. An anomalous feature had to do with her + description of her feelings. She claimed to have no memory + of her stupor periods and yet said of them: “I feel + peaceful-like,” or “I feel awfully happy and sad together,” + or “I am sad and contented--I like it that way.” + + A striking symptom was that, when a sensory examination was + made during the first few days during one of the periods + when she responded well, she showed glove and stocking + anesthesia, also anesthesia of neck and left breast. + + But in addition to the above statements the patient also + began to make others of a definite dementia præcox type. + About ten days after admission she said, “What any one says + goes right through my brain,” or she talked of being + hypnotized. “The typewriting machine turned my eyes--three + or four girls turned my eyes--they look at me and get their + chance, their left eye--turning me into images. I want to + be the way I was born--turn my body! look how their bodies + are turned before they die,” or “Take it if you get it--he + got the name out--I was over there to death--himself to + death--of, you know--you played out--she is played out.” + ... This while she snickered between the sentences. As + early as four weeks after admission she had begun to giggle + or laugh, often in an empty fashion, and a transition from + the more constrained stuporous state, with interruptions of + laughter, to an indifferent silly, muttering to herself was + gradual. + + In 1909 she was described as not talking, standing around, + showing no interest in anything, muttering. The only + response obtained was “I don’t know.” In December, 1911, + she was transferred to another hospital as a case of + deteriorated dementia præcox. + +_To Recapitulate:_ We have here a young woman who for a year had +indefinite mental symptoms and suddenly developed a stupor. This was +atypical in that she sang and wrote when otherwise apparently deeply +stuporous. When persuaded to talk, her utterances, even as early as ten +days after admission, were of a malignant type and with such statements +she giggled. This last is apparently a highly important sign. Quite +frequently in our cases the first signal of a dementia præcox reaction +has been giggling in a setting of what was apparently a typical benign +stupor. + +As has frequently been stated, symptoms of benign stupor are closely +interrelated. Consequently the reaction is, when benign, a consistent +one. We do not find free speech with profound apathy and inactivity, +nor do we expect to meet with unimpaired intellectual functions when +other evidences of deep stupor are present. The inconsistency of mental +operations which characterize dementia præcox, however--the “splitting” +tendency which Bleuler has emphasized in his term “schizophrenia”--is +just that added factor which may produce disproportionate developments +of the various stupor symptoms in the dementia præcox type of that +reaction. Examples of this have been given in the two cases just quoted. +The history of the following patient shows this tendency more +prominently. + + + CASE 22.--_Nellie H._ Age: 20. Admitted to the Psychiatric + Institute June 11, 1907. + + _F. H._ The father had repeated depressions; he died of + typhus fever. The mother was living. + + _P. H._ The brother of the patient stated that she was like + other girls, and very good at school. At 16 she became + quieter, less energetic. She came to America at 17. After + arriving here she has seemed low spirited, cranky and + faultfinding. She often complained of indefinite stomach + trouble and headaches; when at home she often had a cloth + around her head. The informant recalled that she said, “I + wish I could get sick for a long time and get either cured + or die.” However, she worked. For one and a half years + prior to admission her “crankiness” is said to have become + much worse. She complained continually of being tired; + quarreled much with her mother; said she did not have + enough to eat. It is also stated that she was constantly + afraid of losing her job. + + _History of Psychosis:_ For six months before admission she + said frequently that her boss was giving her hints that he + liked her. (She did not know him socially at all.) Six days + before admission she came home, saying the boss had told + her he had no more work for her. Nevertheless, she went + back next day and was again sent home. At home she sat + gazing. Next day again wanted to go and see the boss, but + was prevented. At times she tried to get out of the window; + again sat gazing, repeating to herself “Always be true.” + She said she was in love with the boss. When the doctor + gave her medicine she thought it was poison. Finally she + began to be talkative and elated. At the _Observation + Pavilion_ she became very quiet. + + _Under Observation:_ She lay in bed indifferent, not + eating, unless spoon-fed, when she would swallow. She + soiled herself. She answered no questions as a rule, and + only on one occasion, when urged considerably, said in + answer to questions that this was a hospital, so that she + evidently had more grasp on the nature of her environment + than her behavior indicated. To her brother who called on + her during the first ten days she said she could not find + her lover here (an idea inconsistent with the benign stupor + picture). + + Then she became more markedly stuporous, drooling saliva, + very stiff, often lying with head half raised, gazing + stolidly, never answering, soiling. Later, after a month, + this was less consistent. She now and then went to the + closet, sometimes she smiled, ate some fruit brought to + her, spoke a little. Repeatedly when people came she clung + to them, wanted to go home, again was seen to weep + silently. On another occasion she suddenly threw the dishes + on the floor with an angry mood, without there being any + obvious provocation. Again she got quite angry when urged + to eat her breakfast, and on that occasion pulled out some + of her own hair. Usually she had to be fed, was stiff, + sitting with closed fists, not reacting as a rule in any + other way, wholly inaccessible and has been that way for + years. The stupor merged into a catatonic state merely by + the development of the inconsistency in her affective + reactions. + +We see then that inconsistencies among the stupor symptoms themselves +and the intrusion of definitely dementia præcox symptoms differentiate +the malignant from the benign reactions. As a matter of fact, we find, +as a rule, that careful examination of the onset reveals further +atypical features, suggestions or definite evidences of a dementia +præcox reaction before the stupor itself appears. One common occurrence +is a slow deterioration of character and energy that proceeds for months +or years before flagrantly psychotic symptoms appear. + +Then when delusions or hallucinations are eventually spoken of by the +patient, an appropriate or adequate reaction is lacking. In a benign +psychosis false ideas do not appear with an equable mood unless the +stupor reaction has already begun. + +More important than this, although in benign stupors there may be a +reduction or an insufficient affect, it is never inappropriate. This +pathognomonic symptom of dementia præcox frequently occurs in the onset +to malignant stupors. In fact we often find in reviewing such cases that +a plain dementia præcox reaction has been in evidence, that a diagnosis +has not been made simply because the stupor picture blotted out this +earlier psychosis before an opinion was formed. Frequently these early +symptoms are reported in the anamnesis and not actually observed by the +physician. + +Three cases may be cited as examples of dementia præcox onsets. It will +be noted that the ensuing stupors were, like those already quoted, +atypical. + + + CASE 23.--_Catherine H._ Age: 21. Admitted to the + Psychiatric Institute October 10, 1904. + + _F. H._ The mother’s brother had two attacks of delirium + tremens. The mother died when the patient was eleven years + old; she is said to have been normal. The father was + living. + + _P. H._ The patient was always a nervous child, had very + bad dreams, but she was smart at school up to ten or + eleven, and played with other girls. Then she began to work + less well, got thin, more nervous, complained of headaches. + It was about that time that her mother died. (The reaction + to the death was said not to have been different from that + of her sister.) She was kept at home and was quiet.... “You + could see something was working on her.” She began to + menstruate at 14, and it was claimed that she then wakened + up a little. It was further stated that she was always + “stuck up” about her clothes. + + At 16 she went to work in a factory, but her sister thought + the work was too much for her, so she was taken home. + Thereafter she lived alone with her father, doing his + housework, her sister having married about that time. At 17 + her hair began to come out excessively, so that she had to + cut it, and when it grew again it was gray. She became very + sensitive about this, even refused to take positions + because she thought people would remark about it. + + For two years before admission she evidently was different. + Although she did her father’s housework well enough, she + turned against her sister and refused to speak to her + because, she alleged, the sister had not come to help her + in her housework. Another pronounced manifestation during + that time was her frequent talk about her bowels. She + complained of constipation, creepy, crawling sensations in + the stomach which she thought was a “tapeworm.” She got + pamphlets and took patent medicines. She was taken to a + physician nine months before admission, who operated on her + for piles. While still in the hospital she asked her father + to take her home to die (although there was no reason for + such a request). Again she said the gauze had been left in + the rectum too long and that the rectum was full of wind. + Later she said the rectum was closing up. After this, the + sister stated, she was extremely nervous if she passed a + day without a movement of the bowels. She was quiet + henceforth, went out less and said little, claiming it was + better for her head if she said little. She often sat, head + in hand, in the hall. All through the summer she frequently + remarked, “I am a good girl.” Four months before admission + during a period of five weeks she would let her bowels move + when standing up. This was relieved by enemas. The father + states that she was cranky to him, that sometimes when he + merely asked a question she would say, “You hurt my + feelings,” and once, “You break my heart.” Occasionally she + seemed to worry about the money spent for her on doctors + and medicine. + + About two months before admission she said everybody was + looking at her. Ten days before admission she said, “I have + been sick all this time and thought I was going to die. Now + I think Tom (her brother) is going to die.” She became + fearful of being left alone. Finally she went to the + priest, who told her to go home. Then she prayed, leaving + the candles burning in the room. That night she was found + kneeling before a church in her nightgown. Again she threw + a lot of articles into the yard, saying a curse had been + put on her by her father, and she did not wish to give him + anything. When she was taken to the Observation Pavilion + she said, “I am a good girl--my mother is dead--it is all + my father’s fault.” + + At the _Observation Pavilion_ she put her arm under a hot + water faucet “to save the world,” prayed and laughed--again + sank back and appeared as if asleep. She said, “I hear + angels telling me how to pray when I lose my + thoughts--sisters and nuns are all around me here, to save + and purify the world now and forever, and at the hour of + our death.” + + _Under Observation:_ On admission the patient kept her eyes + closed, sang hymns in measured tones, or prayed, or showed + a certain ecstasy in her face while her lips quivered and + tears ran down her cheeks. On the whole, she answered few + questions. When asked how she felt, she said she was happy. + (Why do you cry?) “I was crying when I asked God to save + souls.” (Are you afraid?) “Not now, I have been afraid of + everything on Earth ever since my mother died.” (What do + you mean?) “No one would look at me or talk to me--they + said I was a bad girl, but I was pure.” Again she said, + “They laughed about me, talked about me--and they drew up a + play about me--Devil’s Island.” Or she spoke about having + had stomach trouble, bowel trouble, teeth trouble, eye + trouble, compound, complicated trouble. (What do you mean?) + “Father scolding all the time, he sent me to get bug + medicine (true). God gives that medicine to the one that + started all the trouble--Devil’s Island.” + + She soiled her bed and was asked why she did it. She said + “I have been transformed into a baby, the Lord said I was + too pure to be a woman--I had to become a baby to save the + world.” Or when asked her name she called herself “Baby + Chadwick of the whole world--divine Irish Catholic + World--Amen,” or again “I am the Roman Catholic Irish + Divine Baby.” + + Although she was not essentially disoriented she called the + place “mid-heaven,” or “a holy house, sort of a hospital.” + She also said, “In two years more there will be a new world + and it will be more happy and holy.” + + The day after entrance the patient, though in part as + described, had a spell when she kept her eyes closed and + was rigid. Spells like these returned. (About a month after + admission she became completely stuporous.) She prayed at + times, at other times was constrained, or kept her eyes + closed. Her orientation throughout was good. The content of + her psychosis, in addition to the praying attitude, had a + more or less vague religious coloring. Thus she called the + hospital the “House of God.” Again, when on one occasion + she had jumped at the window guard and was asked “why?” she + said “holy communion.” Again she said she was “Mary, Virgin + Mother.” But this religious trend was intermingled with + remarkable elements of another sort. Thus when in order to + study her knowledge of the events after admission, she was + asked what she had done when she was brought into the ward, + she said, “I went into the sanctuary where my bowels moved + and water passed from me.” (Why do you call it sanctuary?) + “Because Jesus did the same thing I did.” + + Possibly vague sexual allusions are also contained in the + following: She said one day to the doctor, “Everything went + wrong last night, good, pure, true and holy doctor, I led + you astray and you were dying last night, may the Almighty + God forgive me, I ought to have died, but I fought it out, + for, if I had died, my mother’s soul would not have been + saved in Heaven and from the flames of Hell.” Again, “I + will not look at you again, good, pure, holy doctor of the + world.” (Why?) “I am afraid I will lead you astray.” And + also: “I led James. Peter astray too.” It should be added + that she sometimes masturbated rather shamelessly. + + She said she heard her mother’s voice. (What did she say?) + “Something in the sky for me, angels call for me.” (What do + the angels say?) “The name of my good mother in Heaven.” + Again she said she had heard her mother the night she came + here. (What did she say?) “It was like a voice--feed the + calf--that means me, I suppose.” + + Then after a month the stupor became more continuous. She + lay totally inactive for the most part, had to be fed, + soiled herself, drooled saliva, was at times cataleptic, + often rigid. Her limbs became cyanotic. A few times tears + were seen. On other occasions she whispered “peace,” or + “peace for hazing,” or “pray--peace,” or “I like to be + good.” Usually no responses could be obtained. + + After some months she was at times seen laughing. This + gradually passed into a state of total disinterestedness + and inaccessibility. She could finally be made to polish + the floor in an automatic fashion, but never spoke, and + five years after admission she was transferred to another + hospital, where she died (eleven years after admission to + the ward of the Institute) without any change in her mental + condition having taken place. + + + CASE 24.--_Adele M._ Age: 22. Admitted to the Psychiatric + Institute November 11, 1904. + + _P. H._ The father stated that the patient was always + “cranky,” had outbursts of temper, even when a small child + and was quarrelsome; also said that she was “seclusive,” + had few friends, was averse to meeting people, never had a + beau. She was taken out of school at 14 because she was not + promoted on two successive occasions from the same class. + Then she was put to work, but she was usually discharged + for incompetency. + + _Onset of Psychosis:_ Three years before admission it was + noted that she laughed occasionally without cause. She was + idle. This laughing, and also crying, was sometimes more + frequent, again less noticeable. + + Six months before admission she began to say she wanted to + leave home, but made no move to do so. Then she began to + speak of bad odors, made some remarks about the neighbors + talking about her--saying she should kill herself; again + she said the family would be brought to death, or the + mother was falling to pieces, the father looked sick. She + also said her head was swelling and was getting thick. + Finally she wanted to hire a furnished room and kill + herself and asked if 75 cents which she had was enough to + do it with. + + Two weeks before admission she left home, wandered about + all night, was picked up by the Salvation Army, and + returned to her home. She said she wanted to die. + + At the _Observation Pavilion_ she stated that her mother + was falling to pieces and her father sick. She also said + she wanted to die. + + _Under Observation:_ The patient was at first petulant, + saying “I don’t want to stay here,” turning her face away + from the doctor, generally uninterested. Though it could be + established that she was quite oriented, often her answers + were “I don’t know,” or she did not answer. But she was + also seen crying at times, and she was apt to bite her + finger nails. She had to be tube-fed. Gradually these + tendencies increased so that she lay in her bed with head + covered, saying in a peevish tone, when spoken to, “Oh, let + me alone.” And for years she was mute, lying with her head + covered, tube-fed. When reëxamined in 1914 (ten years + later), she was found lying in bed with an empty smile. + There was paper stuffed in her ears. When approached, she + turned her head away and would not talk. + + + CASE 25.--_Catherine W._ Age: 42. Admitted to the + Psychiatric Institute November 11, 1904. + + _F. H._ The father died at 75, the mother at 44. Two + sisters died of tuberculosis. A brother wanted to marry but + was opposed by the father; he set fire to the house of the + girl and then drowned himself. + + _P. H._ The patient came to this country when 20, and + worked for some years as a servant. Then she married after + a short acquaintance. The husband, according to his own + statement, drank, and there was friction from the first. + She left him a few weeks after marriage, and a few months + later he went to Ireland; she also went some time later but + did not go to see him. Then they lived together again. They + had four children, but had had no intercourse for nine + years. + + _Development of Psychosis:_ Eight years before admission + the patient became nervous, slept badly, but got better. It + was claimed that for six years she had been quieter and + more sullen than before. Three years before admission the + patient had to take a place as janitress, since she needed + the money. From the first she had trouble with the tenants + and accused everybody of being in league against her. Some + six or eight weeks after she had taken the position, she + developed what was called typhoid fever, and some time + later the daughter came down with the same disease. After + the typhoid she was more antagonistic towards her husband, + accused him of infidelity, repeatedly locked him out of the + house, but continued to do her housework. About six months + after this illness she left her home, but returned in a + week. She had vague ideas thereafter that the priests were + saying things against the family, and she often quarreled + with the tenants. For a year she had done no work but sat + about. Ten days before admission she stopped eating. + + _Under Observation:_ The patient was mute, stolid, gazing + straight ahead, sometimes cataleptic. She had to be + tube-fed, was usually very resistive to any passive + motions; quite often she retained her urine, but she did + not hold her saliva. Yet there was some quick responses at + least in the beginning. At such times it was found that she + was oriented, but nothing could ever be obtained about her + feelings, etc., except that she once said, when asked + whether she was worried, that she “felt weak,” had “nothing + to worry about.” Occasionally she was seen to cry silently; + at times she would breathe faster when questioned, or + flush; once she took hold of the doctor’s hand when he + questioned her, and cried, but made no reply. On another + occasion she was affectionate to her son, kissed him, + although she paid no attention to her daughter who + accompanied the son. Later she said to the nurses, “He is + the best son that ever lived.” But more and more she became + disinterested, totally inaccessible, resistive, had to be + tube-fed. In this condition she remained for five and a + half years. At the end of that time she died of tubercular + pneumonia. + + + + +CHAPTER XII + +DIAGNOSIS OF STUPOR + + +In any functional psychosis an offhand diagnosis is dangerous. When one +deals with such a condition as stupor, however, the problem is exacting, +for, although “stupor” may be seen at a glance, what is seen is really +only a symptom or a few symptoms. “Stupor,” then, is more of a +descriptive than a diagnostic term. The real problem is to determine the +psychiatric group into which the case should be placed. This is a +difficult task, for the differential diagnosis rests on the observation +and utilization of minute and unobtrusive details. A correct +interpretation can be only reached by obtaining a complete history of +the onset and observing the behavior and speech of the patient for a +long period, usually of weeks, sometimes of months. With these +precautionary words in mind, it may be well to summarize briefly the +diagnostic problems in connection with benign stupor. + +In the first place one naturally considers the differentiation from +conditions of organic stupor or coma. Since psychotic stupors never +develop without some signs of mental abnormality, the history is usually +a sufficient basis for final judgment. In case no anamnesis is +obtainable the functional nature of the trouble may be recognized by the +absence of those physical signs which characterize the organic stupors. +One sees no violent changes in respiration, pulse or blood-pressure, +such as are present in the intoxication comas of diabetes or nephritis. +There is no characteristic odor to the breath, and the urine is +relatively normal. The unconsciousness of trauma or apoplexy is +accompanied by focal neurological signs. Even in aerial concussion (so +frequently seen in the war) where no one part of the brain is +demonstrably affected more than another, there are neurological +evidences of what one might call “physiological” unconsciousness. The +eyes roll independently, the pupils fail to react to light. On the other +hand, there are definite symptoms characteristic of the functional +state. Mental activity is evidenced by a muscular resistiveness or +retention of urine. Even in states of complete relaxation the eyes move +in unison, the pupils react to light, and almost universally the corneal +reflex is present. The patient appears in a deep sleep rather than +actually unconscious. + +The post-epileptic sleep may resemble a stupor strongly. But this +condition is temporary and the situation and appearance of the patient +betrays the fact that he has just had a convulsion. Rarely, protracted +stuporous states occur in epilepsy which closely resemble the conditions +described in this book. In fact it is probable the true stupors may +occur in epilepsy just as in dementia præcox or manic-depressive +insanity. + +There is usually little difficulty in the discrimination of hysterical +stupor. Occasionally it shows, superficially, a similarity to the +manic-depressive type. Fundamentally, there is a wide divergence between +the two processes, in that in the hysterical form a dissociation of +consciousness takes place, the patient living in a reminiscent, +imaginary or artificially suggested environment, while in a true stupor +there is a withdrawal of interest as a whole and a consequent diffuse +reduction of all mental processes. This difference is sooner or later +manifested by the appearance in the hysteric of conduct or speech +embodying definite and elaborated ideas. + +As has been stated fully in the last chapter (to which the reader is +referred), the stupor of dementia præcox is to be differentiated from +that of manic-depressive insanity by the inconsistency of the symptoms +in the former and the appearance of dementia præcox features during the +stupor, such as inappropriate affect, giggling, or scattering. Further, +the nature of the disorder is usually manifest before the onset of the +stupor as such. + +Sometimes very puzzling cases occur in more advanced years when it is +difficult to say whether one is dealing with involution melancholia or +stupor. Such patients show inactivity, considerable apathy and wetting +and soiling, and with these a whining hypochondria, negativism, and +often a rather mawkish sentimental death content without the dramatic +anxiety which usually characterizes the involution state. In these cases +the diagnosis is bound to be a matter of taste. In our opinion it is +probably better to regard these as clinically impure types. They may be +looked on as, fundamentally, involution melancholias (the course of the +disease is protracted, if not chronic) in whom the regressive process +characteristic of stupor is present as well as that of involution. + +Great difficulties are also met with in the manic-depressive group +proper. So often a stupor begins with the same indefinite kind of upset +as does another psychosis that the development may furnish no clew. Any +condition where there is inactivity, scanty verbal productivity and poor +intellectual performance resembles stupor. This triad of symptoms occurs +in retarded depressions, in absorbed manic states and in perplexities. +Negativism and catalepsy are never well developed except in stupor. So +if these symptoms be present the diagnosis is simplified. But they are +often absent from a typical stupor. Let us consider these three groups +separately. + +The most important difference between stupor and depression lies in the +affect. Although inactive and sometimes appearing dull the depressive +individual is not apathetic but is suffering acutely. He feels himself +wicked, paralyzed by hopelessness, and finds proof of his damnation in +the apparent change of the world to his eyes and in the slowness of his +mind. But he is acutely aware of these torments. The stupor patient, on +the other hand, does not care. He is neither sad nor happy nor anxious. +This contrast is revealed not only by the patients’ utterances but by +their expressions. The stuporous face is empty, that of the other lined +with melancholy. The intellectual defect, too, is different. In retarded +depression the patient is morbidly aware of difficulty and slowness, but +on urging often performs tests surprisingly well. In the stupor, +however, one is faced with an unquestionable defect, a sheer +intellectual incapacity. + +In Chapter VIII the differential diagnosis between perplexity and stupor +has already been touched upon. Here again the affect is a point of +contrast. The patient has not too little emotion but too much. The +feeling of intangible, puzzling ideas and of an insecure environment +causes the subject distress, of which complaint is made and which can be +witnessed in the furrowed brow and constrained expression. There is +also, as we have seen, a rich ideational content in these cases, if one +can get at it. The mind is not a blank, as in the stupor, or concerned +only with delusions of death. + +Finally, there are the absorbed manic states. These are the most +difficult, inasmuch as the patient is often so withdrawn and so +introverted that at any given interview there may be no objective +evidence of mood or ideas. Here the development of the psychosis is +often an aid to diagnosis. The patient passes through phases of +hypomania to great exultation, the flight becomes less intelligible, +with this the activity diminishes until finally expression in any form +disappears. If this sequence has not been observed, continued +observation tells the tale. The patient still has his ideas and may be +seen smiling contentedly over them (not vacuously as does the +schizophrenic) or he may break into some prank or begin to sing. Any +protracted familiarity with the case leads to a conviction that the +patient’s mind is not a blank, but that his attention is merely directed +exclusively inward. Then, too, when his ideas are discovered, it is +found that they are not exclusively occupied with the topic of death. + + + + +CHAPTER XIII + +TREATMENT OF STUPOR + + +In dealing with cases of benign stupor the first duty of physician and +nurse is naturally the physical hygiene of the patient. More is needed +to be done in the bodily care of these persons than for most of the +inmates of our hospitals for the insane. It is perhaps no exaggeration +to claim that a deeply stuporous patient needs as much attention as a +suckling babe. In the first place, the patient must be fed. It is +important for mental recovery that the individual in stupor should be +stimulated to effort as much as possible. Consequently there is an +economy of time in the long run in taking pains to get the patient to +feed himself in so far as that is possible. He should be led to the +table and assisted in handling his own spoon and cup. If this is not +practicable, he should then be spoon-fed, and if this in turn is found +to be out of the question, tube-feeding should be resorted to. But this +last should never be looked on as a permanent necessity, but only as a +method of maintaining the patient’s health until such time as he may be +capable of independent taking of nourishment. In exactly the same way it +is of prime importance to get the patient to attend to the natural +habits of excretion. He should be led to the toilet or to a chair +commode, and efforts to this end should be persistent, just as are those +of a good child’s nurse who has the ambition of making her charge +develop normal habits. Naturally those who retain urine and feces should +be watched to see that this retention does not last long enough to +menace health. The physical aspects of treatment are exhausted with +consideration for cleanliness. On account of the stupor patients’ +inactivity and frequent tendency to wetting and soiling, this is a +particularly important consideration. It goes without saying that the +perineal region should be kept scrupulously clean. If any infections are +to be avoided, eyes, nose and mouth should also be cleansed frequently. +A patient who is so indifferent as to keep the eyelids open for such a +long time that the sclera dry and ulcerate is also apt to let flies +settle and produce serious ophthalmic disease. + +Less obvious and more important are the measures undertaken for the +mental hygiene of the case. On account of the tendency present in so +many patients for sudden action while in the midst of an apparently deep +and permanent inactivity, it is necessary that these cases be not +isolated but remain under constant observation. This is particularly +true of those who have demonstrated impulsive suicidal explosions. + +Not only on the basis of the psychological theory of the stupor process, +but from the observed phenomena of recovery, we gather that mental +stimulation is of first importance if an amelioration of the condition +is to be attempted. If the stupor reaction be a regression, which is +essentially a withdrawal of interest and energy rather than a fixation +on a false object, then excitement is desirable and interest must be +reawakened. The withdrawal is temporary (inasmuch as the psychosis is +benign), but just as a normal person wakes more readily on a clear +sunshiny day than when it rains, so the more cheering the environment +the more rapid the recovery. + +Consequently, although trying to those in charge, persistent attention +should be given the patient. Feeding and hygienic measures probably have +considerable value in this work. As soon as it is at all possible the +patients should be got out of bed and dressed. When up, efforts should +be directed towards making them do something, even if it be something as +simple as pushing a floor polisher. On account of their lack of +enthusiasm the stupor cases are often omitted from the list of those +given occupation and amusement. Even if they go through the motions of +work or play with no sign of interest, such exercise should not be +allowed to lapse. Then, too, the environment should be changed when +practicable. A patient may improve on being moved to another building. + +Perhaps the most potent stimulus that we have observed is that of family +visits. In most manic-depressive psychoses visits of relations have a +bad effect. The patients become excited, treat the visitors rudely, +perhaps even assault them, and all their symptoms are aggravated. But +the stupor needs excitement, and an habitual emotional interest is more +apt to arouse him than an artificial one. In another point the situation +differs. As a rule manic-depressive patients have delusional ideas or +attitudes in connection with their nearest of kin, so that contact with +these stirs up the trouble. The stupor regression going beneath the +level of such attachments leaves family relationships relatively +undisturbed. Hence, while the visit of a husband is likely to produce +nothing but vituperation or blows from a manic wife, the stuporous woman +may greet him affectionately and regain thereby some contact with the +world. + +So many cases begin recovery in this manner that it cannot be mere +chance. One patient’s improvement, for instance, dated definitely from +the day a nurse persuaded her to write a letter home. It is striking, +too, how quickly a patient, while somewhat dull and slow, will brighten +up when allowed to return home. A similar improvement under these +circumstances is often seen in partially recovered cases of involution +melancholia, in whom a psychological regression similar to that of +stupor takes place. Such experiences make one wonder whether perhaps +these alone of all our insane patients would not recover more quickly at +home than in hospitals, provided nursing care could be given them. + +This is a mere suggestion. Before treatment can be rational the nature +of any disease process must be known, and we do not pretend to have done +more as yet than outline the probable mental pathology of the benign +stupors. The next step is to put theory into practice and experiment +widely with various means to see if by appropriate stimulation the +average duration of these psychoses cannot be reduced. It is largely +with the hope of inducing other psychiatrists to carry on such work that +this book is written. There is no other manic-depressive psychosis +which, theoretically, offers such hope of simple psychological measures +being of therapeutic value. + + + + +CHAPTER XIV + +SUMMARY OF THE STUPOR REACTION + + +Having discussed in detail the various symptoms and theoretic aspects of +the benign stupors, it may be well to have these observations and +speculations summarized. + +It being established that stupors occur as a temporary form of +insanity[12] psychiatry is faced at once with the problem of describing +these conditions accurately in order to ascertain their nosological +position. To this end we first examined typical cases of deep stupor and +found that the clinical picture is made up of the following symptoms: In +the foreground stands _poverty of affect_. The patients are almost +unbelievably apathetic, giving no evidence by speech or action of +interest in themselves or their environment, unmoved even by painful +stimuli. Their faces are wooden masks; their voices as colorless when +words are uttered. In some cases sudden mood reactions break through at +rare intervals. The second cardinal symptom is _inactivity_. As a rule +there is a complete cessation of both spontaneous and reactive movements +and speech. So profound may this inhibition be that swallowing and +blinking of the eyes are often absent. The trouble is not a paralysis, +however, for reflexes without psychic components are unaffected. +Possibly related to the inactivity is the preservation of artificial +positions which is called _catalepsy_, a fairly frequent phenomenon. A +tendency opposite to the inactivity is seen in _negativism_. This +perversity is present in all gradations from outbursts of anger with +blows and vituperation to sullen, or even emotionless, muscular +rigidity. This last occurs most often when the patient is approached but +may be seen when observations are made at a distance. Frequently +_wetting_ and _soiling_ are due to negativism, when the patient has been +led to the toilet but relaxes the sphincters so soon as he leaves it. A +constant feature is a _thinking disorder_. On recovery memory is largely +a blank even for striking experiences during the psychosis and, when +accessible during the stupor to any questioning, a failure of +intellectual functions is apparent. An _ideational content_ may be +gathered while the stupor is incubating, during interruptions, or from +the recollections of recovered patients. Its peculiarity is a +preoccupation with the theme of death, which is not merely a dominant +topic but, often, an exclusive interest. Probably to be related to this +is a tendency, present in some cases, to sudden suicidal impulses, that +are as apparently planless and unexpected as the conduct of many +catatonics. Finally the disease is prone to exhibit certain _physical_ +peculiarities. A low fever is common and so are skin and circulatory +anomalies. A loss of weight is the rule, and menstruation is almost +always suppressed. + +As to the frequency of stupor no figures are available, for the simple +reason that the diagnosis in large clinics has not been made with +sufficient accuracy to justify any statistics. Most of these cases are +usually called catatonia, depression, allied to manic-depressive +insanity or allied to dementia præcox. The majority of the stupors +reported in this book were in women, but this is merely the result of +chance, since it has been easier in the Psychiatric Institute to study +functional psychoses in the female division, while the male ward has +been reserved largely for organic psychoses. The majority of the +patients seem to be between 15 and 25 years of age, so that it is, +presumably, a reaction of youthful years. In our experience most cases +occur among the lower classes, which agrees with the opinion of Wilmanns +who found this tendency among prisoners. + +This gives a brief description of the deep stupor. But even our typical +cases did not present this picture during the entire psychosis. They +showed phases when, superficially viewed, they were not in stupor but +suffered from the above symptoms as tendencies rather than states. There +are also many psychoses where complete stupor is never developed. This +gives us our justification for speaking of the _stupor reaction_, which +consists of these symptoms (or most of them) no matter in how slight a +degree they may be present. The analogy to mania and hypomania is +compelling. The latter is merely a dilution of the former. Both are +forms of the manic reaction. We consequently regard stupor and partial +stupor as different degrees of the same psychotic process which we term +the stupor reaction. To understand it the symptoms should be separately +analyzed and then correlated. + +The most fundamental characteristic of the stupor symptoms is the change +in affect which can be summed up in one word--apathy. It is fundamental +because it seems as if the symptoms built around apathy constitute the +stupor reaction. The emotional poverty is evidenced by a lack of +feeling, loss of energy and an absence of the normal urge of living. +This is quite different from the emotional blocking of the retarded +depression, for in the latter the patient shows either by speech or +facial expression a definite suffering. The tendency to reduction of +affect produces two effects on such emotions as internal ideas or +environmental events may stimulate. Exhibitions of emotion are either +reduced or dissociated. For instance, anxiety is frequently diminished +to an expression of dazed bewilderment; or, isolated and partial +exhibitions of mood occur, as when laughter, tears or blushing are seen +as quite isolated symptoms. This latter--the dissociation of +affect--seems to occur only in stupor and dementia præcox. It should be +noted, however, that inappropriateness of affect is never observed in a +true benign stupor. A final peculiarity is the tendency to interruption +of the apathetic habit, when the patient may return to life, as it were, +for a few moments and then relapse. + +Closely related to the apathy, and probably merely an expression of it, +is the inactivity which is both muscular and mental. It exists in all +gradations from that of flaccidity of voluntary muscles, with relaxation +of the sphincters, and from states where there is complete absence of +any evidence of mentation to conditions of mere physical and psychic +slowness. After recovery the stupor patient frequently speaks of having +felt dead, paralyzed or drugged. + +By far the commonest cause of emotional expression or interruption in +the inactivity is negativism. This is a perversity of behavior which +seems to express antagonism to the environment or to the wishes of those +about the patient. In the partial stupors it is seen as active +opposition and cantankerousness. In the more profound conditions it is +represented by muscular resistiveness or rigidity, or refusal to swallow +food when placed in the mouth. Occasionally, too, the patient may even +in a deep stupor retain urine so long that catheterization is necessary. +All the explanations which one may gather from the patients’ own +utterances, mainly retrospective, seem to point to negativism expressing +a desire to be left alone. The appearance of perverse behavior in +aimless striking or mere muscular rigidity seems to be an example of +dissociation of affect. + +Catalepsy is an important symptom because, although it occurred in +slightly less than a third of our cases, it seems to be a peculiarity of +the stupor reaction found but rarely in other benign psychoses. It seems +never to occur without there being some evidence of mental activity, +and, consequently, we are forced to conclude that it is of mental rather +than of physical origin. Just what it means psychically it is impossible +to state without much more extended observations. We conjecture +tentatively, however, that the retention of fixed positions is in part +merely a phenomenon of perseveration, and in part an acceptance of what +the patient takes to be a command from the examiner, and sometimes a +distorted form of muscular resistiveness. + +The intellectual processes suffer more seriously in stupor than in any +other form of manic-depressive insanity. Not only do the deep stupors +betray no evidence of mentation during the acme of the psychosis, but +retrospectively they usually speak of their minds being a blank. +Incompleteness and slowness of intellectual operations are highly +characteristic features of the partial stupors and of the incubation +period of the more profound reactions. The features of this defect are a +difficulty in grasping the nature of the environment, a slowness in +elaborating what impressions are received, with resulting +disorientation, poor performance of any set tests and incomplete memory +for external events when recovery has taken place. At times the thinking +disorder may develop with great suddenness or improve as quickly, and a +tendency to isolated evidences of mental acuity is another example of +the inconsistency which is so highly characteristic of stupor. We should +note, however, that these sporadic exhibitions of mentality are always +associated with brief emotional awakening. + +When we turn to examine the fragmentary utterances of stupor patients, +we are surprised by the narrowness and uniformity of the ideational +content. It seems to be confined to thoughts of death or closely related +conceptions. Thirty-five out of thirty-six consecutive cases at one time +or another referred literally to death. It is commonest during the +onset, as all but five of these patients spoke of it during the +incubation of their psychoses. Hence we conclude that death ideas and +stupor are consecutive phenomena in the same fundamental process. As +two-thirds of the series interrupted the stupor to speak of death or to +attempt suicide, we assume that this relationship persists. Only a +quarter gave any retrospective account of these fancies, so we presume +that their psychotic experiences were repressed with recovery. + +The usual form in which the idea appears is as a delusion of going to +die or, literally, of being dead. It may appear as being in Heaven or +Hell. A theoretically important group is that which includes the +patients who, in addition, speak of being in situations such as under +the water or underground, which we have mythological and psychological +evidence to believe are formulations of a rebirth fantasy. Not rarely, +preoccupation with death is expressed in sudden impulsive suicidal +attempts. + +The affective setting of these different formulations is important. A +delusion of literal death occurs with complete apathy. The wish to die +is apt to appear without the usual accompaniment of sadness or distress +but still with considerable energy when impulsive suicidal attempts are +made. A prospect of death, particularly when there is anticipation of +being killed, is apt in manic-depressive insanity to occur in a setting +of anxiety. Similarly one ordinarily observes fear in the patient who +has delusions of drowning or burial. In the stupor cases, however, this +painful affect seems to be reduced to a mere dazed bewilderment or +feeble exhibitions of a desire for safety, such as the slow swimming +movements of a patient who thought she was under the water. When these +ideas of danger become allied to everyday interests--husband or child +imperiled, etc.--a weak affect in the form of depression is apt to +occur. + +Physical symptoms are more common than in any other benign psychosis. Of +these the most nearly constant is a low fever, the temperature running +between 99° and 101°. Twenty-eight out of thirty-five cases had this +slight elevation with a tendency for it to occur immediately at the +beginning of marked stupor symptoms. Although the evidence does not +positively exclude any possibility of infection, it speaks distinctly +against this view. A possible explanation is that the low fever is a +secondary symptom. The suprarenal glands may function insufficiently as +a consequence of the emotional poverty, since all emotions which have +been experimentally studied seem to stimulate the production of +adrenalin. Without this normal hormone for the activity of the +sympathetic nervous system, there would be a disturbance of skin and +circulatory reactions that would interfere with the normal heat loss. +Suggestive evidence to support this view comes from the frequency with +which the extremities are cyanotic or cold, the skin greasy, sweating +profuse or absent, and so on. Further observations are necessary to +confirm or disprove this hypothesis, but we feel inclined to accept it +tentatively because it is plausible and consistent with the view that +stupor is essentially a psychogenic type of reaction. Another physical +anomaly, which is presumably of endocrine origin, is the suppression of +the menses. This probably results from lowered nutrition. In some cases +it ensues directly on a psychic crisis before any nutritional change can +have taken place. Finally, among the symptoms of possible physical +origin, epileptoid attacks were described in two of our cases. This is +chiefly of interest in that such phenomena are extremely rare in the +benign psychoses. + +We believe that the mental symptoms summarized above constitute a +specific psychotic type of reaction capable of appearing in any severity +from mere lethargy and indifference to profound stupor. Since the +prognosis is good, we feel obliged to classify this with the +manic-depressive reactions. Further justification for this grouping is +found in the occurrence of the stupor reaction as a phase in many +manic-depressive psychoses. A patient may swing from mania to stupor as +from mania to depression, and when the partial stupors are recognized as +milder forms of the same process, it seems to be a frequent type of +reaction. + +If stupor be a reaction type, its laws must be psychological. According +to the view of modern psychopathology, the essence of insanity is +regression with indolent thinking as opposed to progressive and +energetic mentation. One can look on stupor as being a profound +regression. Effort is abandoned (apathy and inactivity), while the +ideational content expresses a desire for a retreat from the world in +death. It is possible to think of this regression as a return to the +mental habit of the suckling period, when spontaneous effort is at its +minimum. This, too, is the time when petulance and tantrums are frequent +expression of a wish to be left alone, which may account for the +negativism as a consistent symptom of the same regressive progress. + +Just as we regress in sleep, to rise refreshed for a new day’s duties, +so the stupor case often shows excessive energy in a hypomanic phase +before complete normality is reached. This corresponds again to the +age-old association of the ideas of death and rebirth which we see +together so frequently in stupor. It is the psychology of wiping the +slate clean for a fresh start. + +The development and symptoms of stupor furnish evidence in support of +the hypothesis of this type of regression. Dissatisfaction of any kind +is the setting in which the psychosis begins and the commonest +precipitating factor is some reminder of death. That loss of energy +appears with the stupor is evident from the inactivity and apathy, while +the thinking disorder can be shown to be the result of the same loss. +The different “levels” of the stupor reaction also conform to a theory +of regression. First there is mere indifference and quietness; then +appear false ideas when normality is so far abandoned as to mean a loss +of the sense of reality; withdrawal of interest from the environment, +with its consequent centering of self, leads to the next stage--that of +the spoiled child reaction; then follows the exclusion of the world +around in the dramatization of death; finally, in the deepest stupor, +mentation is so far abandoned that we can gather no evidence of even +this delusion being present. + +Atypical features in stupor have to do mainly with interruptions, +interludes as it were, of elation, anxiety or perplexity. These are +explicable as awakenings from the nothingness of stupor into +imaginations such as characterize the other manic-depressive psychoses. +When such tendencies are present, the co-existence of the stupor process +may tone down the emotional response or prevent its complete repression +so that insufficient or dissociated affects appear. A combination of the +stupor tendency to apathy with the mood of another reaction is probably +the only combination of affects to be met with in psychiatry. + +The stupor reaction, then, is a simple regression, with a limitation of +energy, emotion and ideational content, the last being confined to +notions of death. All functional psychoses are regressions. How do the +others differ from this? We need only answer this question in so far as +it concerns the clinical states resembling benign stupors. Stupors occur +frequently in catatonic dementia præcox. In this disease there is a +regression of interest to primitive fantastic thoughts, and with this a +perversion of energy and emotion. This corrupts the purity of the stupor +picture so that inconsistencies, such as empty giggling, atypical +delusions and scattered speech, occur. Other impurities are to be found +in the frequent orientation of the dementia præcox stupor patient which +is discovered to be astonishingly good, or in free speech associated +with apathy and inactivity. Such symptoms usually appear quite early and +should enable one to make a positive diagnosis within a short time after +patient comes under observation. As a matter of fact, in many if not +most cases there is a slow onset characterized by the pathognomonic +symptoms of dementia præcox before the actual stupor sets in. + +Other psychoses superficially resembling stupor are the perplexity and +absorbed manic (manic stupor) states. We have reason to believe that +both these conditions are essentially the result of absorption in +kaleidoscopic ideas. Their appearance is that of inactivity and +indifference to the outside world, just as a dreamer seems placid and +apathetic. But these reactions are not without emotion which may +sometimes be obvious, and the richness of the mental content is sooner +or later manifest. + +Finally, from a practical standpoint, an important peculiarity of benign +stupor is the tendency for response to stimulation in amelioration of +the process. Close attention to these patients is advisable, therefore, +not merely for the sake of their physical health, but also because any +attention tends to keep them mentally alive or revive their waning +energy. Visits of relations often initiate recovery in a striking way. +From occurrences such as these, psychiatrists should gain hints for +valuable therapeutic experiments. + +So much for the technical, psychiatric aspects of the stupor problem. We +have frequently spoken of it, however, as a psychobiological reaction. +If this be a sound view, similar tendencies should appear in everyday +life, the psychotic phenomena being merely the exaggerations of a +fundamental type of human and animal behavior. Shamming of death in the +face of danger and animal catalepsy come to mind at once, but since we +know nothing of the associated affective states we should be chary of +using them even as analogies. We are on safer ground in discussing +problems of human psychology. + +It is evident that there are psychological parallels between the stupor +reaction and sleep, while future work may show physiological +similarities as well. Apathy towards the environment, inactivity and a +thinking disorder are common to both. But sleep reactions do not occur +in bed alone. Weariness produces indifference, physical sluggishness, +inattention and a mild thinking disorder such as are seen in partial +stupors. The phenomena of the midday nap are strikingly like those of +stupor. The individual who enjoys this faculty has a facility for +retiring from the world psychologically and as a result of this psychic +release is capable of renewed activity (analogous to post-stuporous +hypomania) that cannot be the result of physiological repair, since the +whole affair may last for only a few minutes. + +In everyday life there are more protracted states where the comparison +can also be made. When life fails to yield us what we want, we tend to +become bored--a condition of apathy and inactivity, forming a nice +parallel to stupor inasmuch as external reminders of reality and demands +for activity are apt to call out irritability. A form of what is really +mental disease, although not called insanity, is permanent boredom, a +deterioration of interest, energy and even intelligence by which many +troubled souls solve their problems. A sudden withdrawal from the world +we call stupor. When the same thing happens insidiously, the condition +is labeled according to the financial and social status of the victim. +He is a bum, a loafer, a mendicant or, more politely, a disillusioned +recluse. Frequently this undiagnosed dement has satisfied himself with a +weak, cynical philosophy that life is not worth while. + +It is but a step from valueless life to death and the same tendency +which makes the patient fancy he is dead, leads the tired man to sleep, +the poet to sigh in verse for dissolution, and the myth maker to +fabricate rebirth. The religions of the world are full of this yearning, +which reaches its purest expression in the belief and philosophy of +Nirvana. The ideational content of stupor has also its analogue in +crime. The desire for perpetuation of relationships unprosperous in this +world is not seen only in the delusion of mutual death. One can hardly +pick up a newspaper without reading of some unhappy man or woman who has +slain a disillusioned lover and then committed suicide. + + +FOOTNOTES: + +[12] Kirby, George H.: “The Catatonic Syndrome and Its Relation to +Manic-Depressive Insanity.” _Jour. of Nervous and Mental Disease_, Vol. +XL, No. 11, 1913. + + + + +CHAPTER XV + +THE LITERATURE OF STUPOR[C] + + +The cases of benign stupor which we report here are not clinical +curiosities. Taking the symptoms as the products of a reaction type, the +latter is really quite common. One, therefore, asks what other +psychiatrists have done with this material. How have they described +these stupors, how classified them? This chapter, essentially an +appendix, attempts to give a brief answer to this inquiry. No attempt is +made to catalogue all that has been written on or around this subject +but only to mention typical reports and viewpoints. + +The French, beginning with Pinel in the 18th Century, were the first to +write extensively of stupor. An excellent paper by Dagonet[13] appeared +in 1872, in which such literature as had appeared up to that time is +discussed. He defines “Stupidity” as a form of insanity in which +“delirious” ideas may or may not be present, which has for its +characteristic symptoms a state of more or less manifest stupor and a +greater or less incapacity to coördinate ideas, to elaborate sensations +experienced and accomplish voluntary acts necessary for adaptation. This +would seem to include our “partial stupor,” as well as the more marked +cases. + +He quotes an excellent definition from Louyer Villermay (Dict. des sc. +méd. t. LIII, p. 67). “Stupor is a term applied to stupefaction of the +brain. It is recognizable by the diminution or enfeeblement of internal +sensation and by a greater difficulty in exercising memory, judgment and +imagination. It is accompanied by a general numbness and a weakness of +feeling and movement. The patient, then, has an indefinite and stupid +expression, he understands questions put to him with difficulty, and +answers them with effort or not at all. He seems overwhelmed with sleep, +he forgets to withdraw his tongue after showing it to the doctor, he +complains of no uncomfortable sensation, of no illness, he seems to take +no interest in what goes on about him.... The stupor patient is a fool +who does not speak, in this being more tolerable than the one who speaks +[delightful naiveté!]. One who is dumbfounded by surprise or fright is +also to be called stuporous.” + +Dagonet says stupor results from various causes, such as exhaustion, or +emotional and intellectual factors. Clinically it varies in kind and +degree according to the situation in which it develops. When it develops +during normal mental health, it disappears when its cause does. In +insanity it appears in the course of a psychosis of some duration, of +which it seems a part, an exaggeration of some symptom of the general +condition. Evidently he views stupor as a type of reaction: as a more or +less complete suspension of the operation of intellectual faculties, a +more or less sudden subtraction of nervous forces. This reaction can +result from a fright or the memory of it, a brain lesion or trauma, the +action of narcotics, exhausting fevers, excessive grief, the terrors of +alcoholic hallucinations, epileptic seizures, profound anemia and +nervous exhaustion consequent on sexual excess. He is careful to say +that both symptoms and treatment vary with the varied etiologies. + +He credits Pinel with being the first to call attention to stupor. This +author claimed that some persons with extreme sensibility could be so +upset by any violent emotion as to have their faculties suspended or +obliterated. He noted, too, that stupors frequently terminated in manic +phases of 20 to 30 days’ duration. Pinel also emphasized the apathy of +these cases. Esquirol called stupor “acute dementia,” a term which +persisted in French literature for a long time. He described an +interesting circular case where alternations between mania and typical +stupor took place. He mentions too the dangerous, impulsive tendencies +of many patients. Georget emphasized the fact which Pinel had also +noted, that retrospectively the stupor patient says his mind was a blank +during the attack. In 1835 Etoc-Demazy published on the subject. He +regarded stupor not as a separate form of insanity but a complication +ensuing on monomania or mania. He recognized the partial as well as +complete stupor. He thought the condition was due to cerebral edema, as +did other writers of that period. Dagonet remarks about this last--a +lesson not learned in fifty years by the profession--that demonstrable +edema does _not_ produce the typical symptoms of stupor. Baillarger in +1843 (Annales Médico-psychologiques) was the first whose ambition to +simplify psychiatric types led to denial of a separate kind of reaction. +He claimed that stupor was not a form of insanity but an extension of a +“délire mélancholique.” As Dagonet remarks, every symptom by which he +characterizes stupor is a psychiatric symptom and insanity can consist +just as well in the diminution as the perversion or exaltation of normal +faculties. Some of Baillarger’s cases had false ideas, some apparently +none at all. Dagonet thinks this justifies two types, one a dream-like +state and another where no ideas are present, although he admits one may +be an exaggeration of the other. Brierre de Boismont (Annales +Médico-psychologique, 1851, p. 442) compares these two kinds of stupors +to deep sleep when intelligence is completely suspended and to sleep +with dreams. (These two types would correspond to our “absorbed mania” +and true deep stupor.) He urges strongly the separation of stupor from +melancholia as an entirely different type of reaction, in this +connection citing the views pro and con of various authors. Of these +Delasiauve is particularly cogent in discriminating stupor from +melancholia on the grounds of the difference of the emotional reactions +and of the intellectual disorder and the real paucity of thought in the +former psychosis. + +After quoting these and other authors, Dagonet offers an explanation for +the diversity of opinion. He says that stupor following another +psychosis may retain some of its symptoms, so that a mixture obtains, as +often in medicine. He then gives excellent descriptions of three types: +the deep stupor with paralysis of the faculties, the cases that are +absorbed in false ideas, and ecstatic cataleptics. + +The remainder of his paper is concerned with cases and discussions about +them. He cites examples of stupor following fear or other emotional +shocks, following grave injuries such as the loss of a limb, following +head trauma and with typhoid fever. As to the last he points out that +delirious features are prominent. Many authors have assigned sexual +excesses as a cause of stupor. The psychosis, Dagonet says, is not pure +but more a mixture of hypochondria and depression. Relationship with +mania is next considered. He says that stupor may succeed, alternate +with or precede mania. His cases seem mainly to have been what we call +absorbed manics or manic stupors. In fact, he uses the last term. The +commonest introductory psychosis, he claims, is depression, but from his +brief case reports it would seem that most of his patients were not +stuporous, in the narrow sense of the term, but severely retarded +depressions. In fact, in perusing his case material comprising “stupors” +in the course of many types of functional insanity, or as a complication +of epilepsy or general paralysis, it is evident that in practice he does +not follow the discriminative definitions of the earlier portion of his +paper. For him, apparently, patients who are markedly inaccessible to +examination from whatever cause are “stuporous.” He closes with +excellent remarks on physical and psychic treatment. As to prognosis he +has nothing to say beyond the opinion that most of the cases recover. + +If Dagonet be accepted as summarizing the early French work, we can +conclude that their generalizations were on the whole quite sound. These +were: that stupor is an abnormal mental reaction, usually psychogenic +but often the result of exhaustion, that it consists in a paralysis of +emotion, will and intelligence; that the prognosis is usually good; that +mental stimulation may produce recovery. What remained to be done after +this work was the refinement in detail of these generalizations, +particularly in respect to the differentiation of prognostically benign +and malignant types. But other Frenchmen did not take up this work, +apparently, for the brilliant psychopathologists of the next generations +attended to stupor only in so far as it was hysterical. + +An Englishman, however, soon took up the task, adding more exactness to +his formulations. Newington[14] published his important paper in 1874. +A nascent stage of stupor, he thinks, is a common reaction to great +exhaustion, “such as hard mental work, prolonged or acute illness, +dissipation, etc.” Such conditions, like the grave psychotic forms, he +regarded as due to physical exhaustion of the brain cells, but, since he +thought psychic stress could produce this exhaustion, this “organic” +view did not bias his general formulations. He makes a division into two +stupors: Anergic Stupor and Delusional Stupor. The former may be +primary, being generally caused by a sudden intense shock (Esquirol’s +“Acute Dementia”), or secondary (a) to convulsions of any kind, (b) to +mania in women, (c) to any other prolonged nervous exhaustion. The +delusional form results from (a) intense melancholia, (b) from general +paralysis in which it may be intercurrent, (c) from epileptic seizures. +When one examines his points of difference between these two types, it +becomes clear that Newington really gave an excellent differentiation of +benign and malignant stupor--in fact, it is the only serious attempt at +such discrimination prior to this present work. What is more remarkable +is the fact that, although he clearly saw the clinical differences, he +failed to see that the two types differed prognostically. His +description is given in a table sufficiently concise to justify its +quotation _in extenso_. + + _ANERGIC STUPOR_ _DELUSIONAL STUPOR_ + + _Etiology_--Hereditary and Hereditary. + individual liability to + sudden loss of _vis nervosa_. + + _Onset_--Rapid. Usually insidious, may be almost + instantaneous. + + _Symptoms_--Intellect greatly Conduct shows reasoning power. + impaired. + + _Memory_--Seems to be swept Found after recovery to have + away as far as possible. been preserved to a great + extent. + + _Emotional Capacity_--Nil or Evidence of grief, fear, etc., in + almost so. Tears frequent facial expressions and wringing + but due to relaxation of and clasping of hands. + sphincter muscles. Features Tears rare. Great contraction + relaxed, eyes vacant and not of features [grimacing?]. + constantly fixed. Eyes fixed on one + point, usually upwards or + downwards, or else obstinately + closed. + + _Volition_--Almost absent. Frequently great stubbornness, + refusal to do what is + wanted. On the other hand, + intense determination in + following out own plan. + + _Motor System_--Weak and uncertain. But little interfered with, + Patient has to be independently of sheer + led about and if placed on a asthenia, produced by + seat or in some position does patient’s conduct. May stand + not move. (“Cataleptoid” behind door or kneel on floor + condition.) in constrained position even + for days. + + _Sensory System_}--Both dull. Ditto. There seems to be a + _Reflex System_ } much greater ability to bear + severe pain. + + _Pupils_--Dilated. Tendency to contraction. + + _Sleep_--Generally good. Intense sleeplessness. + + _General bodily condition_-- Affected _pari passu_ with + Emaciation, sometimes extreme, mental state and seems + usually rapid, with governed by it. + rapid recovery of flesh. + Often not much loss of + weight, though whole tone is + lowered. + + _Vascular System_--Pulse slow, Pulse weak and often quick + sometimes almost imperceptible. and thready. Complexion + Cyanotic appearance, edema anemic and sallow. The + and iciness of extremities. other appearances may be + Great decrease of vitality present but come on later + in peripheral structures, and are less marked. + as shown by asthenic + eruptions and production of + vermin. + + _Digestive System_--Tongue Tongue dry, small and furred. + clean or if furred it is moist. Refusal of food. Great + Appetite _apathetic_, bowels constipation. Dirtiness of + not irregular, but habits habits rare. + very dirty. + +If one compares these data with those given in the chapter on Malignant +Stupors, it is seen that in the main Newington has made the same +discrimination as we have. He is certainly wrong in denying “negativism” +to his anergic type. Probably, too, he attempts too fine a distinction +between the physical symptoms of the two groups. His conclusions are +interesting: that in the anergic cases there is an _absence_ of +cerebration, while amongst the delusional there is an abnormal +_presence_ of intense but perverted cerebration. This is not unlike our +own view. He thinks the difference in memory is the most important +differential point. Sex is important in determining the nature of the +stupor, for he found the anergic type following mania in females only. +He observed such an end to manic attacks in 6 out of 36 cases. All his +cases were under 30 and he regards the prognosis as good on the whole. +As to treatment he emphasizes the necessity for “moral pressure” as a +stimulus and cites a case of rapid improvement after a change of scene. + +Since 1874 very little advance has been made by British psychiatrists, +as seen by a perusal of Clouston’s[15] summary in 1904. He regards sex +exhaustion as a highly frequent cause, although Dagonet had shown 32 +years before that sex abuse does not produce a true stupor. He thinks +stupor usually follows depression or mania and says that “the +‘Confusional Insanity’ of German and American authors is just a lesser +degree of stupor.” Omitting his stupors in general paralysis and +epilepsy he makes three clinical divisions: _melancholic or conscious +stupor_, which is not a product of delusions, although delusions of +death or great wickedness may be present, impulsiveness and fits may be +observed; _anergic or unconscious stupor_, which corresponds roughly to +our deep, benign stupor; and _secondary stupor_ after acute mental +disease, which resembles our partial stupor. He warns against a rash +diagnosis of dementia in this last group. His views on the importance of +mental causation and the relation to manic-depressive insanity may be +gathered from these sentences: “The condition of the mental portion of +the convolutions in stupor is probably analogous to the stupidity of a +nervous child when terrified or bullied.” “Stupor is frequently one of +the stages of alternating insanity following the exalted condition. It +is more apt to occur in those where the exalted period is acutely +maniacal. The stupor is usually melancholic in form.” Since he claims +that the anergic is a “very curable form of mental disease,” while only +50% of the melancholic cases recover, it seems clear that this division +is not prognostically final. The “melancholic” is evidently Newington’s +“delusional” without his more accurate discrimination of symptoms. + +From the standpoint of accurate description the opinion may be ventured +that there is a gap in the literature from the early French writers and +Newington up to the paper by Kirby, which has been discussed in the +first chapter. This gap is filled by literature of the German schools +and their adherents in other countries. German psychiatry has been +concerned mainly with classification or the elaborate examination of +certain symptoms. Inevitably such a program militates against detached +objective clinical description. It is hard to record symptoms that +interfere with classification. German psychiatry has tended to make the +insane patient a type rather than an individual. Hence the gap in the +descriptive literature of stupor. + +The necessity of establishing the possibility of some stupors having a +good prognosis has arisen from Kraepelin’s work. He can rightly be +viewed as the father of modern psychiatry because he introduced a +classification based on syndromes and taught us to recognize these +disease groups in their early stages. Inevitably with such an ambitious +scheme as the pigeon-holing of all psychotic phenomena some mistakes +were made. Most of these appear in the border zone between dementia +præcox and manic-depressive insanity. The latter group being narrowly +defined, the former had to be a waste basket containing whatever did not +seem to be a purely emotional reaction. Clinical experience soon proved +that many cases which, according to Kraepelin’s formulæ, were in the +dementia præcox group, recovered. Adolf Meyer was one of the first to +protest and offered categories of “Allied to Manic-Depressive Insanity” +or “Allied to Dementia Præcox,” as tentative diagnostic classifications +to include the doubtful cases. + +Difficulties with stupor furnish an excellent example of the confusion +which results from the adoption of rigid terminology. The earlier +psychiatrists were free to regard a patient in stupor as capable of +recovery as well as deterioration. When Kahlbaum included stupor with +“Catatonia,” the situation was not changed, for he did not claim a +hopeless prognosis for this group. But when Kraepelin made catatonia a +subdivision of dementia præcox, all stupors (except obvious phases of +manic-depressive insanity) had to be hysterical or malignant. Faced with +this dilemma psychiatrists have either called recoveries “remissions” +or, like E. Meyer, claimed that one-fifth or one-fourth of catatonics +really get well. + +As a matter of fact it seems clear that stupor is a psychobiological +reaction that can occur in settings of quite varied clinical conditions. +It is not necessary to detail publications describing stupors in +hysteria, epilepsy, dementia præcox or in the organic psychoses. It may +be of interest, however, to cite some examples of acute, benign stupors +and the discussion of them which appear in the literature of recent +years. + +An important group is that of stupors occurring as prison psychoses. +Stern[16] mentions that acute stupors are found in this group. +Wilmanns[17] examined the records for five years in a prison and +discovered that there were two forms of psychotic reaction, a paranoid +and a stupor type. It is interesting psychologically that the former +appeared largely among prisoners in solitary confinement, while the +stupors developed preponderantly among those who were not isolated. The +stupors recovered more quickly. He describes the psychosis thus: The +prisoner becomes rather suddenly excited, destructive and assaultive; +then soon passes into an inactive state, where he lies in bed, mute, +with open expressionless eyes. He is clean, however; eats spontaneously +and attends to his own hygienic needs. Some cases are roused by +transport from the jail to the hospital but sink into lethargy again +when they reach their beds. Physically, they show disturbances of +sensation which vary from analgesia to hypesthesia. There are a rapid +pulse, positive Romberg sign, exaggerated reflexes, fibrillary twitching +of the tongue and tremor of the hands. Recovery takes place gradually. +They begin to react to physical stimuli and to answer questions, +although still inhibited, until consciousness is quite clear. When +speech begins, it is found that they are usually disoriented for place +and time as the result of an amnesia which sets in sharply with the +excitement. This memory defect gradually improves _pari passu_ with the +other symptoms. + +Two attacks in the same prisoner of what seem to have been typical +stupor are reported by Kutner[18] and Chotzen.[19] The patient was a +recidivist of unstable mental make-up. At the age of 34 he was sent to +prison for three years. Shortly after confinement began, he became +stuporous, being mute and negativistic, soiling, refusing food and +showing stereotypy. On being shifted to another institution he appeared +suddenly much better, although he remained apathetic and dull for some +months. A striking feature was a complete amnesia, not merely for the +stupor but also for his trial and entrance to the prison. At the age of +42, he was again incarcerated. A practically identical picture again +developed, with recovery when his environment was changed, and with a +similar amnesia. Recovery seemed to be complete and there were no +hysterical stigmata. The interesting features of this case are that a +typical stupor seems to have been precipitated by imprisonment, while +the retroactive amnesia covering a painful period of the patient’s life +reminds one of hysteria. + +A case which is more difficult to interpret is reported briefly by +Seelig.[20] A man of 20 with bad inheritance tried to steal 100 marks. +When sent to jail he became ill shortly before his trial was due and was +sent to a hospital. There he seemed anxious, was shy, and gave slow +answers, with initial lip motions and had to be urged to take hold of +objects. All this sounds more like a pure depression than a stupor. But +he also had paralogia. This might make one think of a Ganser reaction on +the background of depression. S., however, calls it an hysterical +stupor, although he agreed with Moeli that it was hard to differentiate +from a catatonic state. + +Löwenstein[21] reports an interesting case of a dégénéré who had had +hysterical attacks. He suddenly developed stupor symptoms, which lasted +with interruptions for nearly two years. After recovery and during the +interruptions the patient explained his mutism, refusal to swallow, his +filthiness and general negativism as all occasioned by delusions. He was +commanded by God to act thus, the attendants were devils, and so on. He +spoke, too, of being under hypnotic influence. In addition there were +other delusions such as that he had killed his brother. The attack came +on with the belief that he was going to die, otherwise none of the ideas +were typical of the stupors we have studied. Another incongruous symptom +was that he did not seem to be really apathetic, he reacted constantly +to the environment. The author comments on the absence of senseless +motor phenomena, such as would be expected in a “catatonic.” His +complete memory of the psychosis also speaks against the usual form of +stupor. It seems possible that this psychosis was neither hysterical nor +a benign stupor in our sense, but, rather, an acute schizophrenic +reaction such as one occasionally sees. From the account which +Löwenstein gives, one gathers that the patient was absorbed in a wealth +of imaginations. + +Gregor[22] tells of a stupor which is unusual in that it consisted only +of symptoms connected with inactivity, which did not affect the +intellectual processes. The patient was a rubber worker who suddenly +developed a depression with self-accusation and convulsions. She was +soon admitted to a clinic and then showed mutism and catalepsy. Later +she became totally immobile with no apparent psychic reactions, and +soiled. Gregor studied pulse, respiration and respiratory volume in +their reflex manifestations and found nothing unusual. Next he tried to +discover if there were voluntary alterations in respiration. He +discovered that the respiratory curve could be changed by calling out +words to her, by odors associated with suggestions, menaces, etc. [This +is suggestive of the dissociation of affect, which we have discussed.] +After two months she recovered, _with complete recollection of the +stupor period_. It was then proven that the absence of reactions was not +the same as the lack of perception of stimuli. + +Froederström[23] reports a case that suggests hysteria, where the stupor +lasted for 32 years. A girl at the age of 14 fell on the ice, had a +headache, went to bed and stayed there for 32 years. She lay there +immobile, occasionally spoke briefly and took nourishment, when it was +put at a definite place at the edge of the bed. At first (according to a +late statement of her brothers) this consisted only of water but was +soon changed to two glasses of milk a day. After being in this state for +ten years she was placed in a hospital for two weeks, where she was +mute, did not react to pin pricks and had to be fed. It seems that at +home she secretly looked after herself, for she kept her hair and nails +in condition. Sometimes she sat up and stared at the ceiling. + +After attending to the patient for 30 years, her mother died. The +patient cried for several days when told of it, and after this she took +nourishment of her own accord. Two years later a brother died. Again she +cried on hearing the news. Her father, who looked after her when the +mother was dead, also died. Then a governess came into the home, who +noticed that furniture was moved about when she was alone. + +At the age of 46 she suddenly woke up and asked at once for her mother. +She claimed total amnesia for the period of her stupor, including the +stay at the hospital. She could summon memories of her childhood, +however. Her brothers she did not recognize and said, “They must be +small.” She recalled the fall on the ice and coming home with headache, +toothache and pain in the back. Her general knowledge was limited but +she could read and write. Her expression and appearance was that of a +young person, only her atrophic breasts and the fat on her buttocks +betraying her age. She had been well for four years at the time the +report was made. + +He thinks that a certain tendency to exaggeration and simulation speak +for hysteria. We would be more inclined to view the fact that she looked +after herself in spite of complete amnesia as evidence of hysteria. + +Another protracted case suggestive of hysteria is that reported by +Gadelius.[24] The patient was a tailor, 32 years old, who had always +been rather taciturn and slow. A year before admission he began to have +ideas of persecution and to shun people. Then he developed a stereotyped +response, “It is nice weather,” whenever he was addressed. A month +before admission inactivity set in. He would sit immobile in his chair +with closed eyes and relaxed face; he resisted when an attempt was made +to put him to bed. His color was pale. + +He was taken to hospital on November 1, 1882, where he was observed to +be immobile and to have little reaction to pin pricks. When a limb was +raised, it fell limply. However, he would leave bed to go to the toilet. +Tube-feeding became necessary, but when the tube was inserted in his +nose, he woke up. He then showed an amnesia not merely for his illness +but for his whole life: he did not know his father, that he was married +or that he had a mother. Towards the end of November, he became limp +again and answered, “I don’t know” to most questions. In December, +however, he improved again and for a few months these variations +occurred. From April, 1883, to May, 1886, he was in deep stupor, almost +absolutely immobile and close to being completely anesthetic even with +strong Faradic currents. Towards the end of this period he walked about +_whenever he thought he was not watched_. He was very cautious about +this and became motionless any time he became aware of observation. +(Gadelius thinks this was not simulation but the expression of an +automatism on the basis of a vague fixed idea.) + +This condition persisted apparently for five years more, by the end of +which time the anesthesia had turned into a hyperesthesia. A year later +he began to eat. It was now found that he had an amnesia for his illness +and former life, so that he did not even recognize a needle or pair of +scissors. He knew that he was born in the month of February and retained +some facility in calculation, in speech, walking and usual motions. Then +he regained all his memories and resumed his trade as tailor. He was +discharged in June, 1893, nearly eleven years after admission. + +It seems safe to say that elements at least of hysteria appear in this +history, such as the profound retroactive amnesia and appearance of +simulation in the conduct of the patient. Accurate and rapid grasp of +the environment is necessary for such a watch as he kept on the eye of +his attendants. Mental acuity of this grade combined with amnesia looks +more like an hysterical than a manic-depressive process. + +Leroy[25] describes a case much like ours which is interesting from a +therapeutic standpoint. The patient was a woman who passed from a severe +depression with hallucinations and anxiety into a long stupor, from +which she recovered completely. There was no negativism and no affect, +although the latter appeared so soon as contact began to be established. +When well she had a complete amnesia for the onset of the psychosis. +Leroy attributed the recovery, in part at least, to the thorough +attention given the patient. Kraepelinian rigidity is seen, however, in +the author’s refusal to regard the case as “circular” because of the +lack of all cyclic symptoms. He takes refuge in the meaningless label +“Mental Confusion.” + +An important group of cases is that of the stupors occurring during +warfare. Considering stupor as a withdrawal reaction, it is surprising +there were so few of them, although partial stupor reactions as +functional perpetuation of concussion were very common. The editor saw +several typical cases in young children in London who passed into long +“sleeps” apparently as a result of the air raids. Myers[26] has given +us the best account of stupors in actual warfare. A typical case was +that of a man who was found in a dazed condition and difficult to +arouse. He could give little information about himself, could neither +read nor write and never spoke voluntarily. A week later his speech was +still limited and labored and no account of recent events could be +obtained from him. Under hypnosis he was induced to talk of the accident +which had precipitated this disorder. He became excited in telling his +story, evidently visualizing many of the events. In several successive +séances, more data were obtained and a cure effected. Myers points out +that in all his cases there was a mental condition which varied from +slight depression to actual stupor, all had amnesias of variable extent +and all had headaches. The mental content seemed to be confined to +thoughts of bombardment, with a tendency for the mind always to wander +to this topic. The author thinks that pain is a guardian protecting the +patient from too distressing thoughts. An effort to speak would cause +pain in the throat of a case of mutism and, sometimes, when a +distressing memory was sought after under hypnosis, physical pain would +wake the sleeper. His view is that pains tend to preserve the mutism and +amnesia, so that there are “inhibitory processes” causing the stupor, +which prevent the patient from further suffering. He does not find +either in theory or experience reason to believe that these conditions +are the result of either suggestion or “fixed ideas.” He thinks it +natural that the last symptom of the stupor to disappear should be +mutism, as speech and vision are the prime factors in communicating with +environment. [As has been noted frequently in this book, mutism is a +common residual symptom of the benign stupor.] Myers believes that in +nearly every instance mutism follows stupor and is merely an attenuation +of the latter process. When deafness is associated with mutism, he +thinks it is often due merely to the inattention of the stuporous state. + +In this connection we should mention that Gucci[27] points out that +stupor patients with mutism of long duration may, when requested, read +fluently and then relapse again into complete unreactiveness towards +auditory impressions. This, we would say, is probably an example of a +more or less automatic intellectual operation occurring when the patient +is sufficiently stimulated, although he cannot be raised to the point of +spontaneous verbal productivity. + +As these scattered reports about benign stupors are so unsatisfactory, +one naturally turns to text-books. Little more appears in them. +Kraepelin treats stupors occurring in manic-depressive insanity as +falling into two groups, the depressive and manic. The former seems to +be nearer to our cases, judging by the statements in his rather sketchy +account. He regards stupor as being the most extreme degree of +depressive retardation. [This possibility has been discussed in the +chapter on Affect.] His description seems perhaps to include cases which +we would regard as perplexity states or absorbed manias. Activity is +reduced, they lie in bed mute, do not answer, may retract shyly at any +approach, but on the other hand may not ward off pin pricks. Sometimes +there is catalepsy and lack of will, again there may be aimless +resistance to external interference. They hold anything put into their +hands, turning it slowly as if ignorant of how to get rid of it. They +may sit helpless before food or may allow spoon-feeding. Not rarely they +are unclean. As to the mental content, he says they sometimes utter a +few words, which give an insight into confused delusions that they are +out of the world, that their brains are split, that they are talked +about, or that something is going on in the lower part of the body. The +affect is indefinite except for a certain bewilderment about their +thoughts and an anxious uncertainty towards external interference. +Intellectual processes suffer. They are disoriented and do not seem to +understand the questions put to them. An answer “That is too +complicated” may be made to some simple command. Kraepelin thinks that +the disorder is sometimes more in the realm of the will than of +thinking, for one patient could do a complicated calculation in the same +time as a simple addition. After recovery the memory for the period of +the psychosis is poor and quite gone for parts of it. Occasionally there +may be bursts of excitement, when they leave the bed; they may scold in +a confused way or sing a popular song. + +His manic stupor is a “mixed condition,” a combination of retardation +with elated mood. The condition is different from the depressive stupor +in that activity is more frequent, either in constant fumbling with the +bed clothes or in spasmodic scolding, joking, playing of pranks, +assaultiveness, erotic behavior or decoration. The affect is usually +apparent in surly expression or happy, or erotic, demeanor. They are +usually fairly clear and oriented and often with good memory for the +attack but with evasive explanations for their symptoms. One cannot make +any classification of the ideas he quotes, but it is apparent from all +his description that the minds of these “manic stupors” are not a blank +but rather that there is a fairly full mental content. + +Wernicke, unhampered by classifications of catatonia and +manic-depressive insanity with inelastic boundaries, calls all stupor +reactions akinetic psychoses with varying prognosis. He does not make +Kraepelin’s mistake of confusing the apathy of stupor with the +retardation of depression, stating distinctly that the processes are +different. + +Bleuler also has grasped this discrimination. He points out that the +thinking disorder in what he terms “Benommenheit” (dullness) +differentiates such conditions from affectful depression with +retardation. He writes, of course, mainly of dementia præcox,[28] but +makes some remarks germane to our problem. In the first place he denies +the existence of stupor as a clinical entity, except perhaps as the +quintessence of “Benommenheit”, it is the result of total blocking of +mental processes. Consequently, he says, one can observe the external +features of stupor in all akinetic catatonics, in marked depressive +retardation, when there is a lack of interest, affect or will, in +autism, with twilight states, as a result of negativism or, finally, +when numerous hallucinations distract the patient’s attention into a +world of fancy. He notes that in all stupors (with the exception, +perhaps, of “Benommenheit”) the symptoms may disappear with appropriate +psychic stimulation or that some reaction, no matter how larval, may be +observed. He speaks, for instance, of the visits of relatives waking the +patient up. + +His only real group is “Benommenheit,” which he separates out as a true +clinical entity. This seems to correspond roughly with our “Partial +Stupors.” It is essentially an affectless, thinking disorder, usually +acute, sometimes chronic, occurring among schizophrenics. He believes +that it is the result of some organic process (intracranial pressure or +toxin). Activity is much reduced or absent; they have poor +understanding, answer slowly or confusedly; their actions are sometimes +as ridiculous as those of people in panic (e.g., throwing a watch out +of the window when the house is on fire); the defect is best seen in +writing, for large elisions are found in sentences. He was able to +analyze only one case and she retained her affect; it was even labile +and marked. One suspects that such a case might, perhaps, not really +find a place in the “Benommenheit” group even as Bleuler himself +describes it. + +With the exception of Kirby, whose work has already been discussed in +the introduction, we have been able to find only one author who has +attempted any symptomatic discrimination of the recoverable and +malignant catatonic states. Raecke[29] made a statistical study and +found that 15.8% recovered, 10.8% improved, 54.4% remained in +institutions, while 30% died. With the etiology mainly exogenous 20% +recovered and 14.3% improved. A good outcome was seen in 30.2% of +hereditary cases, while only 22.7% did well in the non-hereditary group. +His most important contribution is in his formulation of good and bad +symptoms. He thinks that dull, apathetic behavior with uncleanliness and +loss of shame are not so unfavorable as has been thought. Malignant +symptoms are grimacing with prolonged negativism but without essential +affect anomaly, decided echopraxia and echolalia and protracted +catalepsy. We would agree with this, although command automatisms have +not been prominent either in our benign or malignant stupors. + +Two writers have made special observations that should be confirmed and +amplified before their significance can be established. Whitwell[30] +thinks that in addition to a diminished activity of the heart there +exists a pathological tension. Ziehen says that he also has frequently +seen angiospastic pulse-curves in exhaustion stupor or acute dementia, +but that other pulse pictures may be seen as well. Any such studies +should be correlated rigorously with the clinical states before they can +have any meaning. Wetzel[31] tested the psychogalvanic reflex in stupors +and in normal persons who simulated stupors. He found them different. + +Only one publication has come to our attention in which an attempt is +made at psychological interpretation of various symptoms in stupor. +Vogt[32] derives much from a restriction of the field of consciousness. +Only one idea is present at a time, hence there is no inhibition and +impulsiveness occurs. Similarly, if the idea appear from without, it, +too, is not inhibited, which produces the suggestibility that in turn +accounts for catalepsy. Stereotypy and perseveration are other evidences +of this narrowness of thought content. Negativism is a state, he says, +of perseverated muscular tension. [This would apply only to muscular +rigidity.] So far as it goes, this view seems sound. Of course it +leaves the problem at that interesting point, Why the restriction of +consciousness? + +If stupor be a psychobiological reaction, it should occur, occasionally, +in organic conditions just as the deliria of typhoid fever may contain +many psychogenic elements. Gnauck[33] reports such a case. The patient, +a woman, was poisoned by carbon dioxide. At first there was +unconsciousness. Then, as she became clearer, it was apparent that she +was clouded and confused. She soiled. Neurological symptoms were +indefinite; enlargement of the left pupil, difficult gait and +exaggerated tendon reflexes. Months later she was still apathetic, +although her inactivity was sometimes interrupted by such silly acts as +cutting up her shoes. After five months she recovered with only +scattered memories of the early part of her psychosis. What seems like a +typical stupor content was recalled, however. She thought she was +standing in water and heard bells ringing. + +Stupor-like reactions are not infrequent in connection with or following +fevers. Bonhoeffer[34] describes a type that follows a febrile +Daemmerzustand of a few hours or a day at most. The affect suddenly +goes, disorientation sets in. Although outbreaks of anxiety may be +intercurrent, the dominant picture is of stupor. Reactions are slowed, +often there is catalepsy. Sometimes there is a retention defect and +confabulation to account for the recent past. Again the retention may be +good. In the foreground stands a strong tendency to perseveration. This +may affect speech to the point of an apparent aphasia or produce +paragraphia. Plainly organic aphasia and focal neurological symptoms are +sometimes seen. + +As Knauer[35] has gone thoroughly into the question of the febrile +stupors, the reader is referred to his paper for a digest of the +literature on this topic. Mention has already been made in Chapter IX to +this publication, where the close resemblance of these rheumatic, to our +benign functional, stupors has been noted. Discrimination seems to be +possible only on the basis of delirium-like features being added in the +organic group. + + +FOOTNOTES: + +[C] This chapter has been written mainly from material in Dr. Hoch’s +notes which was manifestly incomplete. No claim is made for its +exhaustiveness. + + _The Editor._ + +[13] Dagonet, M. H.: “De la Stupeur dans les Maladies Mentales et de +l’Affection mentale désignée sous le Nom de Stupidité.” _Annales +Medico-Psychologiques_, T. VII, 5e Serie, 1872. + +[14] Newington, H. Hayes: “Some Observations on Different Forms of +Stupor, and on Its Occurrence after Acute Mania in Females.” _Journal of +Mental Science_, Vol. XX, 1874, p. 372. + +[15] Clouston: “Mental Diseases.” J. & A. Churchill, 1904. + +[16] Stern: “Ueber die akuten Situations-psychosen der Kriminellen.” +Abstracted, _Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate Bd. +V, S. 554. + +[17] Wilmanns, K.: “Statische Untersuchungen über Gefängnisspsychosen.” +_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 847. + +[18] Kutner: “Ueber katatonischer Zustandsbilder bei Degenerierten.” +_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 375. + +[19] Chotzen: “Fall von degenerativem Stupor.” Abstracted, _Zeitschr. f. +d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 1077. + +[20] Seelig: “Psychiatrischer Verein in Berlin, 1904.” _Neurol. +Centralbl._, 1904, S. 421. + +[21] Löwenstein: “Beitrag zur Differentialdiagnose des katatonische u. +hysterische Stupors.” _Allg. Zeitschr. f. Psychiatrie_, Bd. LXV. + +[22] Gregor: “Über die Diagnose psychischer Prozesse im Stupor.” Leipzig +Meeting, 1907. Reported in _Neurol. Centralbl._, 1907. S. 1083. + +[23] Froederström: “La Dormeuse d’Okno. 32 ans de Stupeur, Guérison +complète. Nouvelles Iconographies de la Salpétrière,” 1912, No. 3. +Reviewed by E. Bloch, _Neur. Centralbl._, 1913, S. 852, and by Forster, +_Zeitschr. f. d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 510. + +[24] Gadelius: “Ett ovanligt fall af stupor med nära 9-arig oafbruten +tvangsmatning; uppvaknande; total amnesi; helsa” (_Hygiea_, 1894, LVI., +Part 2, No. 10, p. 355). Abstracted by Walker Berger, _Neurol. +Centralbl._, 1895, S. 186. + +[25] Leroy: “Un cas de stupeur, guéri au bout de deux ans et demi.” +_Bull. de la Soc. Clin. de Méd. Ment._, III, 276, 1910. Abstracted in +_Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate, Bd. II, S. 495. + +[26] Myers, Charles S.: “Contributions to the Study of Shell Shock.” +_Lancet_, January 8, 1916, pp. 65-69. _Lancet_, September 6, 1916, pp. +461-467. + +[27] Gucci, R.: “Sopra una particolarità del mutismo per stupore +communicazione preventive.” _Archivio italiano per le malattie nervose_, +1889, XXVI, 69-108. Reviewed in _Neurol. Centralbl._, 1889, S. 659. + +[28] “Dementia Præcox oder Gruppe der Schizophrenie” Aschaffenburg’s +“Handbuch der Psychiatrie.” + +[29] Raecke: “Zur Prognose der Katatonie.” _Arch. f. Psychiatrie_, Bd. +XLVII, 1, 1910. + +[30] Whitwell: “A Study of the Pulse in Stupor.” _Lancet_, Oct. 17, +1891. Reviewed by Ziehen, _Neurol. Centralbl._, 1892, S. 290. + +[31] Wetzel: “Die Diagnose von Stuporen.” Baden-Baden Meeting of May, +1911. Reported in _Neurol. Centralbl._, 1911, S. 886. + +[32] Vogt, Ragner: “Zur Psychologie der Katatonischen Symptome.” +_Centralbl. für Nervenheilkunde_, 1902, S. 433. + +[33] Gnauck, R.: “Stupor nach Kohlenoxydvergiftung” (_Charité-Annalen_, +1883, p. 409). Reviewed by Moeli, _Neurol. Centralbl._, 1883, S. 237. + +[34] Bonhoeffer: “Die Symptomatischen Psychosen,” 1910. + +[35] Knauer, A.: “Die im Gefolge des akuten Gelenkrheumatismus +auftretenden psychischen Storungen.” _Zeitschr. f. d. ges. Neurol. u. +Psychiatrie_, Bd. XXI, S. 491-559. + + + + +INDEX + + +absorption, 163 + +activity, reduction of, 36, 100, 120 + +acute dementia, 251 + +adaptation, 107, 192 + +adrenalin, 180 + +affect, 9, 22, 32, 44, 113, 116, 117, _123_, 170 + +affect, dissociation of, 128, 201, 205, 237 + +affect, inappropriate, 216, 237 + +affect, poverty of, 234 + +affect, shallow, 127 + +affectlessness, 171, 172 + +affects, combination of, 245 + +agitation, 156 + +akinesis, 121 + +akinetic psychoses, 4, 274 + +albuminuria, 40 + +allied to dementia præcox, 236, 260 + +allied to manic-depressive, 236, 260 + +allopsychic, 135 + +ambivalence, 147 + +amnesia, 9, 24, 68, 70, 267, 269 + +anergic or unconscious stupor, 258 + +anergic stupor, 255, 256 + +anesthesia, 196, 212, 268 + +anger, 118, 139 + +angiospastic, 276 + +animal, turning into, 171 + +Antæus, 190 + +apathy, 36, 48, 112, 122, 123, 151, 152, 163, 181, 195, 225, 237 + +apathy, resemblance to absorption, 202 + +anxiety, 122, 123, 126, 137, 153, 162, 166, 198, 226 + +apoplexy, 224 + +arteriosclerotic dementia, 80 + +attention, 195 + +atypical features, explanation of, 200 + +autoerotism, 199 + +automatism, 268 + + +Baillarger, 252 + +behavior, 195 + +“Benommenheit,” 67, 273, 274 + +bewilderment, 79, 112, 120, 126 + +Bleuler, 67, 273 + +blocking, 163 + +blood-pressure, 181 + +blushing, 9 + +Bonhoeffer, 277 + +boredom, 247 + +bowels, interest in, 217 + +brain tumor, 5 + +breath, holding, 62 + +Brierre de Boismont, 252 + +burial, 111, 192 + + +Calculation, 23, 24 + +Calvary, 111 + +Cannon, 180 + +Cases + Adele M. (Case 24), 220 + Alice R., 135, 140, _192_ + Anna G. (Case 1), _6_, 47, 48, 68, 74, 77, 109, 127, 136, 140, 145, + 147, 183 + Anna L. (Case 16), 135, _149_, 158 + Anna M., 135 + Annie K. (Case 5), _24_, 69, 72, 105, 110, 111, 136, 139, 141 + Bridget B., 135 + Caroline de S. (Case 2), _11_, 68, 109, 141, 178, 193 + Catherine H. (Case 23), _216_ + Catherine M. (Case 18), _158_ + Catherine W. (Case 25), _221_ + Celia C. (Case 17), _155_ + Celia H. (Case 19), _167_ + Charles O., 143, 144, 178 + Charlotte W. (Case 12), _83_, 106, 112, 113, 116, 127, 136, 141, 144, + 166, 201 + Emma K., 71, 140 + Harriett C., 138 + Helen M., 130 + Henrietta B., 138, 140 + Henrietta H. (Case 8), _42_, 74, 77, 105, 106, 110, 111, 115, 136 + Isabella M., 136, 144, 147 + Johanna B., 135, 138 + Johanna S. (Case 13), _91_, 120, 127, 136 + Josephine G., 138 + Laura A., 71, 77, 135, 138, 140, 142, 193 + Maggie H. (Case 14), 71, 96, 109, 140, 194 + Margaret C. (Case 10), _55_, 75, 78 + Mary C. (Case 7), _39_, 42, 71, 74, 77, 121, 136, 138, 178, 194 + Mary D. (Case 4), _20_, 47, 69, 70, 71, 74, 76, 109, 136, 145 + Mary F. (Case 3), _14_, 68, 105, 110, 111, 115, 140, 142, 164, 183 + Mary G., 140, 141 + Meta S. (Case 15), _99_, 109, 127, 135 + Nellie H. (Case 22), _214_ + Pearl F. (Case 9), _51_, 75, 142 + Rose S. (Case 21), _210_ + Rose Sch. (Case 6), _35_, 74, 75, 145 + Rosie K. (Case 11), _62_, 75, 105, 112, 178 + Winifred O’M. (Case 20), _207_ + +catalepsy, 13, 21, 31, 32, 36, 86, 94, 95, 102, 115, 128, _143_, 144, +145, 147, 209, 211, 235, 239 + +catatonia, 4, 5, 50, 128, 205, 236, 261 + +catheterization, 85, 86, 102 + +cemetery, 105, 112 + +childbirth, 159 + +childhood, 188, 195 + +Chotzen, 262 + +Christ, 86, 115 + +Christian Science, 150 + +circular psychosis, 5, 126 + +circulation, 180 + +Clark, 184 + +clouding, 67 + +Clouston, 258 + +cocoon, 109 + +coffin, 88, 106, 114 + +coma, 176, 223 + +concussion, aerial, 224 + +confusion, 163 + +constipation, 92 + +convent, 117 + +convulsive attacks, 15 + +crime, 248 + +crucifix, 88 + +crucifixion, 86, 106, 114, 161 + +crustaceans, 148 + +cut-up idea, 94 + +cyanosis, 32, 63, 180 + + +Dagonet, 3, 249, 250, 253, 254, 258 + +death, feigned, 5, 83, 137, 196, 246 + +death, mutual, 192 + +death, projected, 198 + +death, relation with affect, 110 + +death ideas, 3, 46, 47, 50, 52, 58, 65, 83, 97, _104_, 107, 109, 110, +111, 114, 115, 119, 122, 136, 137, 138, 152, 153, 156, 159, 163, 166, +187, 190, 191, 192, 199, 212, 225, 235, 240 + +death of others, 192 + +deep stupor, _1_, 6, 41, 199 + +deep stupor, explanation of, 197 + +Delasiauve, 253 + +delirium, 176 + +delusional stupor, 255, 256 + +delusions, 165 + +délire mélancholique, 252 + +dementia præcox, 4, 5, 62, 123, 127, 128, 205, 225 + +depression, 5, 117, 123, 137, 156, 236, 253 + +depression, differentiation of, 48, 124, 226 + +dermatographia, 102, 180 + +deterioration, 210 + +diabetes, 224 + +diarrhea, 45, 64, 178 + +dissociation, 225 + +distress, 119, 122, 154, 156, 162 + +dreams, 161, 190 + +drooling, 132, 181 + +drowning, 87, 192 + + +Earth, 107, 111, 190 + +echolalia, 275 + +echopraxia, 275 + +ecstasy, 91, 162, 191 + +_élan vital_, 123 + +elation, 44, 91, 123, 127, 151, 157 + +electric chair, 85, 110, 119 + +electricity, 150 + +emaciation, 8, 32, 58 + +emotion, 62 + +emotion, inconsistency of, 126 + +emotions and contact with reality, 164 + +energy, 187, 194 + +epilepsy, 5, 183, 199, 224, 242, 254 + +epileptic aura, 184 + +epileptic confusion, 80 + +epileptic deterioration, 80 + +erotic, 161 + +erotic ideas, 90 + +Esquirol, 251 + +Etoc-Demazy, 251 + +Euripides, 2 + +excretion, habits of, 230 + +extroversion, 195 + + +family visits, 232 + +father, 104, 109, 110 + +fear, 111 + +fever, 8, 13, 26, 32, 38, 40, 45, 64, 102, 160, _176_, 235, 241 + +filthiness, 210 + +fire, 151, 157 + +flippancy, 129 + +flushing, 27, 127, 128, 180 + +food, refusal of, 99, 104 + +Forel, 182 + +Froederström, 265 + + +Gadelius, 267, 268 + +Ganser reaction, 263 + +Georget, 251 + +German psychiatry, 259 + +Gnauck, 277 + +giggling, 206 + +God, 115, 160, 162 + +Golden Age, 187 + +Gregor, 265 + +Gucci, 271 + +guilt, 157 + + +hair, loss of, 32, 58, 180 + +heat production and loss, 179, 181, 242 + +Heaven, 87, 88, 104, 106, 108, 109, 111, 114, 115, 117, 118, 160, 162, +166, 171, 191, 240 + +Hell, 240 + +Hoch, 164 + +hyperæmia, 8 + +hyperesthesia, 268 + +hypochondria, 225, 253 + +hypomania, 243 + +hypnotism (see mesmerism), 145, 213 + +hysteria, 3, 135, 184, 225, 264, 267, 269 + + +ideational content, 82, 235 + +immobility, 85, 94, 196 + +immorality, 150 + +impulsiveness, 50, 113, 128, 172 + +impurities in stupor reaction, 66 + +inaccessibility, 141 + +inactivity, 17, 30, 40, 48, 56, 62, 88, 97, 102, 123, _132_, 152, 163, +194, 225, 234, 238 + +inactivity, patients’ explanation of, 134 + +incest ideas, 209 + +inconsistency of reaction, 134, 214, 215, 245 + +incontinence (see _wetting_ and _soiling_), 52, 57 + +indifference, 123, 124, 142 + +infantile reactions, 196 + +infections, 5, _178_, 241 + +insight, 157 + +insomnia, 39 + +instinct of self-preservation, 188, 191, 198 + +interest, 99, 195 + +internal secretions, 178 + +internal thoughts, 163 + +interruptions of stupor, 130, 197, 238, 244 + +introversion, 164, 227 + +involuntary nervous system, 178, 180 + +involution melancholia, 129, 195, 225, 226 + + +jaundice, 21 + +Jung, 107 + + +Kahlbaum, 4, 260 + +Kirby, 4, 6, 164, 234 + +Knauer, 175, 278 + +Kraepelin, 4, 260, 269, 271, 272, 273 + +Kutner, 262 + + +laughter, 56, 141 + +Leroy, 269 + +leucocytosis, 8, 13, 40, 64, 178 + +levels, principle of, 198, 244 + +Löwenstein, 264 + + +MacCurdy, 2, 184 + +make-up, mental, 5 + +malignant stupors, _205_ + +mania (or manic), 5, 126, 137 + +mania, absorbed, 125, 226, 245 + +manic content, 166 + +manic-depressive insanity, 149, 167 + +manic-depressive insanity, mixed conditions in, 202 + +manic-depressive insanity, pathology of, 174 + +manic episodes, 191 + +manic stupor, 125, 245, 253 + +marriage, 160, 169 + +masturbation, 196, 209, 219 + +melancholic or conscious stupor, 258 + +memory (see thinking disorder), 40, 67, 168, 195 + +menstruation, 8, 56, 61, 100, 168, _182_, 236, 242 + +mesmerism, 86, 114, 117, 141, 144 + +Meyer, Adolf, 260 + +Meyer, E., 261 + +midday nap, 247 + +mixed conditions, 202, 273 + +Moeli, 264 + +Moses, 108 + +mother’s body, 108 + +movement, spontaneous, 133 + +muscular resistiveness, 224 + +mutism, 10, 22, 31, 57, 62, 88, 104, 124, 134, 209, 271 + +mutual death, 165, 192, 196, 248 + +Myers, 270, 271 + +mystics, 3 + +mythology, 107, 108, 190, 240 + + +negativism, 5, 31, 52, 56, 65, 128, _138_, 139, 199, 209, 225, 235, 238, +243, 276 + +negativism, explanation of, 196 + +nephritis, 224 + +neuropsychic defect, 174 + +neurotic, 150 + +nervous, 159 + +Newington, 3, 254, 255, 257 + +Nirvana, 166, 188, 200, 248 + +nourishment, 229, 242 + + +Œdipus, 165 + +œstrous cycle, 182 + +onset, 96 + +onset, depressive, 99 + +ophthalmic disease, 230 + +Orestes, 2 + +organic delirium, 175 + +organic dementia, 67 + +organic stupor, 223 + +orientation (see thinking disorder), 9, 53, 154, 156, 159, 170, 245 + +Osiris, 108 + + +pain, 133 + +Papanicolaou, 182 + +paragraphia, 80 + +paralysis, feeling of, 105 + +paralysis, general, 5, 254 + +partial stupor, _34_, 206 + +perplexity, 125, 152, 153, 154, 155, 156, 160, 162, 164, 165, 169, 172, +208, 226, 245 + +perplexity, differentiation of, 227 + +perseveration, 145, 148, 276 + +personality, 1 + +perversity, 138 + +physical disease, 175 + +physical symptoms, _174_, 176 + +Pinel, 249, 251 + +poison, 97, 172 + +primitive ideas, 108 + +prison, 105, 169 + +prognosis, 4, 5, _206_ + +prostitution, 157, 161 + +psychoanalysis, 161 + +psychobiological reaction, 246 + +psychogalvanic reflex, 276 + +psychological explanation, 186 + +psychological factors, 175 + +pulse, 63, 92, 128, 180 + + +Rank, 107 + +reality, 107, 187 + +recuperation, 189 + +rebirth, _107_, 110, 114, 115, 119, 120, 121, 122, 187, 189, 190, 191, +240 + +regression, 187, 188, 191, 192, 194, 198, 199, 243 + +religious visions or ideas, 2, 162 + +resentment, 98 + +resistiveness, 54, 97, 102, 112, 127, 129, 133, 141, 147, 156, 211, 225 + +respiration, 180 + +resurrection, 159 + +restlessness, 53, 120, 169 + +retention of urine, 224, 230 + +rheumatism, 175 + +rigidity, muscular, 142, 179 + +Romberg sign, 262 + +rousing, 176 + + +sadness, 111, 113, 121, 122, 124 + +St. Catherine of Siena, 2 + +St. Paul, 2 + +saliva, 30, 63, 181 + +scattered speech, 207, 208 + +schizophrenia, 67, 214 + +seclusiveness, 207 + +secondary stupor, 259 + +Seelig, 263 + +self-injury, _50_, 57 + +sexual excess, 251, 253, 258 + +sexual ideas, 209, 219 + +sexual sensations, 209 + +ship, 87, 106, 118 + +sick, 136 + +skin, dry, 180 + +skin, greasy, 43, 180 + +sleep, 188, 189, 247 + +slowing of thought, 125 + +slowness, 85, 119, 160 + +smearing of feces, 142 + +smiling, 127 + +social status, 236 + +soiling, 30, 132, 172, 196, 225, 230, 235 + +somatopsychic, 135 + +sphincters, control of, 133 + +spirits, 89 + +spoiled child reaction, 129, 139 + +starvation, 182 + +stereotypy, 276 + +Stern, 261 + +stimulation, mental, 231, 246 + +Stockard, 179, 182 + +stubbornness, 142 + +stupidity, 93 + +stupor, diagnosis of, _223_ + hysterical, 225 + malignant, _205_, 206 + organic, 223 + reaction, _35_, 236 + relation to manic-depressive insanity, 173 + +sudden mental loss, 71 + +suggestibility, 145, 198, 276 + +suicidal impulses, _50_, 84, 104, 116, 118, 128, 172, 230, 235, 240 + +suicide, 188 + +sulkiness, 129 + +sullenness, 142 + +suprarenals, 242 + +swallowing, 133 + +sweating, 63, 102, 179, 180 + +swimming movements, 94 + +syncopal attacks, 64 + + +tears, 95, 98, 117, 128, 153 + +tense of ideas, 116 + +thinking disorder, 22, 31, 37, 39, 41, 45, 48, 59, _67_, 75, 124, 125, +148, 152, 157, 235, 239, 247 + +thinking disorder, explanation of, 195 + +tongue, coated, 13 + +toxins, 175 + +trauma, 5, 224 + +treatment, _229_ + + +ulceration of eyes, 133 + +unconscious ideas, 163 + motives, 186 + +unconsciousness, physiological, 199, 224, 277 + +underground, 240 + +understanding, 67 + +uneasiness, 93, 94, 95, 121 + +unfaithfulness, 97 + +unhappiness, 192 + +urine, retention of, 31 + + +Villermay, 250 + +Vogt, 276 + +vomiting, 45 + + +water, 94, 95, 106, 107, 114, 120 + +weakness, 137, 160 + +wealth, 169 + +wedding ring, 117 + +weight (see emaciation), 38, 52, 61 + +Wernicke, 3, 273 + +wetting, 30, 40, 132, 151, 170, 172, 196, 225, 230, 235 + +Wetzel, 276 + +whining, 171, 225 + +Whitwell, 276 + +Wilmanns, 261 + +womb, 108 + +worry, 110 + +writing, 27 + + +Ziehen, 276 + + + + +[Transcriber’s Note: + + +The following corrections have been made: + +p. 1: antequated to antiquated (antiquated methods) + +p. 11, 97, 100: period to colon (Under Observation:) + +p. 53: extra “when” removed (from “In June, 1914, when she was seen +smiling at times.” to “In June, 1914, she was seen smiling at times.”) + +p. 64: period to colon (Physical condition during the stupor:) + +p. 84: 24 italicized to match other dates (October 24) + +p. 91: missing blank line added between Case 12 and 13 + +p. 93: aswer to answer (in answer to questions) + +p. 145: diaeresis added to coöperation to match other instances + +p. 150: fatiguable to fatigable (nervous and fatigable) + +p. 153: phenomenom to phenomenon (unusual phenomenon for a stupor +patient) + +p. 159: comma added (correcting his grammar, and cried easily.) + +p. 161: missing “in” added (appeared in the statement that her father) + +p. 171: missing open quote added (she wants to go “to the river,”) + +p. 198: funadmental to fundamental (most fundamental symptoms) + +p. 211: salivia to saliva (drooling saliva) + +p. 220: inaccesibility to inaccessibility (disinterestedness and +inaccessibility) + +p. 252: dimunition to diminution (just as well in the diminution) + +p. 256: or to of (relaxation of sphincter muscles) + +p. 262, Footnote 19: v. to u. (Zeitschr. f. d. ges. Neur. u. +Psychiatrie) + +p. 265, Footnote 23: Zeitsch. to Zeitschr. to match other instances +(Zeitschr. f. d. ges. Neur. u. Psychiatrie) + +p. 271, Footnote 27: Archivo to Archivio (Archivio italiano per le +malattie nervose) + +p. 280, Index: catherization to catheterization + +p. 282, Index: ophtalmic to ophthalmic (ophthalmic disease) + +Irregularities in capitalization (e.g. Dementia vs. dementia) and +hyphenation (e.g. off-hand vs. offhand) have not been corrected. A +repetitive sentence on p. 46 (Then she became stupid, although neither +sad nor happy. Then, she claimed, she got stupid, but neither sad nor +happy.), and two spaced em-dashes on p. 87 have also been retained. +Minor punctuation errors (e.g. missing period, missing close or open +quote where intended placement is clear) have been corrected without +note. The abbreviations “p.m.”, “e.g.” and “i.e.” have been +standardized, with no space.] + + + + + +End of the Project Gutenberg EBook of Benign Stupors, by August Hoch + +*** END OF THE PROJECT GUTENBERG EBOOK 30065 *** diff --git a/30065-h/30065-h.htm b/30065-h/30065-h.htm new file mode 100644 index 0000000..c17cda4 --- /dev/null +++ b/30065-h/30065-h.htm @@ -0,0 +1,11375 @@ +<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" + "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> + +<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en"> + <head> + <meta http-equiv="Content-Type" content="text/html;charset=UTF-8" /> + <meta http-equiv="Content-Style-Type" content="text/css" /> + <title> + The Project Gutenberg eBook of Benign Stupors, by August Hoch, M.D. + </title> + <style type="text/css"> + +body { +margin-left:10%; +margin-right:10%; +} + +h1,h2,h3,h4 { +clear:both; +text-align:center; +} + +h2 { +font-size:125%; +line-height:1.75em; +padding-top:3em; +} + +h3 { +font-size:100%; +} + +h4 { +font-size:110%; +font-variant:small-caps; +text-decoration:underline; +} + +p { +margin-bottom:.75em; +margin-top:.75em; +text-align:justify; +} + +ul { +list-style-type:none; +} + +table { +margin-left:auto; +margin-right:auto; +} + +th { +font-weight:400; +} + +h1.intro { +font-size:x-large; +padding:2.5em 0; +} + +h1.tpg { +line-height:.5em; +} + +h1.ch1 { +padding-top:3em; +} + +p.ralign { +margin-right:2em; +text-align:right; +} + +p.phead { +font-size:105%; +padding-top:.5em; +} + +p.auth { +margin:auto; +padding:2em 0 3.5em; +width:25em; +} + +p.copy { +padding:2em 0; +} + +table.symp { +font-size:90%; +} + +table.symp td,th { +padding-top:1em; +vertical-align:top; +} + +th.toc { +font-size:x-small; +} + +th.rhead { +text-align:left; +} + +div.tp,div.copy,div.ded { +padding:3em 0 2em; +} + +div.blockquot { +font-size:85%; +padding:1em 0; +} + +div.tn { +background-color:#CFC; +border:dotted 1px; +color:#000; +font-size:80%; +margin:4em; +padding:1em; +} + +span.pagenum { +color:gray; +font-size:small; +font-style:normal; +left:92%; +position:absolute; +text-align:right; +} + +span.wider { +letter-spacing:.15em; +} + +span.tpsub { +font-size:50%; +font-weight:400; +} + +.center { +text-align:center; +} + +.smcap { +font-variant:small-caps; +} + +.pad-l { +padding-left:1em; +} + +.wee { +font-size:65%; +} + +.sm { +font-size:75%; +} + +.med { +font-size:110%; +} + +.lg { +font-size:125%; +} + +.xlg { +font-size:175%; +} + +.footnotes { +border:dotted 1px; +margin-top:2em; +padding:1.5em; +} + +.footnote { +font-size:small; +margin-left:10%; +margin-right:10%; +} + +.footnote .label { +position:absolute; +right:84%; +text-align:right; +} + +.fnanchor { +font-size:.8em; +font-weight:400; +text-decoration:none; +vertical-align:super; +} + +.poem { +margin-left:10%; +margin-right:10%; +text-align:left; +} + +.poem br { +display:none; +} + +.poem .stanza { +margin:1em 0; +} + +.poem span.i0 { +display:block; +margin-left:0; +padding-left:3em; +text-indent:-3em; +} + +.poem span.i1 { +display:block; +margin-left:.5em; +padding-left:3em; +text-indent:-3em; +} + </style> + </head> +<body> +<div>*** START OF THE PROJECT GUTENBERG EBOOK 30065 ***</div> + +<h1 class="intro">BENIGN STUPORS</h1> + +<p class="center phead">THE MACMILLAN COMPANY</p> + +<p class="center sm">NEW YORK · BOSTON · CHICAGO · DALLAS<br /> +ATLANTA · SAN FRANCISCO</p> + +<p class="center phead">MACMILLAN & CO., <span class="smcap">Limited</span></p> + +<p class="center sm">LONDON · BOMBAY · CALCUTTA<br /> +MELBOURNE</p> + +<p class="center phead">THE MACMILLAN CO. OF CANADA, <span class="smcap">Ltd.</span></p> + +<p class="center sm">TORONTO</p> + +<div class="tp"> +<h1 class="tpg"> +<span class="wider">BENIGN STUPORS</span><br /><br /> + +<span class="tpsub"><i>A STUDY OF<br /> +A NEW MANIC-DEPRESSIVE REACTION TYPE</i></span></h1> + +<p class="center auth">BY<br /> +<span class="med">AUGUST HOCH, M.D.</span><br /> + +<span class="sm">LATE DIRECTOR OF THE PSYCHIATRIC INSTITUTE OF THE +NEW YORK STATE HOSPITALS, WARD'S ISLAND, NEW +YORK. LATE PROFESSOR OF PSYCHIATRY, CORNELL +UNIVERSITY MEDICAL COLLEGE, NEW YORK</span></p> + +<p class="center">New York<br /> +<span class="med">THE MACMILLAN COMPANY</span><br /> +1921</p> + +<p class="center wee"><i>All rights reserved</i></p> +</div> + +<div class="copy"> +<p class="center sm">PRINTED IN THE UNITED STATES OF AMERICA</p> + +<p class="center sm copy"><span class="smcap">Copyright, 1921,<br /> +By THE MACMILLAN COMPANY</span><br /> +Set up and printed. Published July, 1921.</p> + +<p class="center sm">Press of<br /> +J. J. Little & Ives Company<br /> +New York, U. S. A. +</p> +</div> + +<div class="ded"> +<p class="center">TO<br /> +MY FORMER COLLEAGUES<br /> +IN THE<br /> +NEW YORK STATE HOSPITAL SERVICE</p> +</div> + +<p><!-- Page vii --><span class='pagenum'><a name="Page_vii" id="Page_vii">[vii]</a></span></p> + +<h2>EDITOR'S PREFACE</h2> + +<p>A word should be said as to the origin and history +of this book. When the late Dr. Hoch became Director +of the Psychiatric Institute of the New York +State Hospitals in 1910, he found there an interest +in just the kind of psychiatric research which it was +his ambition to further. His predecessor, Adolf +Meyer, had developed the conception that the +psychoses should be looked on as psychobiological +reactions rather than rigid nosological entities and +had inculcated the habit of scrupulously thorough +examination and record of what the patient said and +did. Meyer had broken away from the sterile habit +of making diagnoses in accordance with the set terms +used to label symptoms; and his work and that of +his assistants thus led to a collection of valuable +material which could serve as a useful starting point +for the keen clinical investigation of Hoch. Specifically, +attention had already been fixed on the +study of the so-called functional psychoses, comprising +what are generally termed Dementia Præcox and +Manic-Depressive Insanity. An urgent problem in +this field was to separate different reaction types in +order to discover which were recoverable and which +chronic or progressive. In order to understand +psychological reactions, interrelation rather than<!-- Page viii --><span class='pagenum'><a name="Page_viii" id="Page_viii">[viii]</a></span> +mere coincidence of symptoms must be studied and, +to aid in this, free use was made of the fundamental +principles of unconscious mentation as exposed in +the theories of Freud and his followers.</p> + +<p>Almost at the outset it had been discovered that +many patients presented clinical pictures that would +not fit into existing diagnostic pigeon holes. Dr. +George H. Kirby, whose skill and industry had made +the most valuable contributions to the archives of +the Institute, published in 1913 a brief paper in +which he pointed out, not only that many cases with +"catatonic" symptoms recovered, but also that clinically +the behavior of stupor showed it to be related +to manic-depressive insanity as well as dementia +præcox. Dr. Hoch took up the problem at this point. +Using Dr. Kirby's material and adding to it his +earlier observations as well as current cases, he endeavored +to work out the essentials of the stupor reaction. +It was his ambition to describe stupor not +only in its psychiatric bearing but also as a life +reaction.</p> + +<p>The significance of this task is to be realized only +when one considers the general import of the functional +psychoses. They are, biologically, failures +of adaptation. The chronic and deteriorating cases +give up the struggle permanently, while the temporary +insanities lay bare the soul of man as he catches +a glimpse of unreality but turns back to face the +world as it is. When one realizes that emotional +disturbances are characteristic of the benign psychoses, +it is easy to imagine how much such studies<!-- Page ix --><span class='pagenum'><a name="Page_ix" id="Page_ix">[ix]</a></span> +may ultimately illuminate the problems of normal +life.</p> + +<p>The technical value of this work to psychiatry is +more immediate. Kraepelin laid the foundations for +systematic classification with his dementia præcox +and manic-depressive groups. But the rigidity of +the latter, allegedly descriptive, term has confused +the problem of classifying many benign psychoses. +It was Hoch's ambition to prove that, although elation +and depression were the commonest mood +anomalies in this group, they had no more theoretic +importance than anxiety, distressed perplexity or +apathy. These other moods, although less frequent, +are just as characteristic of the psychoses in this +group. In other words, the name "Anxiety-Apathy +Insanity" would be as appropriate, theoretically, +as Kraepelin's term. In 1919 Hoch and +Kirby published a report on the perplexity cases. +This present book was designed to show that the +symptom complex centering around apathy is as distinct +as that which is recognized by all psychiatrists +as mania with its predominant characteristic of +elation.</p> + +<p>In 1917 ill health forced Dr. Hoch to resign from +his official duties. He retired to California with the +purpose of adding to psychiatric literature the +fruits of his long experience and unrivaled judgment. +His first task was this book. In the midst of +this work came a sudden collapse. As I had been in +close touch with his researches, coöperating in +psychological speculations, and was free to devote<!-- Page x --><span class='pagenum'><a name="Page_x" id="Page_x">[x]</a></span> +some time to it, he asked shortly before his death +that I complete the book. This obligation is incommensurate +with the debt I owe for years of inspiration, +tuition and criticism.</p> + +<p>The task has been mainly literary. I found the +first five chapters practically completed, while it has +not been difficult, as a rule, to discover from his +copious notes what his intentions were as to the +details of the following chapters. I have been +greatly aided by the assistance of Dr. Adolf Meyer +and of Dr. Kirby. The latter has been good enough +to read the entire manuscript, making invaluable +suggestions and criticisms.</p> + +<p class="ralign"> +<span class="smcap">John T. MacCurdy.</span> +</p> + +<p>New York.</p> + +<p><!-- Page xi --><span class='pagenum'><a name="Page_xi" id="Page_xi">[xi]</a></span></p> + +<h2>TABLE OF CONTENTS</h2> + +<table cellspacing="3" summary="Table of Contents"> + +<tr><th align="left" colspan="2" class="toc">CHAPTER</th><th class="toc">PAGE</th></tr> + +<tr><td></td><td class="smcap pad-l">Editor's Preface</td><td align="right"><a href="#Page_vii">vii</a></td></tr> + +<tr><td align="right">I.</td> <td class="smcap pad-l">Introduction and Typical Cases of Deep +Stupor</td> <td align="right"><a href="#Page_1">1</a></td></tr> + +<tr><td align="right">II.</td> <td class="smcap pad-l">The Partial Stupor Reactions</td> <td align="right"><a href="#Page_34">34</a></td></tr> + +<tr><td align="right">III.</td> <td class="smcap pad-l">Suicidal Cases</td> <td align="right"><a href="#Page_50">50</a></td></tr> + +<tr><td align="right">IV.</td> <td class="smcap pad-l">The Interferences with the Intellectual +Processes</td> <td align="right"><a href="#Page_67">67</a></td></tr> + +<tr><td align="right">V.</td> <td class="smcap pad-l">The Ideational Content of the Stupor</td> <td align="right"><a href="#Page_82">82</a></td></tr> + +<tr><td align="right">VI.</td> <td class="smcap pad-l">Affect</td> <td align="right"><a href="#Page_123">123</a></td></tr> + +<tr><td align="right">VII.</td> <td class="smcap pad-l">Inactivity, Negativism and Catalepsy</td> <td align="right"><a href="#Page_132">132</a></td></tr> + +<tr><td align="right">VIII.</td> <td class="smcap pad-l">Special Cases: Relationship of Stupor to +Other Reactions</td> <td align="right"><a href="#Page_149">149</a></td></tr> + +<tr><td align="right">IX.</td> <td class="smcap pad-l">The Physical Manifestations of Stupor</td> <td align="right"><a href="#Page_174">174</a></td></tr> + +<tr><td align="right">X.</td> <td class="smcap pad-l">Psychological Explanation of the Stupor +Reaction</td> <td align="right"><a href="#Page_186">186</a></td></tr> + +<tr><td align="right">XI.</td> <td class="smcap pad-l">Malignant Stupors</td> <td align="right"><a href="#Page_205">205</a></td></tr> + +<tr><td align="right">XII.</td> <td class="smcap pad-l">Diagnosis of Stupor</td> <td align="right"><a href="#Page_223">223</a></td></tr> + +<tr><td align="right">XIII.</td> <td class="smcap pad-l">Treatment of Stupor</td> <td align="right"><a href="#Page_229">229</a></td></tr> + +<tr><td align="right">XIV.</td> <td class="smcap pad-l">Summary of the Stupor Reaction</td> <td align="right"><a href="#Page_234">234</a></td></tr> + +<tr><td align="right">XV.</td> <td class="smcap pad-l">The Literature of Stupor</td> <td align="right"><a href="#Page_249">249</a></td></tr> + +<tr><td></td><td class="smcap pad-l">Index</td> <td align="right"><a href="#Page_279">279</a></td></tr> +</table> + +<p><!-- Page 1 --><span class='pagenum'><a name="Page_1" id="Page_1">[1]</a></span></p> + +<h1 class="ch1">BENIGN STUPORS</h1> + +<h2>CHAPTER I<br /> +<span class="sm">INTRODUCTION AND TYPICAL CASES OF DEEP STUPOR</span></h2> + +<p>The fact that psychiatry lags in development and +recognition behind other branches of medicine is due +in part to the crudity of its clinical methods. The +evolution of interest in science is from simple, +obvious and tangible problems to more intricate and +impalpable researches. Refined laboratory work has +been done in psychiatric clinics, particularly along +histopathological lines, but clinical studies follow +antiquated methods. The internist does not say, +"The patient has sugar in his urine, therefore he +has diabetes and therefore he will die." He finds a +glycosuria and looks for its cause. If this symptom +is found to be related to others in such a way as to +justify the diagnosis of diabetes, a therapeutic +problem arises, that of adjusting the chemistry of +the body. The prognosis depends not on the disease +but the interreaction of the organism and the morbid +process. Both in diagnosis and treatment an individual +factor, the patient's metabolism, is of prime +importance. Now in psychiatry, although the personality +is diseased, this personal factor has been<!-- Page 2 --><span class='pagenum'><a name="Page_2" id="Page_2">[2]</a></span> +almost entirely neglected. Text-books furnish us +with composite pictures which are called diseases, +not with descriptions of reactions brought about by +the interplay of personal and environmental factors. +Educated people are not satisfied with novels that +fail to depict real characters. Clinical psychiatry, +however, has been content with the dime-novel type +of character delineation. This is all the more disappointing, +inasmuch as the study of insanity should +contribute largely to our knowledge of everyday life. +This defect can only be remedied by looking on every +case as a problem in which the origin of each symptom +is to be studied and its relation traced to all +other symptoms and to the personality as a whole. +This is an ambitious task and we do not pretend to +any great achievement, merely to a beginning.</p> + +<p>No better psychoses could be chosen for a preliminary +effort than benign stupors. Every psychiatrist +has seen them, although they are wrongly diagnosed +as a rule, and they play no small rôle in the world's +history. Euripides represents Orestes as having a +stupor which is pictured as accurately as any modern +psychiatrist could describe an actual case.<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a> St. +Paul is chronicled as falling to the ground, being +thereafter blind and going without food or drink for +three days. While apparently unconscious he had +a religious vision. St. Catherine of Siena had several +unquestionable stupors, which are fairly well<!-- Page 3 --><span class='pagenum'><a name="Page_3" id="Page_3">[3]</a></span> +described. In fact the mystics in general seem to +have had communion with God and the saints most +often when they seemed unconscious to bystanders.<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a> +The obsession with death, which seems so intimate +a part of the stupor reaction, is a fundamental theme +in poetry, religion and philosophy. The psychology +of this interest is, speaking broadly, the psychology +of stupor. So, from a general standpoint, our problem +is related to the study of one of the most potent +ideas which move the soul of man.</p> + +<p>Psychiatrically, stupors have long remained an +unsolved riddle. In the century prior to 1872 (See +the digest of Dagonet's publication in <a href="#CHAPTER_XV">Chapter XV</a>) +French psychiatrists wrote some good descriptions +of stupor and offered brilliant, though sketchy generalizations +about the condition. Two years later +an English psychiatrist (Newington, See <a href="#CHAPTER_XV">Chapter +XV</a>) improved on the French work. Little light has +been thrown on the subject since then. The researches +of the later French School showed that +stupor often occurs in the course of major hysteria, +but this left many of these episodes obviously not +hysterical. When serious attempts were made at +classification, this ubiquitous symptom complex was +hard to handle. Wernicke wisely refrained from +attempting more than a loose descriptive grouping. +He called all conditions with marked inactivity and<!-- Page 4 --><span class='pagenum'><a name="Page_4" id="Page_4">[4]</a></span> +apathy "akinetic psychoses" and said that some +recovered, some did not. Taxonomic zeal began to +blind vision when Kahlbaum formulated his "Catatonia" +and included stupor in the symptom complex. +The condition which we call stupor occurs in the +course of many different types of mental disease. +It is true that it is frequent in catatonia but is not +exclusively there. Mongols have black hair and +straight hair, but one cannot therefore say that any +black and straight haired man is a Mongol. Fortunately +Kahlbaum prevented serious error by leaving +the prognosis of his catatonia open. When Kraepelin +included it in his large group of Dementia +præcox, however, it implied that stupor could not +be an acute, recoverable condition.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a> He unquestionably +advanced psychiatry greatly but his scheme was +too ambitious to be accurate. Many observers saw +patients, classified as dements according to Kraepelin's +formulæ, return, apparently normal, to normal +life. Finally Kirby<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a> published a series of cases +which showed decisively that this classification was +too rigid.</p> + +<p>Since his paper is the foundation for this present +study, it should be reviewed carefully. He first +points out that Kraepelin's "Dementia præcox"<!-- Page 5 --><span class='pagenum'><a name="Page_5" id="Page_5">[5]</a></span> +includes much more than it should with its inevitably +bad prognosis. He shows how others have found +patients with catatonic symptom complexes proceed +to recovery and speaks of these symptoms occurring +in epilepsy and even in frankly organic conditions, +such as brain tumor, general paralysis, trauma and +infections. Kirby's first claim is that there are +probably fundamentally different catatonic processes, +deteriorating and non-deteriorating. Lack +of knowledge has prevented us from understanding +the meaning of the symptoms and hence making the +discrimination. He points out that stupor seems to +represent an attitude of defense, similar to feigned +death in animals, and that in a number of his cases +it was clear that the stupor symbolized the death of +the patient. Apparent negativism, he found to be +often a consciously assumed attitude of aversion +towards an unpleasant emotional situation. In +cases where there had been no prodromal symptoms +pointing definitely to dementia præcox the outcome +was almost always good. To discriminate the cases +with good outlook from those with bad, he discerned +no difference in the stupors themselves, but observed +that the mental make-up and initial symptoms +differed sufficiently for diagnosis to be made. +His most important point is, perhaps, that these +benign stupors showed a definite relationship to +manic-depressive insanity in that some patients +passed directly from stupor to typical manic excitement, +while in others a "catatonic" attack replaced +a depression in a circular psychosis.</p> + +<p><!-- Page 6 --><span class='pagenum'><a name="Page_6" id="Page_6">[6]</a></span> +Kirby introduces, then, the idea of stupor being a +type of reaction which can occur either in dementia +præcox or in manic-depressive insanity. The matter +cannot be left there, in fact it raises new +problems: what constitutes the reaction? how are +the various symptoms interrelated? are they different +in deteriorating and acute cases? what is the +teleological significance of the reaction? if it be an +integral part of the manic-depressive group, how +does it affect our conceptions of what manic-depressive +insanity is? More than five years have been +spent in endeavors to answer these questions and the +results of the study are now presented.</p> + +<p>Naturally the first point to be settled is: what +constitutes the stupor reaction itself. We can say at +the outset that it is seen in the purest form in benign +cases, hence they make up the material of this book. +To discover the symptoms of the disorder one +cannot do better than to study them in their most +glaring form in deep stupors, where consistently +recurring phenomena may be assumed to be essential +to the reaction.</p> + +<div class="blockquot"> +<a name="ChapI_Case1" id="ChapI_Case1"></a> +<p><span class="smcap">Case 1.</span>—<i>Anna G.</i> Age: 15. Admitted to the Psychiatric +Institute July 25, 1907.</p> + +<p><i>F. H.</i> The mother and two brothers were living and said to +be normal. The father died of apoplexy when the patient was +seven.</p> + +<p><i>P. H.</i> The patient was sickly up to the age of seven, but +stronger after that. It is stated that she got on well at school, +though she was somewhat slow in her work. She was inclined +to be rather quiet, even when a child, a bit shy, but she had +friends and was well liked by others. After recovery she made<!-- Page 7 --><span class='pagenum'><a name="Page_7" id="Page_7">[7]</a></span> +a frank, natural impression. She was always rather sensitive +about her red hair. She began to work a year before admission +and had two positions. The last one she did not like very well, +because, she alleged, the girls were "too tough."</p> + +<p>Three weeks before admission she came home from work and +said a girl in the shop had made remarks about her red hair. +She wanted to change her position, but she kept on working +until six days before admission. At that time her mother kept +her at home as she seemed so quiet, and when the mother took +her out for a walk she wanted to return, because "everybody +was looking" at her. For the next two days she cried at times, +and repeatedly said, "Oh, I wish I were dead—nobody likes +me—I wish I were dead and with my father" (dead). She also +called to various members of the family, saying she wanted to +tell them something, but when they came she would only stare +blankly. For a day she followed her mother around, clung to +her, said once she wanted to say something to her, but only +stared and said nothing.</p> + +<p>Four days before admission she became quite immobile, lay in +bed, did not speak, eat or drink. She also had some fever.</p> + +<p>The patient herself, when well, described the onset of her +psychosis as follows: She knew of no cause except that her +brother, some time before the onset (not clear how long), was +run over by an automobile and had his foot hurt. She claimed +that while still working she lost her ambition, lost her appetite, +did not feel like talking to any one; that when she went out with +her mother it merely seemed to her that people stared at her. +The day before she went to the Observation Pavilion her cousin +came to see her, and she thought she saw, standing beside this +cousin, the latter's dead mother. She also thought there was a +fire, and that her sister was sweeping little babies out of the +room. Then, she claimed, she felt afraid (this still on the day +before going to the Observation Pavilion) because she had repeated +visions of an old woman, a witch. This woman said, "I +am your mother, and I gave you to this woman (i.e., patient's +real mother) when you were a baby." She also was afraid her +mother was "going away."</p> + +<p>At the <i>Observation Pavilion</i> she was described as constrained, +staring fixedly into space, mute, requiring to be dressed and fed.</p> + +<p><!-- Page 8 --><span class='pagenum'><a name="Page_8" id="Page_8">[8]</a></span> +<i>Under Observation:</i> 1. For five months the patient presented +a marked stupor. She was for the most part very inactive, +totally mute, staring vacantly, often not even blinking, so +that for a time the conjunctivæ were dry. She did not swallow, +but held her saliva; did not react to pin pricks or feinting +motions before her eyes. Sometimes she retained her urine, +again wet and soiled the bed. Often there was marked catalepsy, +and the retention of very awkward positions. As a rule +she was quite stiff, offering passive resistance towards any interference. +She had to be tube-fed at first. Later she was +spoon-fed, and then would swallow, in spite of the fact that during +the interval between her feeding she would let saliva collect +in her mouth. For a time she had a tendency to hold one +leg out of bed, and when it was put back would stick the other +out. Sometimes she walked of her own accord to the toilet chair, +but on one occasion wet the floor before she got there.</p> + +<p>During the first month after admission, this stupor was interrupted +for two short periods by a little freer action: she walked +to a chair, sat down, smiled a little, fanned herself very naturally +when a fan was given to her, though even then did not +speak.</p> + +<p>There was, as a rule, no emotional reaction, but after some +months she several times wept when her mother came, though +without speaking. Once when taken to the tub she yelled.</p> + +<p>Her <i>physical condition</i> during this stupor was as follows: She +menstruated freely on admission, then not again until she was +well. Several times she had rises of temperature to 102° or 103° +with a high pulse and respiration; again a respiration of 40, +with but slight rise of temperature, though the pulse had a tendency +to go to 130 and over. She was apt to show marked skin +hyperæmia wherever touched. With the fever there was found +a leucocytosis of from 11,900 to 15,000, with marked increase of +polynuclear leucocytes (89%). She got very emaciated, so that +four months after admission she weighed 68 lbs. (height 5' 2").</p> + +<p>2. About five months after admission she was often seen smiling, +and again weeping, and she began to talk a little to the +nurses, though not to the doctors. She also began to eat excessively +of her own accord, and rapidly gained weight, so that<!-- Page 9 --><span class='pagenum'><a name="Page_9" id="Page_9">[9]</a></span> +by January she weighed 98½ lbs., a gain of 30 lbs. in two +months. Yet she continued to be sluggish.</p> + +<p>3. For two more months she was apathetic and appeared disinterested, +often would not reply, again, at the same interview, +she would do so promptly and with natural voice. This condition +may be illustrated by the summary of a note made on January +29, 1908, which is representative of that period. It is stated +that she sat about apathetically all day, appeared sluggish, but +was fairly neat about her appearance and cleanly in her habits. +There was at no time any evidence of affect, except when asked +by the examiner to put out her tongue so that he could stick a pin +in it she blushed and hid her face. When asked whether she +worried about anything, she denied this. When questions were +asked, she sometimes answered promptly and in normal voice, +again simply remained silent in spite of repeated urging. On +the whole, it seemed that simple impersonal questions were answered +promptly; whereas difficult impersonal questions or questions +which referred to her condition were not answered at all. +She proved to be oriented. Thus she gave the day of the week, +month, year, the name of the hospital, names of the doctors and +nurses promptly. She also counted quickly and did a few simple +multiplications quickly. But she was silent when asked +where the hospital was located, how long she had been here, +whether she was here one or six months, how she felt. Questions +in regard to the condition she had passed through, or involving +difficult calculations, she did not answer. However, +some questions regarding her condition asked in such a way that +they could be answered by "yes" or "no" were again answered +quite promptly. Thus when asked whether her head felt all +right she said, "Yes, sir." (Is your memory good?) "Yes." +(Have you been sick?) "No, sir." (Are you worried?) "No."</p> + +<p>4. This apathy cleared up too, so that by the middle of March +she was bright, active and smiled freely. With the nurses she +was rather talkative and pleased, though this was not marked. +Towards the physician only was she natural and free. She then +gave the <i>retrospective account</i> of the onset detailed above. When +questioned about her condition she claimed not to remember the +Observation Pavilion, although recalling vaguely going there in +a carriage. She was almost completely amnesic for a consider<!-- Page 10 --><span class='pagenum'><a name="Page_10" id="Page_10">[10]</a></span>able +part of her stay in the Institute. She claimed it was only +in November or December that she began to know where she was +(five months after admission). In harmony with this is the fact +that she did not recall the tube- and spoon-feeding which had +to be resorted to for about four months of this period. No +ideas or visions were remembered. As to her mutism she said, +"I don't think I could speak," "I made no effort," again "I did +not care to speak." She claimed that she remembered being +pricked with a pin but that she did not feel it. She remembered +yelling when taken to the tub (towards end of the marked +stupor) and claimed she thought she was to be drowned.</p> + +<p>When she went home (March 24, 1908) she got into a more +elated condition. She was talkative, conversed with strangers +on the street, said to her mother that she was now sixteen years +old and wanted "a fellow." When the mother would not allow +her to go out, she said it would be better if they both would jump +out of the window and kill themselves. She then was sent back +to the hospital. In the first part of this period after her return, +she was somewhat elated and overtalkative, though she did not +present a flight of ideas, and was well behaved. She soon got +well, however, and was discharged, four months after her readmission, +fully recovered.</p> + +<p>After that, it is claimed, she was perfectly well and worked +successfully most of the time with the exception of a short period +in the spring of 1909, when she was slightly elated.</p> + +<p>In 1910 she had a subsequent attack, during which she was +treated at another hospital. From the description this again +seems to have been a typical stupor (immobility, mutism, tendency +to catalepsy, rigidity). According to the account of the +onset sent by that hospital (it was obtained from the mother), +this attack began some months before admission, with complaints +of being out of sorts, not being able to concentrate and fearing +that another attack would come on. Finally the stupor was said +to have been immediately preceded by a seizure in which the +whole body jerked. She made again an excellent recovery.</p> + +<p>The patient was seen about two years after this attack, and +described the development of the psychosis as follows: She +claimed she began to feel "queer," "nervous," "depressed," got +sleepless. Then (this was given spontaneously) she suddenly<!-- Page 11 --><span class='pagenum'><a name="Page_11" id="Page_11">[11]</a></span> +thought she was dying and that her father's picture was talking +to her and calling her. "Then I lost my speech." As after the +first attack, she claimed not to have any recollection of what went +on during a considerable part of the stupor but recalled that +she began to talk after her brother visited her. It is not clear +how she was during the period immediately following the stupor.</p> + +<p>She made a very natural impression and came willingly to +the hospital in response to a letter and was quite open about giving +information.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 2.</span>—<i>Caroline DeS.</i> Age: 21. Admitted to the Psychiatric +Institute June 10, 1909.</p> + +<p><i>F. H.</i> The father died of apoplexy when patient was nine. +The mother had diabetes. A paternal uncle was queer, visionary.</p> + +<p><i>P. H.</i> The patient was always considered natural, bright, had +many friends, and was efficient.</p> + +<p>Some months before admission the patient's favorite brother, +who is a Catholic, became engaged to a Protestant girl, and +spoke of changing his religion. The family and the patient were +annoyed at this, and the patient is said to have worried about +it, but was otherwise quite natural until seven days before admission. +Then, at the engagement dinner of the brother, the +psychosis broke out. She refused to sit down to the table, and +then suddenly began to sing and dance, cry and laugh and talk +in a disconnected manner. Among other things, she said "I +hate her," "I love you, papa" (father is dead), "Don't kill me." +She struck her brother. She was in a few days taken to the +Observation Pavilion.</p> + +<p>The patient stated after recovery that what worried her was +that the brother would marry a Protestant and that he would +leave home (favorite brother).</p> + +<p>At the <i>Observation Pavilion</i> she was excited, shouted, screamed, +laughed, called out "Don't kill me," again "Brother, brother," +"You are my brother" (to doctor).</p> + +<p><i>Under Observation:</i> 1. On admission, and for two weeks, the +patient presented a marked excitement, during most of which +she was treated in the continuous bath. She tossed about, threw +the sheets off, beat her breasts and abdomen, put her fingers +into her mouth, bit the back of her hands, waved her arms about,<!-- Page 12 --><span class='pagenum'><a name="Page_12" id="Page_12">[12]</a></span> +sometimes with peculiar gyration, etc., at the same time shouting, +singing, again praying, laughing or crying, sometimes fighting +the nurses and resisting them. She also talked quite a little as +a rule, but there were periods when, although excited, she would +not talk or answer questions. She was very little influenced in +her talk by the environment. When on one occasion asked if she +had any trouble, she said: "No—I don't want, somebody else +gave me a book—all right I love myself, Uncle Mike too—all +right too—all right I am in Bellevue—I love everybody except +the Jews all right, all right—give me water, give me milk, give +me seltzer—white horse uncle—Holy Father, he is killing me, +I want my mother," or "Wait a minute, say, that's a lie—oh no, +Holy water—no I didn't wash the water away—oh, she forgets, +I am sick—mother why don't you come—look at the baby, they +knocked my head against the wall—wait a minute, isn't that terrible?—I +was married—I was so—I forgot—April fool—I kiss +you seven kisses and one more—I love papa and mamma, I like +others too—I am papa's angel child—yes I confess I love him, +but I don't want to die myself." On another occasion, when +asked where she was, she said: "I am at the ball—I am going +to Heaven—don't shoot me" (affectless). (Why are you afraid?) +"Because you see—high water (in the tub)—white horse." +(What about the water?) "My name is Caroline—if you love +me, father, tickle me under my feet," or, rolling her eyes up, +"Oh, isn't that awful, that ring, that diamond, that is the key +to Heaven."</p> + +<p>2. For about ten days she was somewhat different. She became +quieter and at first lay muttering unintelligibly, saying +some things about being killed, but speaking little, often restlessly +tossing about and tremulous. She had to be tube-fed. On one +day (July 1) she smiled more and talked more, said to the +physician "You have been arrested for me—you arrested the +first man that I ever—New York State—let me see that book" +(note pad). Then she went on: "Oh, I am all apart—diamonds—they +didn't know—must I keep them clean?—what is your +name?—that is another thing I would like to know." But when +asked what house she was in she said: "This is the same Ward's +Island" and then added, "How long have I been here?—there is +my picture up there (register), who is that? (listening) it's Ida<!-- Page 13 --><span class='pagenum'><a name="Page_13" id="Page_13">[13]</a></span> +..." She began to sing softly. Then again she whined. +"O mamma, mamma!" When asked how long she had been +here, she said: "Since Decoration Day, when my father went +in my sister's house, nobody could catch up with me—somebody +blackened her eyes." When asked whether she was sick, she +said "No, insane."</p> + +<p>Although, as was stated, she said at one time, "This is the +same Ward's Island," usually questions regarding orientation +were not answered, as she gave few relevant replies, but she repeatedly +said spontaneously that she was in "Hoboken or Bellevue," +and called the nurse by the name of a former teacher. A +few days after this state had developed she had a fever. Once +this rose to 104°. The fever lasted two weeks, coming down +gradually. It was associated with a leucocytosis of 15,000 on +June 29 (no differential count) and with coated tongue. No +Widal (two examinations). No diazo (July 1).</p> + +<p>3. Then while the temperature still lasted she developed a +stupor which persisted for about a year. During this time her +temperature rose to 100° without ascertainable cause. She lay +for the most part motionless, changing her position but rarely; +her expression was stolid; she retained and drooled saliva, wet +and soiled herself. She never answered any questions; showed +no interest whatever. At times she was quite stiff and very resistive +but never cataleptic. Her extremities were cold and cyanotic. +She had to be tube-fed throughout. During this time +she lost much hair.</p> + +<p>After some months she occasionally gazed about furtively, or +later watched everything when unaware of being observed; at +this time she also smiled occasionally at amusing things, or perhaps +said "yes" or "no" to questions, but usually was stolid when +interrogated.</p> + +<p>Then about nine months after admission, while in the condition +just described, she developed a lobar pneumonia. During +it she remained the same. But during convalescence she began +to speak and eat.</p> + +<p>4. A period followed lasting six months during which she was +up and about, but sat or stood around a good deal. On the +other hand, she helped the nurses a little when urged. Her +face was often stolid, again she looked about. At times (even<!-- Page 14 --><span class='pagenum'><a name="Page_14" id="Page_14">[14]</a></span> +nearly to the end) she drooled and soiled. She said little. At no +time was she resistive. On other occasions she smiled or laughed, +not always on provocation, or she showed little playful tendencies, +such as throwing a pillow about the room, tearing leaves from the +plants, taking the doctor's arm and walking down the hall, asking +him to kiss her. At such times she often looked quite bright, +keen, alert and amused. Towards the end she would give at +times playful answers, such as "I came to-day," or "This is the +Hall of Fame." This tapered off, so that by December, 1910, +she was perfectly well.</p> + +<p><i>Retrospectively</i>, the patient claimed not to remember the upset +at the dinner, or what happened afterward, although recalling +the trip to the Observation Pavilion. She denied any +memory of the journey to the hospital, but could tell what ward +she came to. How well the condition after that was recalled, +was not inquired into, except that she could or would not explain +further the utterances during the first period. For the stupor +period it is stated that she remembered many external facts, but +it is not clear in which period they occurred.</p> + +<p><i>Catamnestic Note.</i> May, 1913: She has worked efficiently, and +is said to have been perfectly well.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 3.</span>—<i>Mary F.</i> Age: 21. Admitted to the Psychiatric +Institute June 28, 1902.</p> + +<p><i>F. H.</i> The mother died when the patient was five. The father +was living, an alcoholic and reckless man. Four brothers and +sisters died in infancy.</p> + +<p><i>P. H.</i> The patient was the only surviving child. She was +brought up in a convent and orphan asylum until 11, when +her father remarried. At 12 she had to go to work, hence she +had but little education. She was bright, efficient, well liked +by her employers (in one position five years). As to her peculiarities, +she was thought to be, perhaps, a little headstrong, +and was also described as always very exact, rather quick-tempered +and inclined to be irritable when crossed.</p> + +<p>She was married six months before admission and had a <em>baby +three weeks before admission</em>. The husband stated that when +the father found out she was pregnant, he spoke of killing him. +He frequently upbraided both husband and wife, though he lived<!-- Page 15 --><span class='pagenum'><a name="Page_15" id="Page_15">[15]</a></span> +with them. Even after the child was born he continued to be +disagreeable.</p> + +<p>The patient was rather low spirited and quieter after her marriage. +She worried over her illegitimate pregnancy and the scolding +from her father. But nothing was thought of all this, and +it did not interfere with her activity. The birth was normal. +She had no flow, no unfavorable symptoms, and sat up on the +twelfth day. She is said to have appeared natural mentally.</p> + +<p>A week before admission the family returned from the christening, +having left the patient apparently well. They now found +her sitting in her chair, limp, with closed eyes, giving no answer +to questions. Only after about twenty minutes could she be +aroused. After her father had given her milk with whiskey in +it, she claimed he had poisoned her. In the evening she was +bright and lively, singing and dancing with the others, but in +the night she woke up her husband, seemed frightened, said +somebody was in the room and that he should get a priest as she +was going to die. The husband went to sleep again. The next +forenoon the patient claimed she had been frightened all night +and thought her father was going to kill her husband.</p> + +<p>On the second day, while sitting at breakfast, she groped about +for the bread plate for some time and then said she had been +blind for a short time. During the day she had frequent spells +in which she would close her eyes, become perfectly quiet and +difficult to rouse. Sometimes at the beginning of these spells +she would say "I am going." She was then taken to her aunt +and walked there, a distance of a few blocks. She was there for +two days before going to the Observation Pavilion. In this time +she is said to have been quiet for the most part, often apparently +sleeping or staring. Once she said she was "rather dirty, +filthy." Once she tried to get out of the window, said it was a +door and that she wanted to get out and take a walk. Above +all, she had, in these two days, repeated peculiar seizures which +the aunt and the husband described as follows: When sitting +on a chair she would close her eyes, clench her fists, pound the +side of the chair, get stiff, slide on the floor, then thrash her +arms and legs about and move the head to and fro. She frothed +at the mouth. After the attack, which lasted a few minutes, she +breathed heavily for a while. Once she wiped off the froth<!-- Page 16 --><span class='pagenum'><a name="Page_16" id="Page_16">[16]</a></span> +with a handkerchief and gave the latter to the aunt, saying +"Burn that, it is poison." Before the attack she sometimes said +that it got dark over her eyes and that her face felt funny, again +that she had a pain in the stomach which worked towards her +right shoulder. There was no cry in the beginning of the attack, +but once she wet herself.</p> + +<p>After recovery the patient herself told the development of her +psychosis thus:</p> + +<p>There was trouble between the father and the husband, and +she was afraid of her father. On the day of the christening she +took sick: a queer feeling came over her and she wondered +whether she was going to die, "Then I seemed to lose myself, and +when I came to I found my family standing around me." Her +father gave her whiskey and she thought it was poison. "That +night I had spells of dancing and singing, it must have been +something I took, perhaps the liquor." The same night she was +frightened, thought her father might do some harm, and had a +vision of a person in white standing at her bed. After that she +had repeated spells in which she knew nothing until "I came to +again." "It was a queer trembling."</p> + +<p>At the <i>Observation Pavilion</i> she was described as in a state of +"intense mental depression," taking no interest in things going +on about her. She spoke, however; said she wanted to die, that +she had imagined her father had given her poison, that every +one was against her, and that people were talking about her.</p> + +<p>1. <i>On admission</i> the patient had a slightly elevated temperature, +which soon subsided, full breasts but without inflammation. +Sordes were not mentioned.</p> + +<p>For a few days she was essentially somewhat restless, getting +out of bed, disarranging her clothes, wandering about—all in a +rather deliberate, aimless way, sometimes vaguely resistive, again +with free movements. She looked, dazed, sometimes stared +straight ahead and looked "dreamy." Occasionally there was a +tendency to close her eyes. With the restlessness she looked at +times "a little apprehensive," or shrank away when approached. +She spoke slowly, with initial difficulty, but answered quite a +number of questions. The mental content of this period was +displayed in the following utterances: She would ask for a +priest, or say "Have I done something?" or "Do people want<!-- Page 17 --><span class='pagenum'><a name="Page_17" id="Page_17">[17]</a></span> +something?" or, when asked why she was here, she said "I have +done damage to the city, didn't I?" (What have you done?) +"I don't know." Or she spoke of people watching her. When +asked the day, she said "Judgment Day," yet she knew the month. +Once when asked what the place was she said, "This is the hereafter." +When asked what had happened at home, she said: +"Voices told me I was to be killed." She was not clearly oriented, +called the place Bellevue, asked "Isn't this a hospital?" yet again +said, "Ward's Island, where they work." On the day of admission +she thought she came "the day before," but knew she had come +in a boat. When asked her address, she said slowly, "Didn't I +live at, etc.," giving the address correctly. To the physician she +said, "Are you my brother?" And on another occasion, "My +God! You are Charlie" (brother). It was difficult to get her +to eat, and she had to be spoon-fed.</p> + +<p>2. Then she became more preoccupied, the restlessness was +much less in evidence, it became necessary to tube-feed her, she +retained her urine, answered a few questions, and when asked where +she was, she said, "Calvary, ain't it?" (What house?) "Heaven, +ain't it?" She still called the physician by the name of her +brother. After a few days this gave way to a more marked +stupor which lasted nearly two years. This was characterized +most frequently by a complete inactivity. She usually lay or +sat motionless, sometimes with mouth partly open, letting the flies +crawl over her face, gazing in one direction, soiling, wetting, +resisting moderately or markedly any interference, and had to be +tube-fed. But this was not the invariable state. The most +constant feature was her mutism, but even that was a few times +interrupted. Thus, when after a visit from her uncle (towards +the end of July, 1902) she tried to get out of the window and +was prevented, she swore at the nurse. Or in August, 1902, +when she got into another patient's bed and was taken out, she +resisted and said promptly: "I think it is a damned shame I +can't get into my own bed." But this was the extent of her talk +for a year and a half. Nor was she always totally inactive. In +the middle of July, 1902, she sometimes tried to get out of bed, +wandered about, got into other patients' beds. It was on such +an occasion that the above incident happened. In August, 1902, +she sometimes tried to get out when the door was opened, and<!-- Page 18 --><span class='pagenum'><a name="Page_18" id="Page_18">[18]</a></span> +we have seen that she tried to get out of the window, but she did +not change her placid expression at such times. Her motive was +not known. On two occasions towards the end of 1902, when +she was taken to a dance and was made to take part, she waltzed +with considerable animation but did not speak. This was quite +striking in that these incidents occurred in a setting of marked +inactivity (i.e., a condition in which she had to be pushed to the +table, pushed to the closet). She did not soil any more, but +she sometimes drooled and had to be spoon-fed. However, on a +third occasion when this was tried, she had to be dragged around. +Finally, though her facial expression showed at times a preoccupied +staring, she more often looked around, sometimes quite +freely and often looked up promptly enough when accosted. But +there was very little evidence of any affect at any time. We have +seen that twice she swore a little when opposed. On another +occasion she slapped a patient when the latter helped her. Twice +she was seen crying a little without apparent provocation, but +she did not laugh, and the only suggestion of pleasurable emotion +was that at the two dances mentioned she could be led into a +certain animation. Usually, even when she got less resistive +towards the end, she was essentially apathetic.</p> + +<p>Once in January, 1903, she could be made to write her name +but wrote her maiden name. In the end of 1903 she improved +gradually (a condition not well observed), so that by December +she answered some questions in a low tone. Even in April, 1904, +she was still described as apathetic, though she had begun to do +some work.</p> + +<p>3. Then she improved markedly and began to work, looked +after herself in a natural way, spoke freely, was entirely oriented +and her mood generally presented nothing striking. But her +mental attitude was still peculiar when she was questioned. She +seemed somewhat inattentive, sulky, sneering. Thus, when asked +why she was here, she said, "You will have to ask those who +brought me here."</p> + +<p>She denied ever having been pregnant, said the nurses on the +ward had spoken of her having had a child and that they had +showed her a child (one was born on that ward about August, +1903) but that it was not hers. She thought it was wrong for +the nurses to speak on the ward of her having been pregnant.<!-- Page 19 --><span class='pagenum'><a name="Page_19" id="Page_19">[19]</a></span> +Again questioned about her marriage, she first said she had not +been married, again that she was married "a year ago" (was in +the hospital then). Again she spoke of her husband as her +"gentleman friend," claimed she called herself Mary M. (maiden +name) until a girl friend wrote her a letter addressed to Mrs. F. +From then on, she called herself by her married name. But she +thought that probably they sometimes spoke of her marriage in +fun. If she were Mrs. F. she would be living in Mr. F.'s house.</p> + +<p>On June 29, when again asked about her marriage, she said +she was to have been married in December (correct date). (Were +you?) "So they say." (Do you remember it?) "In a way." +(When was the baby born?) "You will have to ask somebody +more superior to me, more experienced." Then, when further +questioned about the age of the baby, she said, "The baby I saw +in the ward was about a year old," and she claimed not to +remember ever having a baby. When asked why she had come +here she said, "Well, I don't know, perhaps you know better, +through sickness I guess," and later: "Well, don't you ever get +a cold and want doctors to examine you?" (What kind of a +place?) "This is a nice place for sensible people who have +enough knowledge to know and realize what they come for." But +she knew the name of the place, the date, the names of persons.</p> + +<p>Questioned about the trouble with her father or her husband's +trouble with him, she denied it, "If he did (sc. have any trouble), +I don't remember." About her not speaking, she said, in answer +to questions, "I didn't know what I was here for, what was the +object in keeping me here"; and to other questions about her +condition, "I don't know, those who examined me can tell you +more about that." Finally, she said in reply to the question, +why she came here, "I don't remember <em>unless it was through fire</em>," +but would not explain what she meant.</p> + +<p>In the beginning of July, she again said that she had no recollection +of her marriage.</p> + +<p>She then improved a great deal and finally appeared very +natural, gave the retrospective account noted in the history, had +a clear appreciation of the fact that she was married and had a +child. She claimed that she had previously forgotten about her +marriage and thought she was still merely keeping company with +Mr. F. She claimed not to remember coming to the hospital,<!-- Page 20 --><span class='pagenum'><a name="Page_20" id="Page_20">[20]</a></span> +did not know what ward she came to, who the doctor and nurses +were, in fact claimed that it was about a year before she knew +where she was. But she remembered having been tube-fed. She +could not say why she did not speak. But she appreciated that +she had been ill.</p> + +<p>Ten years after discharge the husband, in answer to an inquiry, +stated that she had been perfectly well and had had no trouble +at three successive childbirths.</p></div> + +<div class="blockquot"> +<a name="ChapI_Case4" id="ChapI_Case4"></a> +<p><span class="smcap">Case 4.</span>—<i>Mary D.</i> Age: 20. Admitted to the Psychiatric +Institute September 17, 1907.</p> + +<p><i>F. H.</i> The grandfather and the father of the patient were +alcoholics. The father died three years before the patient's +admission; he was killed in an accident. The mother stated that +she herself was nervous, but she made a normal impression.</p> + +<p><i>P. H.</i> The patient was described as bright at school and +efficient in her work as a dressmaker, but she was rather quiet, +inclined to stay at home and had not much inclination to consort +with the other sex. She was rather proud. As an example of +this is stated the fact that she was always somewhat sensitive, +because the family lived in the basement of the house in which +her mother was janitress. She did not menstruate until 16. It +was about this time that her father was killed in an accident. +She was considerably upset by this, talked a good deal about the +way he was killed, but did not break down. The patient on +recovery stated that it worried her because the father died without +having any chance to get a priest.</p> + +<p>Six weeks before admission the patient was given a vacation, +as there was not work enough in the shop, but she worked at +home.</p> + +<p>Two or three weeks before admission her appetite failed somewhat, +and ten days before admission, without any appreciable +cause, she began to sleep badly, seemed somewhat nervous, became +a little "fidgety" and said she worried because her mother had to +work so hard. Later she began to speak about people saying that +the ambulance would come for her and she heard voices saying +"You will be dead." It is not known in what emotional setting +these remarks were made. Her mother took her to a dispensary. +On the way she asked the mother where she was going and said<!-- Page 21 --><span class='pagenum'><a name="Page_21" id="Page_21">[21]</a></span> +"I can't tell the number and I don't know where I am going. I +think I am losing my mind." She also said she could not understand +any more what she read. She was put to bed. She then +talked less, appeared stupid, and was inclined to refuse food.</p> + +<p>Four days before admission she claimed that she could see her +dead father beckoning to her, again she said a certain young man +was God. She was sent to the Observation Pavilion. On the +day she went there she was reported to have shown a slight +jaundice.</p> + +<p>The patient, after her recovery, added to the above account of +the mother, that about two weeks before admission, for no reason +which she could state, she began to feel quiet, and that after that +her father's death began to prey on her mind, and that later she +had a vision of her father. She claimed that in this period she +had no fear but that her head felt dizzy and her vision +seemed dim.</p> + +<p>At the <i>Observation Pavilion</i> the patient was described as constrained, +refusing food, mute, resistive of attention, sometimes +muttering to herself and having the appearance of uneasiness.</p> + +<p><i>Under Observation:</i> 1. On admission the patient had a slight +jaundice, which disappeared in a few days, and the bile test in +the urine was negative on admission. She was rather thin, but +otherwise in good physical condition. Her temperature was 99.2°.</p> + +<p>For three months the patient was very inactive, moving very +little. She had to be dressed and undressed, when taken out of +bed. She often was markedly constrained, either lying with her +head raised from the pillow, or for long periods of time holding +her arms or hands in rather constrained positions on her body. +But there was at no time any catalepsy when tested by moving +her arms. In the beginning, however, before she lay so persistently +with her head raised, she was found holding it up from +the pillow after her hair had been fixed. Again, she did not +correct other, rather uncomfortable, positions in which she had +been left. There was also at times a slight or occasionally a +somewhat more marked resistance in her arms and neck, but this +never amounted to a pronounced resistance. She sometimes did +not react to pin pricks, sometimes flinched a little, never warded +off the pin, indeed she would put out her tongue repeatedly when +asked to do so in order to have a pin stuck into it. She very<!-- Page 22 --><span class='pagenum'><a name="Page_22" id="Page_22">[22]</a></span> +often wet and soiled, once even immediately after she had been +taken to the closet, on which occasion she did not urinate. Her +face was usually dull, vacant and immobile, but sometimes, when +questioned or when something obtrusive happened, a little puzzled. +Occasionally she looked slowly about or followed people +with her eyes. There was no evidence of any affect as a rule, +but not infrequently she smiled, even quite freely at times, when +the physician came to her or on other appropriate occasions. For +example, once when a nurse came into the ward whom she had +known outside she flushed and smiled a little. Once when the +mother came to see her a few tears appeared, the only time this +occurred.</p> + +<p>Although for the most part immobile, when she did move, she +was distinctly slow. When asked to do certain things, she usually +did not comply, but now and then, after urging, would show her +tongue after delay, or merely open her mouth; or she would +bring the hand forward slowly when the physician offered his +hand in greeting. Once she fumbled with her braids slowly. +When out of bed, she stood about aimlessly or sometimes walked +somewhat slowly.</p> + +<p>She was almost entirely mute, but a few times she returned a +greeting quite promptly, or on another occasion (September 23) +she said quite promptly, when asked how she felt, "I feel better. +I took off my clothes" (correct—she had been up and put to bed +again). Again she sometimes answered simple questions by +"yes" or "no," though sometimes in a contradictory and rather +aimless manner, but promptly enough. Once she said to her +mother, "I can't, I have to remain here." There were some other +replies which we shall presently take up. Several times it was +possible to make her write. On these occasions she wrote her +name promptly, or might write only after much delay or stopping +in the middle of a word.</p> + +<p>This leads us to her capacity to think, the defect of which was +perhaps most clear in her writing. Thus, though having been +told to write her name, and having written it quickly enough, +when, immediately after it, she was asked to write her address or +the name of the hospital, she had to be urged much, and then +wrote each time merely a repetition of her name, this time much +more slowly. On October 13, when she was asked to write her<!-- Page 23 --><span class='pagenum'><a name="Page_23" id="Page_23">[23]</a></span> +name, she wrote it correctly; then for the address she wrote the +house number correctly, but for 90th street she wrote "90theath"; +and, urged again for the address, she added "Dr. Wyeth." Again +when asked to write the word "watch" she was slow, and finally +put down "10." When on October 23 she was asked to write +"Manhattan State Hospital," she wrote "Manhatt Hhospshosh," +and for "Ward's Island" (which she was told), "Ww Iland." +Then she was asked to write "I wish to go home." She wrote +"I wish to go home, go West." Here again the first part was +written promptly.</p> + +<p>We now can add some of the other replies which she gave. +Once she was asked "Do you know where you are?" She +promptly said, "Yes." (Where?) No reply. On another +occasion, at the initial examination, she said she was home or +"in papa's house." Once when asked "Do you know me?" she +said "Yes." (What is my name?) "Miss D." (her name). On +the occasion on which she had stated that she had taken off her +clothes, she was asked "Where have you taken off your clothes?" +She made the irrelevant reply, "That was the girl the one I had."</p> + +<p>2. Then she improved somewhat. On January 5 she walked +about a little more, though slowly, and still looked slightly +puzzled when questioned. She spoke more readily, counted +promptly though once stopped in the middle of the exercise. In +calculation she multiplied correctly 3 × 7, but for 4 × 9 repeated +the 21, and when given 9 × 9 she did not answer. A few days +later, though she lay again motionless with her head raised as +before, and, as she had sometimes done, smiled brightly when +accosted, she gave few replies, but when asked to write down +the month she slowly wrote "December." Asked to write it the +second time, she did it promptly. She also replied promptly by +saying "Yes" when asked whether Christmas, and again whether +New Year's, had passed, but did not reply to the questions how +long ago Christmas, or how long ago New Year's, had occurred. +On January 23 she was decidedly more free and prompt in her +replies, yet she still wet and soiled (in fact this did not cease +until the end of the month, when great improvement occurred). +At this time she gave quite a number of calculations promptly, +about an equal number wrongly. She knew where she was, knew +the names of a number of people about her, but thought she had<!-- Page 24 --><span class='pagenum'><a name="Page_24" id="Page_24">[24]</a></span> +been here about two weeks (four months), and gave the year +and the date, the latter as the 28th of January. When then told +that it was Thursday, January 23, and that she must remember +it, and asked five minutes later what she had been told, she again +said "January 28" and left out Thursday. To some questions +to which she did not know the answers, since she had an amnesia +for the time of their occurrence (the incidents of coming here), +she simply remained silent. Even on February 7, when she was +much freer, helped the nurses, and said herself she was "smarter," +she had difficulty in thinking, said she was 17 (21), gave the date +of her birth correctly, but the current year as 1909 (1908) and +still insisted she was 17. She then did the calculations on paper, +and with considerable difficulty got correctly "22." But she +could not straighten out the discrepancy. At that time, also, +she still wrote "Hospitital," calculated even simple multiplications +with some mistakes, could not get the point of a story, and to +retention tests gave poor results. Indeed, even seven days later, +when she wrote a very rational letter and appeared quite natural, +she made some omissions in her writing, and a few mistakes in +spelling.</p> + +<p>However, she now improved rapidly, and by March 31 she +made a very natural impression, was frank, free, had good insight, +calculated well, etc., understood a story, retention was good.</p> + +<p>She then gave the retrospective account embodied in the history, +and in addition told that she had no recollection of going to the +Observation Pavilion, the coming here, or the first part of her +stay, including presentation of the case at a staff meeting, a +physical examination and a blood examination, and she claimed +for a long time not to know where she was, "I was in a kind +of dazed condition." She also said she could not understand +the questions which were asked her. This probably refers, +however, to the second part, i.e., the partial stupor lasting for +two months. She did not "feel like talking," the limbs "felt +stiff-like."</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 5.</span>—<i>Annie K.</i> Age: 22. Admitted to the Psychiatric +Institute January 7, 1907.</p> + +<p><i>F. H.</i> The father was an alcoholic, who died when patient was +a child. A paternal aunt had a nervous breakdown, with recovery. +The mother appeared to be normal.</p> + +<p><!-- Page 25 --><span class='pagenum'><a name="Page_25" id="Page_25">[25]</a></span> +<i>P. H.</i> The mother stated that the patient was a rather delicate +child. She attended school irregularly, never felt much interest +in it, and was always glad to be at home and help the mother +take care of the other children. On the other hand, she is said +to have been quite lively, rather a tomboy, with a temper. She +left school at 14; learned dressmaking for a year, but did not +get along well. Then she took several other positions, which +she held for about a year, getting on pretty well.</p> + +<p>She married at 20. Her husband never supported her well and +often beat her. She had to borrow money to get along and +worried much. During pregnancy she seemed to worry more, +had crying spells, and often seemed absorbed in thought.</p> + +<p>Three weeks before admission she gave birth to a child. The +labor was somewhat difficult, but she had no fever. She got up +on the tenth day, and then seemed to lose all interest, did not +attend to the baby, said she was not strong enough. She sat +about, appearing depressed. The mother then took her and the +baby to her house. There she sat or walked about, said very +little. But she repeatedly came to her mother, said she had +something to tell her, or that she had "done something," although +she could never be induced to say what. Once she came to her +and said, "You are not going to die." She often moaned. +Finally, she claimed a neighbor had been saying she was poisoning +the baby.</p> + +<p>The patient herself gave, after recovery, the onset as follows: +When she married she knew her husband was not what he should +be, but not that he was so bad as he proved to be. He was a +gambler, did not support her, and this caused her much worry. +When she became pregnant, eight months after marriage, this +increased her worry, and throughout the pregnancy she spoke +much to a neighbor about her worries, and said she did not know +how she could manage, pay the doctor, and the like, but she did +not say much about it to her mother (because the latter would +have made such a fuss about it, or would have said, "It serves +you right"). Then the childbirth came. This further accentuated +her worries. She felt her difficult circumstances, wondered how +she could get the necessary money, "I lay there worrying." And +she claimed she did not sleep at all. About her statement, mentioned +by the mother, that she had done something, she said that<!-- Page 26 --><span class='pagenum'><a name="Page_26" id="Page_26">[26]</a></span> +she thought she had poisoned the child by giving it fennel tea, +and that she thought a neighbor who visited her said she had +poisoned it. She was then put to bed again, and one night she +had a vision of her father. This frightened her. She thought +this meant he had come for her and she wanted to die.</p> + +<p>At the <i>Observation Pavilion</i> she was dull, staring, resisting +attempts at passive motions.</p> + +<p><i>Under Observation:</i> 1. There was nothing noteworthy in her +physical condition, except for a rise of temperature to 100° +occasionally during the first month of her admission. For the +first four months she was often found lying in bed with her head +half raised from the pillow, or standing or sitting about in +constrained positions, immobile, frequently she let saliva collect +in her mouth. She usually wet and sometimes soiled the +bed. Sometimes, when sitting in a constrained position, she let +herself gradually slide on the floor. She often began to feed +herself when urged, but would not finish, and had to be spoon-fed, +as a rule. She was never tube-fed. She was often quite stiff +and showed marked resistance. This was manifested either when +passive motions were tried, at which times she usually resisted +passively, i.e., she became more tense; or when there broke +through a more active aggression and she would strike. Above +all, the opposition showed itself towards the nurses' attention; +in this she also showed either a passive, aimless opposition and +stiffness, or a more active one; but even in the latter an open +show of angry affect, or plain irritation, though present at times, +was by no means constant. When it was present, she would strike +quite aimfully; once she struck the nurse and said, "You are the +cause of it all," and once, when the nurse tried to give her some +milk, she said, in an irritated tone, "I wonder people would not +let me alone some time." Again, she bit a patient who tried to +hold her. On another occasion she quickly jumped up and pulled +the hair of a patient who evidently disturbed her by her noisy +shouting. As was stated, she usually wet the bed, resisted being +taken to the toilet, or when taken there, would not urinate or +defecate, but would do so as soon as she was returned to bed; +or she urinated while standing. The same perverse opposition +was seen when she would refuse a glass of milk, but grab it when<!-- Page 27 --><span class='pagenum'><a name="Page_27" id="Page_27">[27]</a></span> +it was taken away and then refuse to let go. She often would +grasp the bedclothes or other things and hold on aimlessly.</p> + +<p>She rarely spoke, answered almost no questions, complied, as +a rule, not even with the simplest commands. To pin pricks she +did not react except at times by flushing. But she did not stare, +rather looked about, and was at times easily attracted by noises +or happenings about her, and would then look in that direction +not without some interest. Often there was then an expression +of bewilderment. Her mood, however, was, as a rule, apathetic, +but at times, as stated, she showed some anger. Once she wept, +and a few times she smiled or snickered. As a rule, this happened +without appreciable cause. But once, when a cheering +remark was made, she smiled; or, when her picture was taken (to +show the peculiar constrained attitude with the head raised from +the pillow), she laughed loudly.</p> + +<p>Although she spoke rarely, she made a few utterances in the +first few days. Thus she suddenly said: "I want to see Mr. N.—what +I said to him was not right," or "Listen! there are the +priests calling," or "You are all faking—it is me that done it—they +are all dressing up downstairs," or "I told you she was not +able to nurse the baby," or "I have nobody, I am lost—I want to +know the truth—my mamma," or she called her sister, "They are +dead since last night."</p> + +<p>Even during the more stuporous state she could, a few times, +be made to write a little. Then she either wrote very slowly and +not more than a letter, or if she wrote more, it was remarkably +mixed up. Thus when asked to write the date, she wrote, "Jane +(mother's name) to me to Chrichst," or when asked to write her +name: "Annie take you ktusto."</p> + +<p>As to her orientation, nothing could be made out as a rule. +At first, however, a few weeks after admission, she spoke correctly +of the month as January and spoke of the Island. When +at that time she was asked if she had a baby, she said, in an +annoyed tone, "I don't know."</p> + +<p>2. In the beginning of May, i.e., four months after entrance, +her condition changed somewhat, and for two months she presented +the following state: She stood about, or walked around +slowly, usually with her arms folded. She had a tendency to +stand near the door. She had to be assisted in dressing, pushed<!-- Page 28 --><span class='pagenum'><a name="Page_28" id="Page_28">[28]</a></span> +rather than led to her meals, and urged to eat. For the most +part, she would not answer questions, but would either smile in +a sneering way, or just walk away, or say, "Oh, don't bother me," +or "I don't want to talk," and generally her attitude was rather +sulky. Nor was this only towards the physicians but towards +the husband, sister and child as well. When on May 17 the +sister came, she would not speak to her but said "Go away." +The baby she simply pushed away sulkily when it was brought +to her. To the husband she said on May 31, "Go away, you +stink." In the first part of this period, she presented some +bursts of elation, on one occasion turned somersaults, indulged +in a few pranks with laughter, or once, when a knock at the door +was heard, she called out "Holy gee, cheese it, the cop." But +these occurred only in the first part of the period. On June 1 +she spoke to the nurse, said, "What is the matter with these +people, they must be crazy," asked to go home, and was then +by the nurse found to be oriented, and to know the names of +people around her. But when she was asked about the baby +she would not answer, and questioned whether she was not married, +she said "I don't know." Yet when the physician desired to +talk to her, she was just the same as before and remained so for +two more weeks. Another somewhat isolated occurrence was +when on June 18 she spoke a little to the physician, but she sat +in a constrained position when taken into the office and answered +many questions by "I don't know," namely, those regarding her +condition and feelings, the questions about orientation, about her +mother's address, and her child's age; but when asked how long +she had been married she said correctly "Two years."</p> + +<p>At the beginning of July she improved quite rapidly, and on +July 5 appeared fairly free and gave a fair retrospective account, +with some urging, and it was thought that she smiled somewhat +too freely. However, on July 27, she seemed perfectly well, had +normal insight, and then gave the second retrospective account, +which, together with the first, will now be taken up.</p> + +<p><i>Retrospectively:</i> She claimed to remember things at home, +and at both interviews said she recalled being taken to the +Observation Pavilion. While there she thought she knew where +she was, remembered that she did not talk. She had a feeling she<!-- Page 29 --><span class='pagenum'><a name="Page_29" id="Page_29">[29]</a></span> +was going to die and said "I thought I would die if I kept still." +However, the transfer to this hospital was vague in her mind, as +was the entrance on the ward, and she claimed not to have known +for quite a while where she was. She added that she used to +wonder where she was, how she had gotten here, and how she +could get out, and thought the questions which were asked were +queer. Individual occurrences, too, specifically inquired into were +not recollected, such as an examination in a special room. Of +the mixed-up writing at the end of the second week, she had no +recollection even when it was shown to her. She did not recall +having her picture taken (with eyes open) two months after +entrance. Yet a sudden angry outburst ten weeks after admission +was remembered. She stated that she struck the patient because +the latter annoyed her by her shouting. She had a general recollection +of being stiff, having her head raised, and of soiling and +drooling, but could not account for it. She felt stubborn. She +also claimed not to have been hungry and not to have felt pin +pricks.</p> + +<p>In regard to ideas which she had, she claimed to be afraid at +first that she would be cut up. She remembered repeated visions +of her father at night, also once of her dead aunt, who said +"Come to me." She thought she was in a cemetery, all the family +were dead, the baby dead. In the beginning, too, she sometimes +heard a priest whom she had known, say "Be good and God will +look after you."</p> + +<p>In regard to the later period, she recalled that she got up in +May and felt cross. She did not answer because she did not +want to be bothered. She pushed the baby away because she +did not think it belonged to her, the husband because she did +not like him. (She did not think she was not married.) She +evidently remembered the visits, thought she knew where she +was, knew she stood near the door "because I wanted to go home." +Besides the idea that the baby was not hers, she recalled none, +and thought she had no hallucinations.</p> + +<p>She was discharged perfectly well six months after admission +to the hospital. Soon after that, she left the husband, once had +him arrested in 1908 and sent to the workhouse. She was again +examined in 1913, and was found to be perfectly well, and she +stated she had been well since the discharge.</p></div> + +<p><!-- Page 30 --><span class='pagenum'><a name="Page_30" id="Page_30">[30]</a></span> +These five cases will have to suffice for the present. +They were given in full in spite of the fact that we +shall leave out of our present considerations the +history of the cases and certain of the stages, and +confine ourselves to that stage of each case which is +best qualified to give us a good general survey of the +essential features of the stupor reaction.</p> + +<p>These phases are: stage 1 of Case 1, lasting five +months; stage 3 of Case 2, lasting one year; stage 2 +of Case 3, lasting two years; stage 1 of Case 4, +lasting three months; stage 1 of Case 5, lasting four +months.</p> + +<p>We gather from these descriptions that the essentials +of the stupor reaction are (1) more or less +marked interference with activity, often to the point +of complete cessation of spontaneous and reactive +motions and speech; (2) interference with the intellectual +processes; (3) affectlessness; (4) negativism.</p> + +<p><i>Inactivity:</i> There is a complete cessation or more +or less marked diminution of all spontaneous or reactive +movements. This includes such voluntary +muscle reflexes as contain a psychic component. For +instance, there is, often, an interference with swallowing +(letting saliva collect and drooling), winking, +and even with the inhibitory processes used in holding +urine and feces (soiling and wetting). Often +there is no reaction to pin pricks or feinting motions. +The inactivity also often interferes with the taking +of food so that spoon-feeding or tube-feeding has to +be resorted to. The patient may keep his eyes cov<!-- Page 31 --><span class='pagenum'><a name="Page_31" id="Page_31">[31]</a></span>ered +or stare vacantly, the face often presenting a +remarkably immobile wooden, or stolid, expression. +Complete mutism is the rule. When activity is not +totally interfered with, those movements which are +present may be slow. The patient may have to be +pushed around and be able to take a few steps, but +soon relapses. More often they are of normal rapidity. +Speech then may also be slow and low, but +usually shows no change except for the fact that it +is diminished in amount. Sometimes awkward positions +are assumed and retained, and there may be +catalepsy.</p> + +<p><i>Negativism:</i> A common symptom is perverse +resistiveness. It may consist in a marked stiffening +of the body which is assumed spontaneously or appears +only when attempts at interference are made, +or there may be a more active turning away or even +a direct warding off, sometimes with scowling or +anger or even swearing and striking. Retention of +urine, which is seen at times, should, perhaps, be +mentioned here. Now and then we find that a patient +is put on the toilet and cannot be induced to urinate +or defecate, while soiling and wetting occur at once +on returning to bed.</p> + +<p><i>The intellectual processes:</i> Little is known about +the intellectual processes from direct observation in +these more pronounced cases, except for the fact +that in Case 5 questions or obtrusive occurrences +sometimes produced a somewhat puzzled facial expression. +Moreover, the patient retrospectively +stated that she was unable to understand the ques<!-- Page 32 --><span class='pagenum'><a name="Page_32" id="Page_32">[32]</a></span>tions, +which points to marked difficulty in apprehension. +We also find that occasionally there is +evidence of an interference with the intellectual +processes which showed itself in what may be called +"paragraphic" writing when the patient could be +induced to write. Above all, we see that retrospectively +very little is remembered of what took place +during the stupor, even of such obtrusive events as +the moving from one ward to another, tube-feeding, +physical examination, the presentation at a staff +meeting, and the like.</p> + +<p><i>Affect:</i> Complete affectlessness is an integral +part of the stupor reaction. Modification of the +statement will later be mentioned. The patient is +indifferent so far as his basic condition is concerned, +and it is only by certain stimuli that at times emotional +reactions can be elicitated, some tears at a +visit of a relative, an appropriate smile at a joke or +a comical situation when the stupor is not too deep +or an angry reaction called forth by interference.</p> + +<p><i>Catalepsy:</i> Waxy flexibility or merely a tendency +to maintain artificial positions is a frequent but not +an essential symptom.</p> + +<p><i>Physical Condition:</i> Not infrequently we find in +the beginning or in the course of the stupor an elevation +of temperature to 101°, 102° or even 103°. In +one case we found a marked cyanosis in the extremities. +Case 2 showed marked loss of hair. Gain in +weight is never observed and marked emaciation is +the rule. This we may attribute to the refusal of +food.</p> + +<p><!-- Page 33 --><span class='pagenum'><a name="Page_33" id="Page_33">[33]</a></span> +A perusal of these cases, then, shows that the +dominant (and well-nigh exclusive) symptoms of the +stupor are inactivity, apathy, negativism and disturbance +of the intellectual functions. Benign +stupor can be defined as a recoverable psychosis +characterized by these four symptoms. The meaning +of such vague physical manifestations as the low +fever is not clear.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> MacCurdy has discussed the psychological phenomenon of a +dramatist depicting a psychosis correctly in "Concerning Hamlet +and Orestes." <cite>Journal of Abnormal Psychology</cite>, Vol. XIII, No. 5.</p></div> + +<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> Many of these states seem to be hysterical rather than +manic-depressive stupors, but so far as the unconsciousness goes, there +is probably as much psychological as symptomatic resemblance between the +two types of reaction.</p></div> + +<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> Kraepelin recognizes, of course, the occurrence of stupor +symptoms or states in the course of manic-depressive psychoses. It is +stupor as a clinical entity, as a separate psychosis, that he regards as +one form of the catatonic, and therefore of the dementia præcox, +reaction.</p></div> + +<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> Kirby, George H.: "The Catatonic Syndrome and Its Relation +to Manic-Depressive Insanity." <cite>Jour. of Nervous and Mental Disease</cite>, +Vol. 40, No. 11, 1913.</p></div> +</div> + +<p><!-- Page 34 --><span class='pagenum'><a name="Page_34" id="Page_34">[34]</a></span></p> + +<h2>CHAPTER II<br /> +<span class="sm">THE PARTIAL STUPOR REACTIONS</span></h2> + +<p>The cases thus far considered, namely, those of +marked stupor, are fairly well known and have been +studied by others. Less well known and formulated, +but even more important from a practical as well +as from a theoretical point of view, are what may be +called partial stupors.</p> + +<p>The reader has noted that the states of deep +stupor described in the last chapter, did not end +abruptly with a sudden return to health or a sudden +change to another type of psychosis. They all +gradually passed away, not by the disappearance of +one symptom after another, but by the attenuation +of all. Sometimes a more or less stable condition +persisted for months, in which there was no stupor +in a literal, clinical sense but when apathy, inactivity, +interference with the intellectual functions and +negativism all existed. Had these been the only +states observed in these patients, there might have +been some ground for doubt as to the diagnosis. As +it was, it was clear that we were dealing with mild +stages of stupor. When a psychiatrist meets with +an undeveloped manic state, he calls it a hypomania +and does not hesitate to make this diagnosis in the<!-- Page 35 --><span class='pagenum'><a name="Page_35" id="Page_35">[35]</a></span> +absence of complete development into a florid excitement. +This procedure is not questioned, because the +manic <em>reaction</em> as distinguished from a <em>mania</em> is well +recognized. We believe that there is just as distinctive +a <em>stupor reaction</em> which may be exhibited +either in deep stupors or what we may term partial +stupors. Theoretically, complete apathy, inactivity, +etc., make up the clinical picture of a deep stupor. +When these symptoms appear rather as tendencies +than as perfect states, a partial stupor is the product. +That partial stupors occur as well-defined +psychoses, developing and disappearing without the +appearance of deep stupor, we shall attempt to show +in the following three typical cases:</p> + +<div class="blockquot"> +<p><span class="smcap">Case 6.</span>—<i>Rose Sch.</i> Age: 30. Admitted to the Psychiatric +Institute August 22, 1907.</p> + +<p><i>F. H.</i> Both parents were living (father 74, mother 68), as +were two brothers and two sisters. All were said to be normal.</p> + +<p><i>P. H.</i> Nothing was known of the patient's early characteristics, +except that she herself said she was slow at learning in +school and did not have much of an education. But when well +she made by no means the impression of a weak-minded person. +The husband had known her for ten years. He married her +eight years before admission, by civil process, keeping this from +his own family because he was a Jew and she a Christian. He +said that this undoubtedly worried the patient at times and that +she often asked him when he would take her to his family. The +patient herself later also said that this used to worry her. +Finally, one and a half years before admission she agreed, on +account of the children, to accept the Hebrew faith, and they +were then married in the synagogue. But he still did not take +her to his family.</p> + +<p>There were four pregnancies: the first child died; of the +survivors one was 8, a second 5 years old. Finally, a year before<!-- Page 36 --><span class='pagenum'><a name="Page_36" id="Page_36">[36]</a></span> +admission, she became again pregnant. During the pregnancy +one of the children had whooping cough and she herself was +thought to have caught it. The baby was born three months +before admission. It was a blue baby which died two days after +birth. The patient flowed heavily for three weeks and was taken +to a hospital, where she continued to flow intermittently for +some weeks more.</p> + +<p>Finally, three weeks before admission, a hysterectomy was +performed. Several days after this, when the sister-in-law visited +her, the patient begged her to take her home, said the doctor +wished to shoot her and to give her poison. Later the patient +confirmed this, saying that she thought they wanted to give her +saltpeter, and that she heard them say they wanted to shoot her.</p> + +<p>When taken home she refused food; gazed about, was absorbed, +seemed obstinate, and several times tried to jump out of the +window. Retrospectively the patient stated that she heard +children on the street call "Katie." She thought they meant her +child, heard that it was to be taken away from her, and a similar +idea again came out later in her psychosis, namely, that somebody +was going to harm her children.</p> + +<p>At the <i>Observation Pavilion</i> she appeared stupid, rather immobile, +her attention difficult to attract.</p> + +<p><i>Under Observation:</i> On admission the patient appeared sober, +impassive, moved very little, was markedly cataleptic, though not +resistive. On the other hand, her eyes were wide open and she +looked about freely, following the movements of those around her +not unnaturally. When questioned, she looked at the questioner +rather intently, and was apt to breathe a little more rapidly, and +made some ineffectual lip motions but no reply. To simple commands +she made slow and inadequate responses. She flinched +when pricked with a pin, but made no attempt at protecting +herself. She had to be spoon-fed. The catalepsy persisted only +for two days.</p> + +<p>After this she continued to show a marked reduction of activity, +moved very little, said nothing spontaneously, had at first to be +spoon-fed (later ate naturally enough). But she never soiled +herself and went to the closet of her own accord.</p> + +<p>Emotionally she seemed dormant for the most part, though for +the first few days she appeared somewhat puzzled, and one night<!-- Page 37 --><span class='pagenum'><a name="Page_37" id="Page_37">[37]</a></span> +when a patient screamed she seemed afraid and did not sleep, +whereas other nights she slept well. She answered only after +repeated questions and in a low tone. Very often, though her +attention was attracted easily enough, her answers were remarkably +shallow and also showed a striking off-hand profession of +incapacity or lack of knowledge. This was often without any +admission of depression or concern about her incapacity. She +would usually say "What?" or "Hm?" or repeat the question, +but most often would say, "I don't know," this even to very +simple questions. For instance, when asked, "What is your +name?" she answered, "My name? I don't know myself" (but +she did give her husband's name), or when asked to write her +name, she said, "I don't know how to write," or "Call Annie, she +will write my name." When requested to read or write (even +when asked for single letters), she would make such statements +as "I can't read." However, she finally named some objects in +pictures. This condition was characteristic of her for two weeks.</p> + +<p>Then her condition changed a little. She spoke a little more +freely but was similarly vague. The following interview of September +9, is characteristic: When asked how she was, she said, +"Belle." (Are you sick?) "No." (Is your head all right?) +"Yes." (Is your memory all right?) "Yes." (Do you know +everything?) "Yes." (Understand everything?) "Yes." (Are +you mixed up?) "No." (Do you feel sick?) "No." But when +asked where she was, how long she had been here, what the name +of the place was, what was the occupation of those about her, +she said, "I don't know." (How did you come here?) "I couldn't +tell how I came up here." (What are you here for?) "I am +walking around and sitting on benches," but finally, when again +asked what she was here for, she said, "To get cured." She now +gave and wrote her name and address correctly when requested, +also gave the names of her children. Yet when asked about the +age of the girl, said, "I don't know, my head is upside down." +When an attempt was made to make her repeat the name of the +hospital, or the date, or the name of the examiner, she did so +all right, but even if this was done repeatedly and she was asked +a few minutes later, she would say "I couldn't say," or "I forget +things," or "I have a short memory," or she would give it very<!-- Page 38 --><span class='pagenum'><a name="Page_38" id="Page_38">[38]</a></span> +imperfectly, as "Manhattan Island," or "Rhode Island" for +"Manhattan State Hospital, Ward's Island." (How is your +memory?) "All right." But when at this point the difficulty +was pointed out, she cried. (Why?) "Because I forget so +easily." All this was while her general activity was much reduced, +and she seemed to take very little interest in her surroundings.</p> + +<p>Then she improved somewhat, asked the husband some questions +about home, and on one occasion cried much and clung to +him and did not want to let him go without taking her. She +also began to work quite well, but still said very little spontaneously. +During this period when asked questions, she spoke freely +enough, but seemed somewhat embarrassed. What was still +quite marked were striking discrepancies in giving dates, and her +utter inability to straighten them out when attention was called +to them, as well as to her inability to supply such simple data +as the ages of her children. Her capacity was later not gone into +fully but it was certainly less defective on recovery than at this +time. She was rather shallow in giving a retrospective account +during this period. Even later, when she had developed a clear +insight and made, in respect to her activity and behavior, a +natural impression, she was not able to give much information +about her psychosis, although she apparently tried to do so.</p> + +<p>She was discharged recovered four months after admission, her +weight having risen from 93 lbs. on admission to 133 lbs. on +discharge. For the first two weeks of her stay in the hospital, +her temperature varied between 99° and 100°.</p> + +<p><i>Retrospectively:</i> She said in answer to questions about her +inactivity and difficulty in answering that she did not feel like +talking, felt mixed up, could not remember well, did not want +to write.</p> + +<p>Before she was quite well she knew of her entrance to the +Observation Pavilion and her transfer to Ward's Island, of which +she could give some details, but thought she had been in the +Observation Pavilion two weeks instead of three days and in the +admission ward one month instead of a few hours. As to the +precipitating cause of the attack, she spoke of her flowing so +much after childbirth and of her operation.</p> + +<p><!-- Page 39 --><span class='pagenum'><a name="Page_39" id="Page_39">[39]</a></span> +She was seen again in March, 1913, when she seemed quite +normal mentally and claimed that she had been well ever since +leaving the hospital.</p></div> + +<p>With the exception of negativism, which appears +only in the anamnesis, all the cardinal stupor symptoms +are found in this history. Particularly noteworthy +is her intellectual deficiency which seemed +to be made up of a real incapacity plus a remarkable +disinclination for any mental effort whatever. It is +important to note that her attitude towards this +disability was usually one of indifference and that, +in general, there was no show of affect whatever. +Freedom of speech was the last thing for her to +regain.</p> + +<div class="blockquot"> +<a name="ChapII_Case7" id="ChapII_Case7"></a> +<p><span class="smcap">Case 7.</span>—<i>Mary C.</i> Age 26. Single. Admitted to the Psychiatric +Institute April 7, 1907.</p> + +<p><i>F. H.</i> The father had repeated attacks of insanity, from which +he recovered, but he died in an attack at the age of 60. A sister +also had a psychosis, from which she recovered.</p> + +<p><i>P. H.</i> The patient was rather quiet and easily worried. When +14 she had some dizzy spells, with momentary loss of consciousness. +After that time she had no such attacks, except after a +tooth extraction when about 24.</p> + +<p>The patient came to the United States six months before admission. +She went to live with a cousin who died a week after +she arrived at his house. She worried and said that she brought +bad luck. Then she took a position, where she was well liked, +but she was not particularly efficient. In this situation she often +felt homesick and lonely.</p> + +<p>Two weeks before admission an uncle died, which affected her +considerably. She spoke of his leaving three children, and would +not go to the funeral. Then she thought she was going to die. +She felt dizzy, weak, walked with a stooped position, was sleepless. +In the midst of this she suddenly felt frightened and walked<!-- Page 40 --><span class='pagenum'><a name="Page_40" id="Page_40">[40]</a></span> +into her mistress' room, to whom she complained that some one +was talking outside but could not tell what was said. She heard +shooting. Retrospectively, after recovery the patient said that +at that time she suddenly got "mixed up," and that her "memory +got bad."</p> + +<p>She was taken to a general hospital, where she thought there +was a fire, and screamed "Fire!" She was soon transferred to +the <i>Observation Pavilion</i>, where she appeared dazed, moving +slowly, yet showing a certain restlessness. She spoke of "the +boat" being shut up so that no one could go out. Again, she said +"The boat went down and all the people keep turning up." +Retrospectively the patient stated about this condition that she +remembered going to the general hospital but not her stay at the +Observation Pavilion. (The trip to the Manhattan State Hospital +was again clearer to her.) About the ideas she had at the time, +she remembered only that the room seemed to go around, and that +after she had come to the Manhattan State Hospital and was +clearer, she thought she was in Belfast, was on a ship, and that +people were drowning.</p> + +<p><i>Under Observation:</i> On admission she had a temperature of +100°, a coated tongue, suffused conjunctivæ. There were herpes +of the lower lip, a general appearance of weariness and exhaustion, +a flushed face, trace of albumen in the urine, which +was absent on the third day, no leucocytosis, but 41 per cent. +lymphocytes.</p> + +<p>Then and henceforth she was inactive and very slow in all her +movements; she never stirred spontaneously, and had to be pushed +to the toilet and to the table; she ate slowly. She did not speak +spontaneously, and her replies were very slow in coming. She +had to be urged considerably before she would speak and, as a +rule, she did not answer. On one occasion she was for a day +totally inactive and looked duller. That day and on a few other +occasions she wet the bed. There was at times an appearance +of dull bewilderment. When, soon after admission, asked +whether she felt cheerful or downhearted, she said "downhearted," +but this was the only time. Often she answered "I don't +know," when asked whether she was worried, and she could never +say what she was worried about. Again she directly denied +worry. Sometimes she smiled appropriately, and repeatedly,<!-- Page 41 --><span class='pagenum'><a name="Page_41" id="Page_41">[41]</a></span> +when asked how she felt, said, "I feel better." In answer to +questions as to how her head was, she replied several times, "My +memory is gone," also "I can't take in my surroundings," or "I +don't know where I am," or "I cannot realize where I am." +Again, she spoke of being dizzy and once said it was as though +the room went round. Sometimes she knew where she was or +knew names, again said "I forget," but she always was approximately +oriented as to time. There were no special ideas expressed +and no hallucinations, except in the very beginning when she still +thought at night, when she heard the boats on the East River, +that people were being drowned. She later, as stated above, said +she thought she was on a boat and people were being drowned.</p> + +<p>By June, i.e., two months after admission, she began rhythmical +swaying of the body, twisting of the fingers, or pulling out +some of her hair. She ascribed this behavior simply to "nervousness."</p> + +<p>On July 16, after a visit from her cousin, who said to her that +if she worked she would soon get better, she began spontaneously +to occupy herself somewhat. She became more active, said she +felt stronger and brighter, and that her memory was better. By +the beginning of August she was fairly free, but still spoke in a +rather low voice, although answering well. Her capacity to +calculate also remained poor. When asked about the more +inactive state, she said she had been afraid to stir. (What afraid +of?) "I didn't know where to go or what to do." Further, she +recalled that she had had a numb feeling in her tongue, could +not speak quickly, and that her mind had felt confused and "she +could not take in things." Further review with her of the earlier +period of her psychosis showed that there was a blank for +external events and most of the internal events during this time.</p> + +<p>She made a perfect recovery and was discharged August 7, +1907, four months after admission.</p></div> + +<p>This case, although very like the last, differs from +it in two particulars. For one day her symptoms +were sufficiently marked to suggest a deep stupor. +Secondly, her intellectual incapacity was not so +marked (always approximately oriented for time)<!-- Page 42 --><span class='pagenum'><a name="Page_42" id="Page_42">[42]</a></span> +and with this there was some subjective appreciation +of her defect. Apparently, however, this insight +did not cause her any worry. The affectlessness +was equally prominent in both of the foregoing +cases, the fact that Mary C. (Case 7) once admitted +feeling downhearted in response to leading questions, +having little significance in the face of her +expression, actions and usual denial of worry. It is +interesting to note that, during the bulk of her +psychosis, her only complaints were of mental hebetude +and dizziness. Possibly the latter was merely +an expression of her subjective confusion.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 8.</span>—<i>Henrietta H.</i> Age: 22. Admitted to the Psychiatric +Institute March 6, 1903.</p> + +<p><i>F. H.</i> The father stated that both parents were living and +well, also eight brothers and sisters.</p> + +<p><i>P. H.</i> The patient came to this country when she was a baby. +She was bright at school and industrious. From the age of 17 +on, she worked in a drygoods store and gave satisfaction. About +her mental make-up no data were available, except for the statement +that she always made a natural impression.</p> + +<p>When 21 (February, 1902), without known cause, she broke +down and was sent to the Manhattan State Hospital, but was +not observed in the Institute ward. She remained in the hospital +for three months. It was claimed that the attack came on suddenly +two days before she was sent away. She suddenly appeared +anxious, said something had happened and became excited. This +lasted for about a week, and then she was, as the description +says, "depressed and cataleptic." She remained in this condition +for about a month, during which time there was a slight rise +of temperature. Then she improved gradually and was discharged +three months after admission. After recovery from the +present attack the patient stated that during the first sickness +she had visions of dead friends.</p> + +<p>She was perfectly well in the interval.</p> + +<p><!-- Page 43 --><span class='pagenum'><a name="Page_43" id="Page_43">[43]</a></span> +Six days before admission she suddenly became excited, refused +to eat, and began to talk, repeating phrases over and over. Then +she became elated and excited.</p> + +<p>After recovery the patient described the onset of her psychosis +as follows: Six days before admission, after having been perfectly +well and without any known cause, she was feverish and +vomited, but slept well. Next day she felt nervous, and her +thoughts were clear. She constantly thought of dead friends, +heard them talking, when she tried to do anything the voices +said, "Don't do that." She also thought somebody wanted to +harm her people. Soon she started singing and felt happy.</p> + +<p>Then she was sent to the <i>Observation Pavilion</i>, where she appeared +to be in the same condition which was observed in the +Institute.</p> + +<p><i>Under Observation:</i> 1. On admission she was in good physical +condition, except for her skin seeming greasy. She presented for +nine days the following picture: She was essentially elated, +laughing, singing, jumping out of bed, good-natured and tractable, +and very talkative. Her productions showed a good deal of +sameness and a certain lack of progression. She spoke at times +in a rather monotonous voice, but again often in very theatrical +tones, with much, rather slow, gesturing. The following are +very representative samples:</p> + +<p>"I have been suffering from my own blood, my own blood sent +all away from home. I just came from Bellevue. I left here +last May (correct) a healthy girl. A sister is a sister—I wonder +why shorthand is shorthand, a stenographer is a stenographer +(seeing stenographer write)—a kind brother, Bill H.—why H. +his wife is a sister-in-law to us, she has four children—four +beautiful children—sister-in-laws and brother-in-laws—telephone +ringing (telephone did ring)—dear Lord, such a remembrance—remembrance +was remembrance, truth was truth—honesty is +honesty—policy is policy—if she married him, she is my sister-in-law +and he is my brother-in-law—Max knows me—she changed +her name to Mrs. R.—two children who are Rosie and Maud, if +names were given, names should not be mistaken—they are Julia, +Lillian—Rosie and Maud—why should wonders wonder and +wonders cease to wonder, why should blunders blunder and +blunders still blunder; sleep is one dream and dream means sleep<!-- Page 44 --><span class='pagenum'><a name="Page_44" id="Page_44">[44]</a></span>—if +move is moving, why not move?" When she accidentally +heard the word wine, she said "Guilty wine is not in our house—wine +is red and women are women, and women and wine and +wine and women and wine and song." Again, "You are not Mr. +Kratzberger, Mr. Steinberger, Mr. Einberger—you are not Mr. +Horrid or Mr. Storrid—perhaps you are Mr. Johnson or Mr. +Thompson—no, you are Dr. C." (correct).</p> + +<p>She was quite clear about her environment.</p> + +<p>Although the mood was throughout one of elation, on the +ninth day in the forenoon she cried at times, wanted to see her +mother, and spoke in a depressed strain (content not known). +A few hours after that she suddenly became quiet.</p> + +<p>2. Then for four days (March 14-17) she was markedly +inactive, though at times got out of bed. She looked about in a +bewildered manner, did not speak spontaneously, but could with +urging be induced to make some replies. She did this now fairly +promptly, now quite slowly. Questions were apt to bring on the +bewilderment. Thus, when asked where she was, she merely +looked more bewildered, finally said "Bellevue—I don't know," +and questioned who the doctor was whom she had called by name +in her manic state, she said, with some bewilderment, "Your face +looks familiar." (Where have you seen me?) "In New York." +She claimed to feel all right. There was no real affect. She +made the statement that at home she heard voices saying "You +will be killed."</p> + +<p>3. Henceforth this bewilderment ceased, and for 16 or 17 +days she was essentially inactive for the most part, for a short +time with a tendency to catalepsy and some resistiveness, and at +that time lying with eyes partly closed. As a rule she said +nothing spontaneously, but replied to some questions, usually +with marked retardation, again more promptly. She constantly +denied feeling sad or worried, repeatedly said she felt "better," +only on one occasion did she cry a little. When asked to calculate +she sometimes did it very slowly, again fairly promptly. The +simple calculations were usually done without error, the others +with some mistakes. As to her orientation the few answers +obtained showed that at times she knew the name of the place +and the day, again she gave wrong answers (Bellevue). Once +asked on March 23 for the day, she said April. She wrote her<!-- Page 45 --><span class='pagenum'><a name="Page_45" id="Page_45">[45]</a></span> +name promptly on one occasion, again a sentence slowly but +without mistakes. Once during the period she sang at night. +Once she suddenly ran down the hall but quickly lapsed into the +dull condition.</p> + +<p>On April 4, at the end of this period, she suddenly laughed, +again ran down the hall, said she had done nothing to be kept on +Ward's Island. But she quickly lapsed again into the dull state. +Later, on the same day, when the doctor was near, she said, in +a natural tone, "Thank God, the truth is coming out." (What +do you mean?) "That I have been trusting in a false name and +that Miss S. (the nurse) should not nurse me." Then she got +suddenly duller, calculated slowly and with some mistakes, +3×17=41, 4×19=56, and when asked to write Manhattan +State Hospital she wrote (not very slowly) "Mannahaton Hotspalne."</p> + +<p>4. Next day it was noted that she was more stuporous, and +she remained so for two weeks, now showing a decided tendency +to catalepsy and more resistance than before, though not marked, +except in the jaw. She lay often with head raised, sometimes +with eyes partly open, or staring in a dull, dreamy way, neither +soiling nor drooling, however; a few times she looked up when +spoken to sharply. There was no spontaneous speech. Usually +she did not answer at all, but a few times a short low response +was obtained. Once she wrote slowly a simple addition, put +down on paper. When, on one occasion, asked how she felt, she, +as before, said, "I feel better."</p> + +<p>5. Then, with the exception of a day at the end of the month, +when the more stuporous state was again in evidence, she returned +to her former condition without catalepsy or resistiveness and +without staring, but essentially with inactivity or slowness. She +now even dressed herself, answered slowly though not consistently, +but she again denied feeling troubled or sad, "I feel better."</p> + +<p>On July 7 she got brighter but was still rather slow. She then +even began to do some work. She again denied feeling sad.</p> + +<p>In a few weeks, while having a temperature of 102° with +vomiting and diarrhea, she suddenly got freer. She then said, +in answer to questions, that she did not speak because she was +not sure whether it would be right, again because she seemed to +lose her speech. She did not move because she was tired, had a<!-- Page 46 --><span class='pagenum'><a name="Page_46" id="Page_46">[46]</a></span> +numb feeling. She said she had not been sad, "but I had +different thoughts," "saw shadows on the walls of animals, living +people and dead people." She was not frightened, "I just looked +at them." People moved so quickly that she thought everything +was moved by electricity. She thought her head had been all +right.</p> + +<p>After a few days she relapsed into a duller state again, but +then got quite free and natural in her behavior. On August 28 +she gave a <i>retrospective</i> account of her psychosis, a part of +which has been embodied in the history. She had insight in so far +as she knew she had been mentally ill. She claimed to remember +the Observation Pavilion and her coming to the hospital, also the +incidents during the manic state, when she heard cannon and +thought a war was on, and voices she could not recognize nor +understand. Then she became stupid, although neither sad nor +happy.</p> + +<p>Then, she claimed, she got stupid, but neither sad nor happy. +She claimed to have known all along where she was, but felt +mixed up at times, her thoughts wandered and she felt confused +about the people. She thought she was in everybody's way, +thought others wanted to get ahead of her, did not speak because +she did not know if it were right or wrong, felt she might cause +disturbance if she answered. (It is not clear whether she had +complete insight into the morbid nature of these statements.) +She also claimed again that all along she "saw shadows on the +wall," "scenes from Heaven and Earth," "shadows of dead +friends laid out for burial." She had insight into the hallucinatory +nature of these visions. Sometimes she thought she was +dead also. She claimed that she began to feel better when these +shadows stopped appearing in June (the actual time of her improvement).</p> + +<p>She was discharged recovered a month later, after having been +sent to another ward.</p></div> + +<p>In this case, then, we find that the two months of +stupor were ushered in by a brief state in which, in +addition to the usual inactivity, there was a certain +bewilderment, increased by questions, while the<!-- Page 47 --><span class='pagenum'><a name="Page_47" id="Page_47">[47]</a></span> +orientation which in the preceding manic state had +been good became seriously interfered with. The +psychosis bordered on deep stupor for brief periods +when the inactivity seemed to be complete or she lay +in bed with her head raised from the pillow. On +the other hand, there were occasional sudden spells +of free activity even with a certain elation. She +could often be persuaded to answer questions or to +write, the slowness of this spoken or written speech +varying considerably. Her replies revealed the fact +that she was essentially affectless and that her intellectual +processes were interfered with, even to +the extent of paragraphic writing. We have, therefore, +here again features similar to those of the +preceding cases. In addition we must add as important +that this patient said retrospectively that she +thought she was dead, that she saw "shadows from +Heaven and Earth," "shadows of dead friends laid +out for burial," all this without any fear. We shall +see later that this is a typical stupor content.</p> + +<p>We will here include state 3 of Anna G. (See +<a href="#ChapI_Case1">Chapter I, Case 1</a>) who after the pronounced stupor +was for two months merely dull, somewhat slowed +and markedly apathetic. Although her orientation +was not seriously affected, there was considerable +interference with her intellectual processes, as +shown in her wrong answers or her lack of answers +when more difficult questions were asked.</p> + +<p>A similar picture was presented in state 2 of +Mary D. (See <a href="#ChapI_Case4">Chapter I, Case 4</a>.) Here, to be sure, +there were more marked stupor features in that the<!-- Page 48 --><span class='pagenum'><a name="Page_48" id="Page_48">[48]</a></span> +patient wet and soiled, in addition to occasional +spells when she lay with her head raised. But she +spoke and acted fairly freely (even while soiling). +By her replies she showed a considerable intellectual +inefficiency, although, like Anna G., her orientation +was not seriously disturbed. Here again there was +complete affectlessness.</p> + +<p>This gives us, therefore, five states which may be +analyzed for the symptoms of partial stupor. The +pictures of all five are unusually consistent. There +is inactivity, marked but not complete; poverty of +affect without perfect apathy; and a marked interference +with the intellectual processes. The last can +be studied better than in the deep stupors because +these partial cases are more or less accessible to +examination. There is a tendency for the patient to +think much of death either in the onset or during the +psychosis. Negativism seems much less prominent +than in the deep stupors.</p> + +<p>A natural criticism is that these cases merely had +retarded depressions. Although this topic will be +discussed fully in a later chapter, two differential +characteristics should be mentioned now. First, +depression is a highly emotional state in which the +sadness of the patient is as evident from his facial +and vocal expression as from what he says, while +these stupor reactions are by observation and confession +states of indifference. Secondly, there is no +such disturbance of the intellectual processes in depression +as is here chronicled. Let the retardation +once be overcome so that the will is exercised and<!-- Page 49 --><span class='pagenum'><a name="Page_49" id="Page_49">[49]</a></span> +no real defect is demonstrable. In our experience +the cases of apparent depression with intellectual +incapacity are found on closer study to be really +stupors as other symptoms show.</p> + +<p><!-- Page 50 --><span class='pagenum'><a name="Page_50" id="Page_50">[50]</a></span></p> + +<h2>CHAPTER III<br /> +<span class="sm">SUICIDAL CASES</span></h2> + +<p>An important "catatonic" symptom is a tendency +to sudden, impulsive, unexplainable acts. Such +actions occur occasionally in benign stupors and, +since we attempt an understanding of the reaction +as a whole, an effort should be made to study these +phenomena as well. The cases chosen showed persistent, +quite affectless, yet very impulsive attempts +at self-injury. They characterized the first of the +three cases throughout, were present in one stage +(the second) of the second patient, while in the last +for one day there was behavior which can be similarly +interpreted.</p> + +<p>Mention has been made of the prominence, approaching +universality, of the death idea in stupor. +This is a subject to be discussed in length presently, +but for the present we may say that there may be a +delusion of death with dramatization of that state +or a mere abandonment of the mental activities of +life. It is but a step from corpse-like behavior to +suicidal attempts, psychologically speaking, yet this +transition necessarily modifies the clinical picture, +since one necessitates inactivity and the other activity. +Secondarily, other atypical clinical features +appear, as will be seen.</p> + +<div class="blockquot"> +<p><!-- Page 51 --><span class='pagenum'><a name="Page_51" id="Page_51">[51]</a></span> +<span class="smcap">Case 9.</span>—<i>Pearl F.</i> Age: 24. Admitted to the Psychiatric Institute +July 26, 1913.</p> + +<p><i>F. H.</i> A paternal aunt was insane. Both parents died long +ago; the mother when the patient was a baby; the father when +she was a girl. She came to this country when 17. In this +country she had generally been a domestic. An older brother +and sister were also in America.</p> + +<p><i>P. H.</i> She was described as sociable, good-natured, bright +enough, not inclined to be depressed. She had little education. +There was no former attack.</p> + +<p>Four months before admission, the patient did not menstruate +but was said not to have worried about this. A month later she +began to show symptoms. She said she did not want to live, had +done something wrong but could not or would not say what it +was. Again she said a young man was going to sue her, a young +Jewish fellow whom she had seen only a few times. She talked of +turning on the gas. She also complained that people were looking +at her and that the food was poisoned.</p> + +<p>The patient after recovery gave the following version of the +onset: She had a position on 99th St. for 2½ years. She liked +the people there and often went to see them later. Her next position +was in the Bronx. She was there for nine months. In the +same house lived "Harry." After the work she used to talk to +him in the yard and, after she left, she used to think of him and +long for him. But she denied, with a very natural attitude, that +she worried about him at the beginning of her psychosis. After +the position in the Bronx she went to one on 96th St., where +she was for four months. In the same house was a girl whom she +liked and who was lively. When she left, the patient left too. +This was a month before the psychosis began. When she left +there, she got word that her employer on 99th St. had developed +consumption and had to go out West, but did not worry over this +news, she claimed. She looked for another position and had one +for two weeks, but felt lonely, did not care to live. Then her +sister took her to her home. She thought people were looking +at her and were making remarks because she was not working. +During this time she had a dream one night in which her dead +mother appeared to her (in ordinary street clothes) and said to +her that she (the patient) "was going away." She woke up<!-- Page 52 --><span class='pagenum'><a name="Page_52" id="Page_52">[52]</a></span> +frightened. She was worried, thought she had not prayed enough +for her mother, and asked her sister to pray also and to give +money to the poor. She did not recall, or at any rate denied, +speaking of the young man suing her.</p> + +<p>She was then taken to a <i>private sanatorium</i>, where she was for +two months preceding her admission to this hospital. There she +was described as quiet, mute, tube-fed, resistive.</p> + +<p>When well, the patient said that in this sanatorium she was +first spoon-fed, cup-fed, later tube-fed, "I used to be scared of +them, they used to put a spoon way down my throat and I had no +appetite—I did not like them around me, they were mean to me. +They used to let me stand without clothes, used to spite me." "If +I did not want to dress myself, they used to hit me." "I used +to feel lonesome for home and I imagined my people were there +and that my sister passed the place without stopping." She was +afraid of the nurses, thinking they wanted to kill her.</p> + +<p>At the <i>Observation Pavilion</i> the patient was described as dull, +but brightening up under examination. She made few spontaneous +remarks, but in answer to questions said she was melancholy, +tired of life, because she was in love with a Gentile fellow who +refused to marry her. She also said "I get peculiar thoughts +that I am going to die."</p> + +<p><i>Under Observation:</i> The patient's condition lasted for about +two years. Much of the time she lay in bed, often with the covers +pulled over her, sometimes with her legs drawn up, again in a +more natural, comfortable position, or she sat up with her head +bowed. She obeyed almost no commands. For months she soiled +and wet herself, but never drooled. For a time she refused food +consistently, lost flesh and had to be tube-fed. For the most part +she said very little and, when one accosted her, she was apt to +turn away. A few times, when further urged, she swore at the +examiner. There was also persistent marked resistance towards +any interference, sometimes merely passive or quite often, especially +at first, with wriggling or severe scratching of her own +body. There was often with this evidence of irritation or she +moaned. Again she was described as quite affectless. One of +the most striking features throughout a large part of the course +were her suicidal attempts. She would try to strike her head +against the iron bedpost, throw herself out of bed, throw herself<!-- Page 53 --><span class='pagenum'><a name="Page_53" id="Page_53">[53]</a></span> +about generally, try to strangle herself with the sheets, try to +pull out her tongue, all of which seemed to be done with great +impulsiveness. Almost her only utterances had to do with death. +She said she wanted to die, wanted to drop dead, did not want +to live, wanted to kill herself, that she did not eat because she +wanted to die. When once she was found tossing about and +was asked whether she worried, she said "I know I am going to +die." (You mean you will be killed?) "I don't care."</p> + +<p>There were a few episodes which still have to be mentioned. +Quite early in the course of the stupor, when she was restless, +scratching herself and moaning, she once spoke quite freely. She +said "Give me that fellow (Harry), I don't care, I can't help it. +I must have him, even if it costs me my life." "I would feel +happy if I could get him. O God, I love him—I will never get +him even if I drop dead, I know I won't get him, the darling" +(cries). (What if you did get him?) "I know I would lose him +again." Then with shame she claimed she had had sexual relations +with him (when well, denied). At the same interview, when +the doctor sneezed, she said "Gesundheit." In June, 1914, +she was seen smiling at times. But the first was the only episode +when she spoke more freely, and the two occasions the only ones +when she showed a frank affect.</p> + +<p>The improvement commenced in April, 1915. Although still +very inactive, she sometimes began to laugh and sing and talk +a little to other patients. She also answered a few questions on +April 22, 1915. Thus, when asked whether she wanted to go +home, she said "No, I want to stay here." (Do you like it here?) +"Yes" (smiles), "I can't get no other place; I have got to like it +here." She smiled freely. To orientation questions, she knew +the place, month, but not the year.</p> + +<p>She continued inactive and above all diffident, but improved +steadily and, when examined by the writer on November 15, she +made a very natural impression and gave the retrospective account +of the onset embodied in the history. She was quite frank, +thanked the doctor for the interest he took in her case, and said +for example, "You know I never thought I would get well. I +quite gave up—I am very glad I am well now."</p> + +<p>When questioned about her stay here, the patient evidently +remembered much. She was able to say which wards she had<!-- Page 54 --><span class='pagenum'><a name="Page_54" id="Page_54">[54]</a></span> +been in and approximately how long she had been in each one. +She claimed that at first it "seemed strange." "I did not eat, I +did not want to eat, I used to tell them to poison me and that I +wanted to die, I was <em>disgusted</em>, I thought I would never go home." +She also says she felt <em>angry</em>, wanted to kill herself. She bit and +scratched "because I was nervous." She remembered talking +about Harry, "I said I was in love with him, I thought I wanted +to die because I could not have him." She also talked of having +been <em>stubborn</em>. Sometimes she felt like running to the river. She +also claimed she imagined people were false to her.</p> + +<p>In one of the wards she said she thought people were there on +her account, were waiting for her death. She did not care for +a time whether she died or not. She knew she tried to choke herself +occasionally. Asked how she behaved, she first said she was +quiet. (Were you not restless?) "I used to get tired and have +backache and roll around in bed." She also felt like running +away sometimes, wanted to get out of bed and wanted to walk +about. (What about going to the river?) "I used to say that." +She claimed not to have been mixed up at any time and to +remember everything. Remarkable is the fact that she claimed +she <em>did not worry at all</em>, "<em>I felt I was lost and would not worry.</em> +I used to worry at home and at Dr. M.'s (the private sanatorium) +but not here. Here I never worried, I did not care where I +went." She said she did not talk because she was bashful in the +presence of doctors, sometimes she felt afraid of them, afraid +they would kill her, put poison in her food when they fed her. +"When my people came, I said I did not want to live, wanted to +kill myself. I used to cry." Again asked why she did not talk, +she admitted she really did not know. Once she said she was +bashful because she soiled her bed. She did not want to go to +the closet because she was afraid of the nurse. She denied +hearing voices.</p></div> + +<p>In addition to the activity incidental to her attempts +at self-injury, this patient showed an unusual +degree of resistiveness and with this some affect, +for she appeared to be irritated and at times +moaned. Still more unusual were the appearances<!-- Page 55 --><span class='pagenum'><a name="Page_55" id="Page_55">[55]</a></span> +of delusions not associated with death but with a +vivid form of life, namely, a love affair. Occasionally +she spoke of her imaginary lover "Harry." +Another atypical feature was a fair memory for the +period when she was in stupor. She claimed to remember +much of her movements and this claim was +substantiated by her answers to questions after recovery.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 10.</span>—<i>Margaret C.</i> Age: 23. Single. Admitted to the +Psychiatric Institute November 13, 1913.</p> + +<p><i>F. H.</i> Heredity was absolutely denied. The mother is living +and made a natural impression. The father died at 65, nine +months before patient's admission, of cardio-renal disease. Two +brothers and one sister died of acute diseases. One sister died in +childbirth. Three brothers and one sister were said to be well.</p> + +<p><i>P. H.</i> The patient was bright and passed successfully through +high school. For seven years prior to the psychosis she worked +for the same company as clerk. She was described as efficient, +conscientious, systematic, though sometimes upset by her work; +as lively, talkative, cheerful, with somewhat of a temper and +easily hurt, also as quite religious. She was more attached to +her mother than to her father, but still more to her older sister, +whose death precipitated her psychosis. She never had any love +affair and was said not to have cared for men. Two months before +admission, when her favorite sister was confined, the patient +was quite worried about her, but relieved when she heard good +news. A few hours later, however, the sister died suddenly. +When the patient learned of the sister's death, she screamed, and +screamed several times at the funeral. She did not cry, said she +could not. After this she slept poorly, seemed nervous, went to +church more, but there was no other change. She continued to +work and, according to the employer, worked well.</p> + +<p>Nine days before admission she would not get out of bed in +the morning, said little and refused food. A few days later she +was induced to take a walk, but she seemed to have no interest +in anything. When she talked at all it was about her sister and<!-- Page 56 --><span class='pagenum'><a name="Page_56" id="Page_56">[56]</a></span> +of wanting to go to a convent. When asked to do anything she +said she would if it were God's will. She did not menstruate +after her sister's death. When practically recovered, the patient +attributed her breakdown to this tragedy. She added to the description +above given that, soon after losing her sister, she had +a fright at home. "It was the house in which my father died +and one day when I was in bed I thought somebody came in." +But she denied a vision and could not further explain.</p> + +<p>At the <i>Observation Pavilion</i> she was very inactive, so that she +had to be fed and cared for in every way, mute, often covering +her head with a sheet, turning away when questioned and resistive +when the physical examination was attempted. But at +times she smiled or laughed.</p> + +<p><i>Under Observation:</i> 1. For two months the patient was generally +inactive, sometimes lying in bed with her eyes tightly +closed, or with her face covered by the sheets or buried in the +pillow; or she sat inactive, staring, or with eyes closed, or her +head buried in her arms. On one visit she had to be brought into +the examining room in a wheel chair and lifted into another seat. +A few times she was observed holding herself very tense with her +head pressed against the end of the bed. But this inactivity was +often interrupted by her going quickly into various rooms to kneel +down, though she was never heard praying. Or she ran down the +hall for no obvious reason. Or, again, she was found lying on +the floor face down. She ate very poorly and had to be tube-fed +a considerable part of the time. When this was done, she sometimes +resisted severely, as she did in fact most nursing attentions. +Thus she soon began to struggle when her hair was combed. She +also resisted being taken to the toilet or being brought back. +She did not soil or drool, however, but sometimes seemed to be +in considerable distress before she finally literally ran to the +closet. This resistance just spoken of consisted chiefly in making +herself stiff and tense. Sometimes at the feeding she pulled up +the cover when preparations were made and held to it tightly. +Quite striking was the fact that with such resistance she sometimes, +though by no means always, laughed loudly, as she did +occasionally when she was talked to, or even without any external +stimulation. This laughter always was one of genuine merriment +and quite contagious, and by no means shallow or silly.</p> + +<p><!-- Page 57 --><span class='pagenum'><a name="Page_57" id="Page_57">[57]</a></span> +Usually the patient was totally mute. The exceptions occurred +mostly when her resistance was called forth. Thus one day when +fed she said, "I wish you people would have more to do," or on +another occasion, when she had resisted being brought into the +examining room, she said, "I will get out of here if I break a leg." +But once when the nurse accidentally tickled her, she said, "Since +I am ticklish, I must be jealous—I should worry." She also +answered very few questions and such responses as she made were +chiefly expressions of resentment. Thus, when one kept urging +her, she finally would say "stop," or after much urging "I am +going to hurt you pretty quick." Sometimes she said "Go away," +or "Let me alone." She was just as silent with the mother and +the priest as with the physicians. On one occasion she told the +nurse that the priest had told her to talk to the doctors, but +that she had nothing to say. Sometimes she did not even look +at the visitors, but turned away from them, as she did from the +physicians, but at one visit from a priest, though she scarcely +said anything, she held on to him when he was about to depart +and would not let him go. Throughout this period, since scarcely +any answers were given, nothing was known about her orientation, +except when on admission she gave a few answers. She then +thought she was at the Observation Pavilion, seemed unable to +tell even that the physician was a doctor, but knew the date. +When asked how she came to Ward's Island, she said "By ambulance." +The physical condition presented nothing of note, except +for a certain sluggishness of the skin with marked comedones.</p> + +<p>2. By <i>January</i>, 1914, the picture changed somewhat and she +then presented the following state for an entire year: The +mutism persisted and indeed became even more absolute, and she +began to wet and soil constantly. This commenced as what +seemed to be an act of spite as a part of her resistiveness, for +the first time she soiled she seemed to do it deliberately when the +nurses insisted that she allow them to put on a dress. Later +this explanation no longer held. Tube-feeding too was for the +most part necessary, the resistiveness continuing as before. But +the inactivity was broken into much more than before by constant +impulsive attempts to hurt herself in every conceivable way—by +bumping her head against the wall, putting her head under the +hot water faucet, trying to pound the leg of the bedstead on her<!-- Page 58 --><span class='pagenum'><a name="Page_58" id="Page_58">[58]</a></span> +foot, striking herself, pinching her eyelids, pulling out her hair, +trying to pick her radial artery, throwing herself out of bed, +knocking her head against the bed rail, etc. This was done in +silence but with what appeared a great determination that occasionally +showed itself in her face. She also sometimes scowled +and frowned. With the difficulty in feeding her and the constant +impulsive excitement in which bruises could not always be avoided +(once an extensive cellulitis developed in the arm which had to be +lanced), the patient got weak, emaciated and exhausted; much +of her hair fell out, although some she pulled out. It should be +stated that during this entire impulsive state she could not be +taken care of in the Institute ward, but was sent to a special +ward in the Manhattan State Hospital, where suicidal patients +are under constant watch. These impulsive attempts at self-injury +lessened only towards the end of the period. Her laughter, +which had been such a prominent trait, disappeared almost entirely +during this entire phase. With all this, the general resistiveness, +as has been stated, remained towards feeding or any +other interference. It was only in the beginning associated with +laughter as in the previous stage.</p> + +<p>Although there were, as a rule, no spontaneous remarks and +no replies, she on one occasion said spontaneously, probably +referring to her unsuccessful attempts to kill herself: "I can't +do it, I have no will." During the same period she once said: +"I don't want to eat, I don't want to get well, I want to do +penance and die."</p> + +<p>By <i>January</i>, 1915 (i.e., a year after the second phase had +commenced), she began to dress herself and eat, and also became +clean. But she remained for the most part very inactive, sitting +stolidly about all day and still without interest in her environment. +The impulsive attempts at killing herself disappeared. +Although she remained for months to come still inactive, she +gradually began to talk a little, began to play a little on the +piano, but said little to any one.</p> + +<p>By <i>August</i>, 1915, she still was inactive, shy, standing about, +or sitting picking her fingers, occasionally going to the piano, +but evidently unable to finish anything. She had to be coaxed +to come to the examining room and talked in a low tone. Often +she commenced vaguely to speak and then stopped and could not<!-- Page 59 --><span class='pagenum'><a name="Page_59" id="Page_59">[59]</a></span> +be made to repeat what she had been saying. Affectively she +was remarkably frank, sometimes a little surly, or she showed +a slight empty uneasiness. She could, however, be made to laugh +heartily at times, or did so spontaneously on very slight provocation.</p> + +<p>Some of her utterances were in harmony with her apparent +indifference. It was difficult to get her to say how she felt +even when thorough inquiries were made. Once she said, when +asked about worrying, "I don't worry," or again "I get angry +sometimes," or "I used to worry about my health, I don't now," +or, when asked what her plans were, she said directly: "I don't +care what happens." Again she said "I guess I am disagreeable," +or "I guess I am a crank." Another interesting indication +of her state was expressed in her repeated statement, "I +don't know what I want." But she was oriented in a way, +though not sure of her data. She would give most of her answers +with a questioning inflection, "This is the Manhattan State +Hospital, isn't it?" or she would say, "I don't know exactly where +I am, it's Ward's Island, isn't it?" and in the same way she gave +the day, date and year correctly. But she did not know the names +of the physicians. At that time she could give many data about +her family correctly, but was slow, even if correct, in calculation, +and, though she got the gist of a test story, she left out some +important details.</p> + +<p>A retrospective account at that time showed she was uncertain +about the Observation Pavilion, that she was not certain how she +came to Ward's Island, "On a boat, I believe." It was clear that +she did not remember the admission ward, about the Institute +ward (in which she had been for the first two and a half months +and in which she was again examined); she said it was familiar +to her, but she was not certain that she had been in it. About +the physician who saw most of her in these first two and a half +months, she said that his voice seemed familiar, and she asked +him whether he had tube-fed her (she had been tube-fed by him +many times), but she again said, "No, you are not the one," and +described as the man who had fed her the one who did it on the +second ward where she was for a year. But she knew that she +had been sent to the second ward, because she constantly tried +to injure herself. These injuries she recalled but was unable<!-- Page 60 --><span class='pagenum'><a name="Page_60" id="Page_60">[60]</a></span> +to say why she attempted them, "I suppose I didn't know what +I was doing." She claimed she heard voices and had "all sorts" +of imaginations, but could not be gotten to tell about them. +When it was difficult for her to give an answer, she was apt to +keep silent and then could be prodded without much success.</p> + +<p>In <i>October</i>, 1915, there was further improvement, inasmuch +as she began to converse some with other patients, played the +piano and seemed able to carry a piece through. She was put +in the occupation class and did quite well. At the interview +with the physician she was still apt to laugh boisterously at +slight provocation. Even now she had great difficulty in describing +her condition and at the examination was often still quite +vague. Thus, when asked how she felt, she said, "I do know I +feel ridiculous—sometimes I feel kind of angry—I don't know—they +say I am crazy but I am not, but I am hungry—I don't +know whether I am or not, I don't know what I can do well," +etc. This is quite characteristic. When asked whether she was +worried, she said: "I don't know, am I worried?—yes, a little +sometimes, I am to-day—I am so untidy—don't know what is +the matter with me." Again: "Sometimes I lose my speech—I +can't say what I feel, I don't know what it was." Later, half +to herself: "I don't know what is the matter with me—I don't +care anyway."</p> + +<p>In <i>December</i>, 1915, there was still further improvement, and on +the ward and in superficial conversation she made, towards the +end of the month, in many ways a natural impression, though +the laughter before described was still somewhat in evidence. +It usually came not without occasion, but was, as a rule, quite +out of proportion to the stimulus. She again said she could +not explain why she tried to injure herself, claimed she did not +feel it, and even claimed she did not remember doing it in the +Institute but only in the second ward.</p> + +<p>The defect in thinking which still remained is very difficult to +formulate. She was now entirely oriented, no longer with any +hesitation about the correctness of her information. She subtracted +7 from 100 very quickly and could from memory write a +long poem, but there was a certain vagueness about her which +partly may have been due to a still existing indifference. This +vagueness consisted chiefly in a difficulty of attention or in her<!-- Page 61 --><span class='pagenum'><a name="Page_61" id="Page_61">[61]</a></span> +capacity to grasp fully what was wanted. It is best illustrated by +a few examples: After she had been asked about the <em>onset</em> of her +sickness and she had said that what was on her mind then were +prayers for the salvation of her relatives, she was asked exactly +when it was that she thought of this; she answered "Now?" +(What period were we talking of, the present or past?) "The +present." (What did I ask you?) "About this period of my +sickness." (Which one?) "What sickness?" She said herself +at this point, "I am rather stupid" (quite placidly). Or again +she said she did not know why she pounded her head, but finally +said, "To get better and go home." (Do you think if you +pounded your head against the wall you would go home sooner?) +"I don't know—maybe." (How would it help you?) "You +mean to go to the city?" (Yes.) "I don't know." Again when +asked how her mind worked, she said, "Pretty quickly sometimes—I +don't know." (As good as it used to?) "No, I don't think +so." (What is the difference?) This had to be repeated several +times, at which she said, "There is no difference." (What +did I ask you?) "The difference." (The difference between +what?) "You did not say." Equally striking was the fact that +when she was jokingly told "If it snows to-night, we shall have +a black Christmas," she did not grasp the absurdity at once, +but in a rather puzzled way asked, "Why?"</p> + +<p>She was then discharged on parole, two years and one month +after admission. Soon after discharge her menstruation, which +had been absent throughout her psychosis, returned. On her +discharge she had regained her normal weight, and during the +two subsequent months gained fifteen pounds.</p> + +<p>She then recovered completely, so that three months after +discharge she made a very natural impression. She said, on +looking back over her state with impulsive excitement, that she +constantly had the idea that she wanted to punish herself, but +that <em>she did not know why</em>, and did not think she was sad or +worried.</p></div> + +<p>Considering only the second phase of the psychosis, +this deep stupor showed many interruptions, due +not merely to her suicidal efforts but also to her +resistiveness. The condition, too, was not so com<!-- Page 62 --><span class='pagenum'><a name="Page_62" id="Page_62">[62]</a></span>pletely +affectless as one expects a deep stupor to be. +In the first stage there was much sudden laughter, +reminding one of dementia præcox (except for its +never being shallow or silly) and this persisted into +the first part of the second phase. The actual attempts +at self-injury brought out emotion, for with +them she scowled and frowned as well as showing +considerable energy.</p> + +<p>To these may be added the following case. It is +not unlike the ordinary stupor in the fact that there +was intense inactivity and mutism with great tenseness. +The remarkable trait was, however, that for +a whole day she forcibly held her breath until she +got blue in the face. The case in detail is as follows:</p> + +<div class="blockquot"> +<p><span class="smcap">Case 11.</span>—<i>Rosie K.</i> Age: 18. Admitted to the Psychiatric +Institute January 24, 1907.</p> + +<p><i>F. H.</i> Both parents were living. The father was a loafer. +Nine brothers and sisters were said to be well, with the exceptions +of one brother who had an irritable temper, and of a +markedly inferior sister.</p> + +<p><i>P. H.</i> The patient was a Galician Hebrew, a shirtwaist operator. +Not much was known about her make-up, but it is certain +that she was a bright girl. The patient herself said after recovery +that her father was nagging her constantly with complaints +that she was not making enough money, although he himself did +not work and she contributed much to the support of her family. +She disliked him very much and claimed that all her relatives +worried her, except her mother.</p> + +<p>Nine weeks before admission a messenger came into the shop +where she worked and said, "Rosie, your father is dead" (the +message was intended for a fellow worker). In spite of the +fact that the matter was explained, she was upset and nervous +enough to be taken home. Though she continued to work for +over two weeks, she worried over many trivial matters and talked<!-- Page 63 --><span class='pagenum'><a name="Page_63" id="Page_63">[63]</a></span> +much about this. She also said that everything looked queer at +her home and complained of having difficulty in concentrating +her mind. Finally she became elated and talkative. Nothing is +known of any special ideas.</p> + +<p>At the <i>Observation Pavilion</i> she appeared to be typically +manic.</p> + +<p>Then she was sent to an institution where she remained for +six weeks. The report from there stated that she was for ten +days "elated, excited, talkative, with flight of ideas." Then her +condition suddenly changed to a marked reduction of activity, in +which she neither spoke spontaneously nor answered questions. +She "appeared to sleep," but was said to have talked to her +people. When interfered with, she was resistive and sometimes +let herself fall out of bed. On the other hand, she occasionally +wandered about at night. It should be added that during the +stupor an alveolar abscess developed which discharged pus. It +was washed out and healed.</p> + +<p>Then she was sent to the Manhattan State Hospital and admitted +to the service of the Psychiatric Institute.</p> + +<p><i>Under Observation:</i> 1. On the first day she lay in bed with +cyanotic extremities, weak pulse, grunting, moaning and not responding +in any way when examined. After this the moaning +and grunting ceased and she was essentially indifferent, and for +the most part kept her eyes closed. Often she wet and soiled +herself. She was resistive to any care or examination. She +would not eat, as a rule, but again gulped down milk offered her. +For a considerable time she had to be tube-fed. During the +early part of this stupor she once took a paper from the doctor, +examined it, and then gave it back without saying anything, or +again she peered around silently, or asked to go home, or again, +on a few occasions, answered a question or two or spoke some +unintelligible words. Orientation could not be established.</p> + +<p>2. After a few weeks she became more rigid, a condition which +continued for six months. She let saliva collect in her mouth, +and drooled. She had to be tube-fed. She lay very rigid, with +very pronounced general tension, with her lips puckered, hands +clenched, sometimes holding her eyes tightly closed, and often +with marked perspiration. For one day she held her breath until +she was blue in the face. On the same day she was extremely<!-- Page 64 --><span class='pagenum'><a name="Page_64" id="Page_64">[64]</a></span> +rigid, so that she could be raised by her head with only her heels +resting on the bed. Her eyes were tightly shut and she was in +profuse perspiration. Sometimes she interrupted this by a deep +breath, only again to resume the forcible holding of her breath. +On another day towards the end of the period, while quite stiff, +she kept grunting and screaming "murder." The soiling continued. +She never spoke.</p> + +<p><i>Physical condition during the stupor:</i> At first she had a coated +tongue, foul breath and a fetid diarrhea. The latter was +treated with high colonic flushing and mild diet. Urine normal—gynecologically +normal. General neurological and physical examination +not possible. At the same time she had for two weeks +a temperature which often reached 100° or a little above, a weak, +irregular but not rapid pulse, a leucocytosis of 17,500 and 80% +hemoglobin. When she began to refuse food and before she was +tube-fed regularly, she twice had syncopal attacks and lost considerable +flesh which was gradually regained under tube-feeding. +After the diarrhea she was habitually constipated. Cyanosis +of the extremities seemed to have been present only at first.</p> + +<p>3. Six months after admission she began to make very free +facial movements—winking, raising the eyebrows—and soon developed +an excitement with marked elation. She had to be kept +in the continuous bath, talked continuously, whistled, sang, was +markedly erotic towards the physician, careless in exposing herself +and often obscene in her talk. Most of her productions +were determined by the environment. She was therefore quite +distractible, very alert; sometimes she was meddlesome, again +irritable, irascible. The following illustrates her productions: +"Send for my husband, S.—He had one sister as big as that. +She likes candy.... My father is underneath and my mother is +on top because she is fat and he is skinny.... Wait till the +sun shines, Nellie—we will be happy, Nellie—don't you sigh, +sweetheart, you and I—wait till the sun shines by and by.... +Come in (as noise is heard)—I bet that is my husband—my name +is Regina K. (mother's name)—my mother's name is the same—I +got a little sister named Regina—she is my husband." When +she heard the word pain, she said, "Who says paint, Pauline used +paint, I used paint," etc.</p> + +<p><!-- Page 65 --><span class='pagenum'><a name="Page_65" id="Page_65">[65]</a></span> +Towards the end of August she had pneumonia, which did not +change her condition.</p> + +<p>By October she was well, having gradually settled down. She +had good insight.</p> + +<p><i>Retrospectively:</i> She laid very little stress on the false report +of the father's death. She claimed to remember being at the +Observation Pavilion, but to recall very little of the other hospital. +Unfortunately an inquiry was not made regarding her +memory during the stupor period under observation with the exception +of the fact that she said she wanted to die and therefore +refused food.</p> + +<p>She was seen in March, 1913, appeared perfectly well, and +stated she had been well during the entire interval.</p></div> + +<p>If this forced holding of the breath had been the +only anomaly, one would, perhaps, not be justified +in drawing any conclusions as to its significance. +But the deep stupor was interrupted again for a day +by grunting and screaming of "murder." This is +certainly indicative of a compulsive death idea and +retrospectively she spoke of having refused food in +order to die. The latter seems to indicate some +connection between her negativism and death. Consequently, +even if we regard the breath holding as +resistiveness, it would still be related to her idea of +dissolution. Her negativism went beyond ordinary +limits in that it affected the expression of the +face.</p> + +<p>When we consider these three cases together, we +see that what would otherwise have been deep +stupors with profound inactivity, were modified by +activity in two directions: suicidal and resistive. +Presuming that the symptoms of stupor are all interrelated, +we can see a reason why the affect should<!-- Page 66 --><span class='pagenum'><a name="Page_66" id="Page_66">[66]</a></span> +also have been altered. When one is modified, this +should influence the other. When the activity is +increased, the emotional concomitants of impulsive +acts tend to break through as well. Hence the +changes observed in these cases in facial expression +and tone of voice. It is noteworthy, too, that all +three showed a tendency for laughter to appear, as +if, the emotions once stirred, it was possible for +them to be exhibited in other than unpleasant forms. +So, too, it was possible for ideas unrelated to the +stupor picture, such as those of lovers, to occur +sporadically. Finally, since activity must imply +some contact with environment, the first of these +cases at least showed less interference with the intelligence +than is usual. In general, one may conclude +that any aberration from the pure type of +stupor tends to allow other impurities to appear.</p> + +<p><!-- Page 67 --><span class='pagenum'><a name="Page_67" id="Page_67">[67]</a></span></p> + +<h2>CHAPTER IV<br /> + +<span class="sm">THE INTERFERENCES WITH THE INTELLECTUAL +PROCESSES</span></h2> + +<p>This is one of the most interesting and important +of the stupor symptoms. We are accustomed to +think of the functional psychoses having symptoms +to do with emotions and ideas in the main, and, +conversely, that disorientation, etc., observed in such +cases is merely the result of distraction, poor attention +or coöperation. But in stupor the deficit in +understanding, incapacity to solve simple problems +and failure of memory seem deep-rooted and fundamental +symptoms. So far is this true that Bleuler<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a> +looks on "schizophrenic" cases with this symptom +of "Benommenheit" as organic in etiology. It may +be said at the outset that we do not share this view +for many reasons. One at least may now be stated +as it seems to be final. In benign stupor purely +mental stimuli may change the whole clinical picture +abruptly and with this produce a change in the intellectual +functioning such as we never see in organic +dementias or clouded states. We find it more satisfactory +to attempt a correlation of this with the +other symptoms on a purely functional basis, as will +be explained later.</p> + +<p><!-- Page 68 --><span class='pagenum'><a name="Page_68" id="Page_68">[68]</a></span> +For the study of the interferences with the intellectual +processes during stupor reaction, we have +two sources of information: The first is derived +from the account which the patient is able to give in +regard to what he remembers as having taken place +around him or in his mind during the stupor period; +the second is the direct observation of partial stupor +reactions.</p> + +<h3>1. Information Derived from the Patient's Retrospective +Account</h3> + +<p>We will start with the cases of marked stupor mentioned +in Chapter I. Anna G.'s (Case 1) psychosis +commenced at home, and under observation lasted +with great intensity for five months. She remembered +only vaguely the carriage going to the Observation +Pavilion, had no recollection of the latter, +nor of her transfer to the Manhattan State Hospital +and of most of the stay at the Institute ward, including +the tube- or spoon-feeding which had to be +carried on for four months. She also claimed that +she did not know where she was until four or five +months after admission. She was amnesic for her +delusions and hallucinations. Of Caroline DeS. +(Case 2) we have no information. Of Mary F. +(Case 3), whose stupor began at home and under +observation lasted two years, we find that she had +no recollection of coming to the hospital, what ward +she came to, who the doctor and nurses were (with +whom she became acquainted later), in fact she<!-- Page 69 --><span class='pagenum'><a name="Page_69" id="Page_69">[69]</a></span> +claimed that for about a year she did not know +where she was. But she remembered having been +tube-fed (this took place over a long period). Mary +D.'s (Case 4) stupor also commenced at home, and +under observation lasted for three months. She had +no recollection of going to the Observation Pavilion, +of the transfer to Manhattan State Hospital, and of +a considerable part of her stay here, including such +obtrusive facts as a presentation before a staff meeting, +an extensive physical and a blood examination, +and she claimed not to have known for a long time +where she was. Annie K.'s (Case 5) stupor commenced +at home. Although she recalled the last +days there and some ideas and events at the Observation +Pavilion, the memory of the journey to +Ward's Island was vague, as was that of entrance +to the ward, and she claimed not to have known +where she was for quite a while. Specific occurrences, +such as the taking of her picture (with open +eyes two months after admission), an examination +in a special room, her own mixed-up writing (end of +second week) were not remembered. But it is quite +interesting that an angry outburst of another patient +within this same period, which was evidently +not recorded, is clearly remembered.</p> + +<p>We shall later show that when the patient comes +out of a stupor the condition may be such that, for +a time at least, retrospective accounts are difficult +to obtain. It must also be remembered that not infrequently +the more marked stupors may be followed +by milder states, and it is important, if we<!-- Page 70 --><span class='pagenum'><a name="Page_70" id="Page_70">[70]</a></span> +wish to determine how much is remembered, not to +confuse the two states or not to let the patient confuse +them. For example, Mary D. (Case 4), who +showed two separate phases, while she claimed not +to know of many external facts, also added that she +could not understand the questions which were +asked. From observation in other cases it seems +that in marked stupor any such recollection about +the patient's own mental processes would be quite +inconsistent. We have to assume, therefore, that this +remark referred in reality to the second milder +phase, for which, as we shall see, it is indeed quite +characteristic. It is not necessary to burden the +reader with other cases, all of which consistently +gave such accounts.</p> + +<p>We see, then, that in the marked stupor the intellectual +processes are regularly interfered with, as +evidenced by almost complete amnesia for external +events and internal thoughts. In other words, this +would indicate that the minds of these patients were +blank. Inasmuch as direct observation during the +stupor adduces little proof of mentation, we may +assume that such mental processes as may exist in +deepest stupor are of a primitive, larval order.</p> + +<p>Before we examine more carefully the milder +grades of stupor, it will be necessary to say a few +words about the retrospective account which the +patient gives of intellectual difficulties during the +incubation period of the psychosis. As a matter of +fact, we find that these accounts are remarkably +uniform. While some patients, to be sure, speak of<!-- Page 71 --><span class='pagenum'><a name="Page_71" id="Page_71">[71]</a></span> +a more or less sudden lack of interest or ambition +which came over them, others of them speak plainly +of a sudden mental loss. Mary. C. (Case 7) claimed +she suddenly got mixed up and lost her memory. +Laura A. spoke at any rate of suddenly having felt +dazed and stunned. Mary D. (Case 4) said she felt +she was losing her mind and that she could not understand +what she was reading. Maggie H. (Case +14) began to say that her head was getting queer. +We see from this that the interferences with the intellectual +processes may in the beginning be quite +sudden.</p> + +<p>In some instances a more detailed retrospective +account was taken, which may throw some light upon +the interferences with the intellectual processes with +which we are now concerned. Emma K., whose case +need not be taken up in detail, had a typical marked +stupor which lasted for nine months, preceded by a +bewildered, restless, resistive state for five days. +She was in the Institute ward for the first four +months, including the five days above mentioned; +later in another ward. When asked what was the +first ward which she remembered, she mentioned the +one after the Institute ward, and when asked who +the first physician was, she mentioned the one in +charge of the second ward. However, when taken +to the Institute ward, she said it looked familiar, and +was able to point to the bed in which she lay, though +somewhat tentatively. The same rousing of memory +occurred when the first physician, who saw her daily, +was pointed out to her. She remembered having<!-- Page 72 --><span class='pagenum'><a name="Page_72" id="Page_72">[72]</a></span> +seen him, and then even recalled the fact that he had +thrown a light into her eyes, but remembered nothing +else. This observation would seem to show that +with some often repeated or very marked mental +stimuli (throwing electric light into her eyes) a +vague impression may be left, so that it may at least +be possible to bring about a recollection with assistance, +whereas spontaneous memory is impossible. +In another instance, the patient was confronted +with a physician who had seen a good deal +of her. She said that he looked familiar to her, but +she was unable to say where she had seen him. Here +then again evidence that a certain vague impression +was made by a repeated stimulus.</p> + +<p>Another feature should here be mentioned, +namely, that isolated facts may be remembered +when the rest is blank. We have seen above +that Annie K. (Case 5), while very vague about +most occurrences, recalled a sudden angry outburst +in detail. Another patient, though the period of the +stupor was a blank, recalled some visits of her +mother. At these times, as she claimed, she thought +she was to be electrocuted and told her mother so, +"Then it would drop out of my mind again." These +facts are very interesting. We can scarcely account +for such phenomena in any other way than by assuming +that certain influences may temporarily lift the +patient out of the deepest stupor. In spite of the fact +that stupors often last for one or two years almost +without change, a fact which would argue that the +stupor reaction is a remarkably set, stable state,<!-- Page 73 --><span class='pagenum'><a name="Page_73" id="Page_73">[73]</a></span> +we see in sudden episodes of elation that this is not +the case, and other experiences point in the same direction. +A similar observation was made on a case of +typical stupor with marked reduction of activity and +dullness. A rather cumbersome electrical apparatus +(for the purpose of getting a good light for pupil +examination) was brought to her bedside. Whereas +before, she had been totally unresponsive, she suddenly +wakened up, asked whether "those things" +would blow up the place, and whether she was to be +electrocuted. During this anxious state she responded +promptly to commands, but after a short +time relapsed into her totally inactive condition. +We have, of course, similar experiences when we try +to get stuporous patients to eat, who, after much +coaxing may, for a short time, be made to feed themselves, +only to relapse into the state of inactivity.</p> + +<p>Such variations are paralleled, as we shall later +show, by a suddenly pronounced deepening of the +thinking disorder. We have already seen that the +onset may be quite sudden. All this indicates that, +in spite of a certain stability, sudden changes are +not uncommon. Finally, we know that, in spite of +the fact that stupor is an essentially affectless reaction, +certain influences may produce smiles or tears, +or, above all, angry outbursts, which again can +hardly be interpreted otherwise than by assuming +that those influences have temporarily produced a +change in the clinical picture, in the sense of lifting +the patient out of the depth of the stupor. All these<!-- Page 74 --><span class='pagenum'><a name="Page_74" id="Page_74">[74]</a></span> +facts suggest that inconsistencies in recollection are +correlated with changes in the clinical picture.</p> + +<p>As is to be expected, the cases with partial stupors +remember much more of what externally and internally +happened during their psychoses. Rose Sch. +(Case 6), who had a partial stupor during which she +answered questions but showed a great difficulty in +thinking, said retrospectively that she felt mixed up +and could not remember. Although she recalled +with details the Observation Pavilion and her transfer, +she was not clear about their time relations +(how long in the Observation Pavilion, how long in +the first ward). Mary C. (Case 7), whose activity +was not entirely interfered with and who showed +some thinking disorder, said retrospectively that she +could not take in things. Henrietta H. (Case 8), who +had a partial stupor, claimed to have known all +along where she was, but that she felt mixed up, +that her thoughts wandered and that she felt confused +about people. In the cases where a partial +stupor was preceded by a marked one, such as in +phase 2 of Anna G. (Case 1) and phase 2 of Mary +D. (Case 4), we have no retrospective account regarding +the partial stupor, because emphasis in the +analysis was naturally laid on the period comprising +the most marked disorder. However, we can gather +from the few cases at our disposal that the patients +retrospectively lay stress chiefly on their inability +to understand the situation.</p> + +<p>We finally have to consider the group of suicidal +cases. We have information only in regard to two<!-- Page 75 --><span class='pagenum'><a name="Page_75" id="Page_75">[75]</a></span> +cases, namely, Margaret C. (Case 10) and Pearl F. +(Case 9). In both of these, we find that a good many +things that happened during the period under consideration +were remembered, as were also the +patients' own actions. In Rosie K. (Case 11) we +have at least the evidence that she remembered her +own impulses, namely, that she refused food because +she wanted to die. In other words, in these partial +stupors with impulsive suicidal tendencies the interference +with the intellectual processes seems to be +moderate, and memory for external events not +markedly affected.</p> + +<h3>2. Information Derived from Direct Observation</h3> + +<p>The evidence can best be presented by considering +the details of some cases.</p> + +<p>Rose Sch. (Case 6) was remarkable, in connection +with the present problem, in her unusually poor +answers. She either merely repeated the questions, +or made irrelevant superficial replies, or said she did +not know, this even with very simple questions. +When better, too, though not quite well, she showed +striking discrepancies in time relations and incapacity +to correct them. It would seem that in this case +there was something more than an acute interference +with the intellectual processes, such as we are +here discussing. As a matter of fact, we have the +statement in the history that the patient herself said +she was slow at learning in school and had not much +of an education. A congenital intellectual defect<!-- Page 76 --><span class='pagenum'><a name="Page_76" id="Page_76">[76]</a></span> +and the attitude which it creates may, however, as +my experience has repeatedly shown me, very +greatly exaggerate an acute thinking disorder. The +case, therefore, while it shows us an unquestionably +acute interference with the intellectual processes, +does not give us useful information about its nature. +More information can be gathered from Mary D. +(Case 4). Even toward the end of her marked +stupor some replies were obtained chiefly by making +her write. When asked to write Manhattan State +Hospital, she wrote Manhatt Hhospshosh, and for +Ward's Island, Ww. Iland. Again, instead of writing +90th Street, she wrote 90theath Street. These +are plainly reactions of the path of least resistance +or, in these instances, of perseveration. Of the +same nature are some of her other replies in writing +or speaking. After she had been asked to write her +name, she was requested to add her address, or the +name of the hospital; she merely repeated the name. +Similarly, when asked whether she knew the examiner, +she said "Yes," but when urged to give his +name, she gave her own. In the partial stupor at a +time when she knew where she was, knew the names +of some people about her, the year and approximately +the date, she made mistakes in calculation and +could not get the point of a test story. Moreover, +she failed in retention tests without there being any +evidence of anything like a marked fundamental +retention disorder, such as we find in Korsakoff +psychosis. It seems that these results are best +termed defects in attention, which chiefly interfere<!-- Page 77 --><span class='pagenum'><a name="Page_77" id="Page_77">[77]</a></span> +with the apprehension of more difficult tasks. As +we shall see later, this seems to be rather characteristic +of these cases. Another point which should be +mentioned is the fact that her reaction to questions +which she was unable to answer (such as matters +which referred to her amnesic periods) was peculiar, +inasmuch as she did not only not try to think them +out, but seemed indifferent to her incapacity, simply +leaving the question unanswered. This too, as we +shall see later, is characteristic. Laura A., at a time +when she could be made to reply, merely repeated +the question, again a reaction of least resistance. +The same patient sometimes asked, "Where am I?" +Mary C. (Case 7) made similar queries. Although +she was at times approximately oriented, she would +say, "I don't know where I am," or "I can't realize +where I am," or more pointedly, "I can't take in my +surroundings." She often did not answer and sometimes +seemed bewildered by the questions. Henrietta +H. (Case 8) again showed some defect of +orientation and mistakes in calculation, and above +all, marked mistakes in writing (for Manhattan +State Hospital—Manhaton Hotspal). A special feature +here is that this occurred immediately after she +had been quite talkative, but suddenly had relapsed +into a dull state. Anna G. (Case 1), during the third +phase of her psychosis, showed the following: Although +she was approximately oriented and answered +promptly simple questions; e.g., about +orientation or simple calculation, she, like these +other patients, simply remained silent when more<!-- Page 78 --><span class='pagenum'><a name="Page_78" id="Page_78">[78]</a></span> +difficult intellectual tasks were required of her (more +difficult calculations); or when she was asked how +long she had been here (which involved data that +could not be available to her, owing to her amnesia); +or when questions were put to her regarding her +feelings or the condition she had passed through. +On the other hand, she sometimes gave appropriate +replies in the words "yes" or "no," but it was +difficult to say whether these answers did not also +represent the path of least resistance.</p> + +<p>We will finally take up the last phase of Margaret +C. (Case 10). Although she was entirely oriented, +there was a certain vagueness about her answers +which is difficult to formulate. She was telling about +the onset of her sickness and said that at that time +her mind was taken up with prayers about the salvation +of her relatives. She was asked exactly when +it was that she thought of this and she answered +"Now?" (What period are we talking about?) +"The present." (What did I ask you?) "About +this period of my sickness." (Which one?) "What +sickness?" She said herself at this point, "I am +rather stupid." Again when asked how her mind +worked, she said, "Pretty quickly sometimes—I +don't know." (As good as it used to?) "No, I +don't think so." (What is the difference?) "There +is no difference." (What did I ask you?) "The difference." +(The difference between what?) "You +did not say." In this the shallowness of her comprehension +and thinking is well shown, and it seems +here again perhaps justifiable to formulate the main<!-- Page 79 --><span class='pagenum'><a name="Page_79" id="Page_79">[79]</a></span> +defect as one of attention, which prevents completion +of a complicated process of comprehension. A +feature of further interest in this case is that automatic +intellectual processes, such as those necessary +for the writing of a long poem from memory, were +not interfered with.</p> + +<h3>Summary</h3> + +<p>In the most pronounced stupor we have evidently +a more or less complete standstill in thinking +processes. Practically no impressions are registered +and consequently nothing is remembered except +events that occurred in some short periods +when some affective stimulus, or a brief burst of +elation, lifts the patient temporarily out of the deep +stupor. It is impossible to say whether the statement +of a complete standstill has to be qualified. In +some stupors repeated environmental stimuli sometimes +make at least a vague impression, so that while +spontaneous recollection is impossible a feeling of +familiarity is present when the patient is again confronted +with this environment. This might be an +exception to the dictum of complete mental vacuity, +or it may be that there are somewhat less pronounced +stupor reactions. When more is perceived, +there is often a retrospective statement of having +felt mixed up, being unable to take in things, or, +directly under observation, the patient may say, "I +cannot realize where I am," "I cannot take in my +surroundings." In harmony with this is the fact +that questions often produce a certain bewilderment.<!-- Page 80 --><span class='pagenum'><a name="Page_80" id="Page_80">[80]</a></span> +In quite pronounced states in which some replies +can still be obtained, we find that the intellectual +processes may be interfered with to the extent of a +paragraphia, i.e., a remarkably mixed-up writing in +which perseveration (one form of following the path +of least resistance) plays a prominent part. This +same principle is also seen in such reactions as the +repetition of the question or the senseless repetition +of a former answer. These phenomena remind us +of what we see in epileptic confusions, in epileptic +deterioration and in arteriosclerotic dementia.</p> + +<p>In milder cases difficulties in orientation may be +more or less marked; or there may be incapacity to +think out problems, although the orientation is perfect. +The more automatic mental processes may +run smoothly (memory and calculation may be excellent) +and there may yet be a certain shallowness +in thinking, a defect of attention (a purely descriptive +term) which is most obvious in the patient's +inability to grasp clearly the drift of what is going +on or the meaning of complicated questions. I am +inclined to think that poor results in retention tests +are entirely due to this attention disorder, for we +have no evidence of any fundamental retention defect +such as we find in the totally different organic +stupors. From a practical point of view it is important +at this place to call attention to the fact +that such mild changes are particularly seen in end +stages. Even when pronounced negativistic tendencies +do not play a prominent rôle, the patient is +then apt to be silent chiefly as a result of the residual<!-- Page 81 --><span class='pagenum'><a name="Page_81" id="Page_81">[81]</a></span> +disorder in the intellectual processes. Still more +striking are the conditions which are on a somewhat +higher level and in which the shallowness of the responses, +due to the residual disorder of attention, +together with the last traces of the affectlessness, +are apt to create the impression of a dementia. In +such cases the opinion is often held that the patient +has reached a defect stage from which recovery is +impossible, whereas a thorough knowledge of these +end stages teaches us that they are not only recoverable +but quite typical for the terminal phases of +stupor.</p> + +<p>Considering these data, especially those gathered +in the end stages, it would appear that there is no +tendency in this intellectual disorder associated with +the stupor reaction for any special side of mental +activity to be most prominently affected. It looks +rather as if it were a question of a general diminution +of the capacity to make a mental effort which in +its different intensities accounts for the symptoms.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> See <a href="#CHAPTER_XV">Chapter XV</a>.</p></div> +</div> + +<p><!-- Page 82 --><span class='pagenum'><a name="Page_82" id="Page_82">[82]</a></span></p> + +<h2>CHAPTER V<br /> + +<span class="sm">THE IDEATIONAL CONTENT OF THE STUPOR</span></h2> + +<p><i>Brief survey of the ideas associated with stupor:</i> +Having thus described the formal manifestations of +the various stupor reactions, it will now be interesting +to see what ideas seem to be associated with +these reactions. It is, of course, impossible to obtain +during a considerable part of the stupor any statement +of the patients' thoughts. We therefore have +to depend on their utterances during periods when +the inactivity temporarily ceases, or on the retrospective +account which the patient gives after the +stupor has completely disappeared; and as we shall +see, we also may obtain considerable information by +studying the ideas which occur in the period preceding +the stupor. These last may be autogenous +delusions or thoughts about actual events which precipitated +the psychosis.</p> + +<p>It is not likely that many observers have a very +clear conception about what sort of ideas to expect. +We have, as a rule, not been in the habit of paying +much attention to the content of delusions, hallucinations, +and the like. So far as we could judge, +therefore, the ideas expressed might be expected to +be fairly multiform, and it was distinctly interesting<!-- Page 83 --><span class='pagenum'><a name="Page_83" id="Page_83">[83]</a></span> +to us when we found a marked tendency for the +trends of ideas to remain within a certain small +compass.<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a> It was possible, to state this at once, to +show that in by far the majority of cases the same +set of ideas returned, and that these ideas had +among themselves a definite inner relationship, being +concerned with thoughts of "death." In isolated +instances other ideas were found as well, and +they will have to be discussed later. For the present +we shall take up more habitual content.</p> + +<p>In addition to the eleven cases already described, +it may be well to cite four others which present +material now of interest to us.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 12.</span>—<i>Charlotte W.</i> Age: 30. Admitted to the Psychiatric +Institute October 21, 1905.</p> + +<p><i>F. H.</i> The father was alcoholic and quick-tempered; he died +when the patient was a child. The mother was alcoholic and +was insane at 40 (a state of excitement from which she recovered). +A brother had an attack of insanity in 1915. A maternal +uncle died insane.</p> + +<p><i>P. H.</i> The patient was described as jolly, having many friends. +She got on well in school and was efficient at her work.</p> + +<p>She was married at 23 and got on well with her husband. +The latter stated, however, that she masturbated during the first +year of her married life. The first child was born without +trouble.</p> + +<p><i>First Attack at 25:</i> Two or three days after giving birth to +a second child, her mother burst into the room intoxicated. The +patient immediately became much frightened, nervous, and developed +a depressive condition with crying, slowness and inability +to do things. During this state she spoke of being bad and told<!-- Page 84 --><span class='pagenum'><a name="Page_84" id="Page_84">[84]</a></span> +her husband that a man had tried to have intercourse with her +before marriage. This attack lasted six months and ended with +recovery.</p> + +<p>When 29, a year before her admission, she had an abortion +performed, and four months later another. Her husband was +against this, but she persisted in her intention. Seven months +before admission she went to the priest, confessed and was reproved. +It is not clear how she took this reproof, but at any +rate no symptoms appeared until three weeks later, after burglars +had broken into a nearby church. Then she became unduly +frightened, would not stay at home, said she was afraid the burglars +would come again and kill "some one in the house." The +patient herself stated later, during a faultfinding period, that +at that time she was afraid somebody would take her honor away, +and that she thought burglars had taken her "wedding dress." +"Then," she added, "I thought I would run away and lead a bad +life, but I did not want to bring disgrace to the family."</p> + +<p>The general condition which she presented at this time is described +as one of apprehensiveness when at home. For this +reason she was for five weeks (it is not clear exactly at what +period) sent to her sister, where she was better. About a month +before the patient was admitted, the husband moved, whereupon +she got depressed, complained of inability to apply herself to +work, became slow and inactive, and blamed herself for having +had the abortion performed. She began to speak of suicide and +was committed because she bought carbolic acid. She later said +that while in the <i>Observation Pavilion</i> she imagined her children +were cut up.</p> + +<p><i>Under Observation</i> the condition was as follows:</p> + +<p>1. For the first three days the patient, though for the most +part not showing any marked mood reaction, was inclined at +times to cry, and at such times complained essentially that this +was a terrible place for a person who was not insane.</p> + +<p>2. On the fourth day the condition changed, and it will be +advisable to describe her state in the form of abstracts of each +day.</p> + +<p>On <i>October 24</i> the patient began to be preoccupied and to +answer slowly. A few days later she became distinctly dull, +walked about in an indifferent way or lay in bed immobile.<!-- Page 85 --><span class='pagenum'><a name="Page_85" id="Page_85">[85]</a></span> +Twice on <i>October 27</i> she said in a low tone and with slight distress, +"Give me one more chance, let me go to him." But she +would not answer questions. At times she lapsed into complete +immobility, lying on her back and staring at the ceiling. When +the husband came in the afternoon, she clung to him and said: +"Say good-by forever, O my God, save me." Again, very slowly +with long pauses and with moaning, she said: "You are going +to put me in a big hole where I will stay for the rest of my life." +<i>On October 28</i> she was found with depressed expression and +spoke in a rather low tone, but not with decided slowness as had +been the case on the day before. She pleaded about having her +soul saved; "Don't kill me"; "Make me true to my husband"; +once, "I have confessed to the wrong man the shame of my life." +Later she said she did not tell the truth about her life before +marriage. Again she wanted to be saved from the electric chair. +At times she showed a tendency to stare into space and to leave +questions unanswered.</p> + +<p>3. From now on a more definite stupor occurred, which is also +best described in summaries of the individual notes.</p> + +<p><i>Oct. 29.</i> Lies in bed with fixed gaze, pointing upward with +her finger and is very resistive towards any interference. She +has to be catheterized.</p> + +<p><i>Oct. 30.</i> Can be spoon-fed but is still catheterized. During +the morning she knelt by the bed and would not answer. At the +visit she was found in a rather natural position, smiling as the +physician approached, saying "I don't know how long I have been +here." Then she looked out of the window fixedly. At first +she did not answer, but, when the physician asked whether she +knew his name, she laughed and said, "I know your name—I know +my name." Then she would not answer any more questions but +remained immobile, with fixed gaze. When her going home was +mentioned, however, she flushed and tears ran down her cheek, +though no change in the fixedness of her attitude or in her facial +expression was seen.</p> + +<p><i>Nov. 1.</i> Lies flat on her back with her hands elevated. She +is markedly resistive.</p> + +<p><i>Nov. 2.</i> Free from muscular tension and more responsive. +When asked whether she felt like talking, she said in a whining +tone, "No, go away—I have to go through enough." Then she<!-- Page 86 --><span class='pagenum'><a name="Page_86" id="Page_86">[86]</a></span> +spoke of not knowing how long the nights and days were, of not +having known which way she was going. When asked who the +physician was she whimpered and said, "You came to tell me +what was right." She called him "Christ" and another physician +"Jim" (husband's name), though, later in the interview, she +gave their correct names. When asked about the name of another +physician, she said: "He looks like my cousin, he was +here, they all came the first night. I did not take notice who +it was till I went through these spirits, then I knew it was right."—She +paused and added: "My God—mother it was; she is here +on Earth, somewhere in a convent—Sister C. (who actually is in +a convent) she was here, too, I could hear her." She said they +all came to try to save her. When asked whether she had been +asleep, she said: "No, I wasn't asleep, I was mesmerized, but I +am awake now—sometimes I thought I was dead." (When?) +"The time I was going to Heaven." Again: "I went to Heaven +in spirit, I came back again—the wedding ring kept me on Earth—I +will have to be crucified now." (Tell me about it.) "Jim +will have to pick my eyes out—I think it is him. Oh, it is my +little girl." (Who told you?) "The spirits told me." Again: +"Little birds my children—I can't see them any more—I must +stay here till I die." (Why?) "The spirits told me—till I +pick every one of my eyes out and my brains too." When asked +what day it was, she said, "It must be Good Friday." (Why?) +"Because God told me I must die on the cross as he did." When +asked why she had not spoken the day before, she said that +"Jesus Christ in Heaven" had told her she should not tell anything, +"till all of you had gone, then I could go home with him, +because that is the way we came in and it was Jim too all the +time." Finally she said crossly, "Go away now, you are all +trying to keep me from Jim" (crying).</p> + +<p><i>Nov. 3.</i> Knelt by bed during the night. This morning lies +in bed staring, resistive, again she is markedly cataleptic. She +has to be spoon-fed, and is totally unresponsive. In the afternoon +she was found staring and resistive. Presently she said +with tears: "I am waiting to be put on the cross."</p> + +<p><i>Nov. 4.</i> Still has to be catheterized. She sits up, staring, +with expressionless face, but when asked how she felt she responded +and said feebly: "I don't know how I feel or how I<!-- Page 87 --><span class='pagenum'><a name="Page_87" id="Page_87">[87]</a></span> +look or how long I have been here or anything." (What is +wrong?) "Oh, I only want to go to a convent the rest of my +days." (Why?) "Oh, I have only said wrong things, I thought +I would be better dead, I could not do anything right." Later +she again began to stare.</p> + +<p><i>Nov. 5.</i> During the night she is said to have been restless and +wanted to go to church. To-day she is found staring, but not +resistive. When questioned she sometimes does not answer. She +said to the physician, "I should have gone up to Heaven to you +and not brought me down here." She called the physician +"Uncle James." Again she said, "I want to go up to see Jim." +Sometimes she looks indifferent, again somewhat bewildered.</p> + +<p><i>Nov. 6.</i> She eats better, catheterizing is no longer necessary. +She is found lying in bed, rigid, staring, resistive, does not answer +at first, later appears somewhat distressed, says "I want to +go and see Jim." (Where?) "In Heaven." She gave the name +of the place and of the physician, also the date.</p> + +<p><i>Nov. 8.</i> In the forenoon, after she had presented a rather +immobile expression and had answered a few orientation questions +correctly, she suddenly beckoned into space, then shook +her fist in a threatening manner. When later asked about this, +she said: "Jim was down there and I wanted to get him in." +(And?) "You was up here first." (And?) "I thought we +was going down down, up up—the boat— —you came in here +for—to lock Jim out so we wouldn't let him in." Later she said, +when asked whether anything worried her, "Yes, you are taking +Jim's place."</p> + +<p><i>Nov. 9.</i> During the night she is reported to have varied between +stiffness with mutism and a more relaxed state. Once, the +nurse found her with tears, saying "I want to go down the hall +to my sister—to the river," and a short time later with fright: +"Is that my mother?" Again she said: "Oh dear, I wish this +boat would stop—stop it—where are we going?" In the forenoon +she was quiet and unresponsive. In the afternoon she said +in a somewhat perplexed way, "We were in a ship and we were +'most drowned." (When was that?) "Day before yesterday +it must have been"—Again she said in the same manner: "It was +like water. I was going down. I could hear a lot of things." +She claimed this happened "to-day." "I saw all the people in<!-- Page 88 --><span class='pagenum'><a name="Page_88" id="Page_88">[88]</a></span> +here, it was all full of water," "I have been lying here a long +time—do you remember the time I was under the ground and it +seemed full of water and every one got drowned and a sharp +thing struck me?" "I was out in a ship and I went down there +in a coffin." When asked whether she had been frightened at +such times, she said: "No, I didn't seem to be, I just lay there." +She also said: "the water rushed in," and when asked why she +put up her arms, she said, "I did it to save the ship."</p> + +<p><i>Nov. 10.</i> She is still fairly free. She said that when she was +on the ship things looked changed, "the picture over there looked +like a saint, the beds looked queer." (How do things look now?) +"All right." (The picture too?) "The same as when I was +going down into a dark hole." When asked later in the day +where she was, she said, "In the Pope's house, Uncle Edward is +it?" but after a short time she added, "It is Ward's Island, +isn't it?"</p> + +<p><i>Nov. 11.</i> Inactive, inaccessible, but for the most part not +rigid.</p> + +<p><i>Nov. 14.</i> Varies between mutism with resistance and more +relaxed inactivity. To-day lies in a position repeatedly assumed +by her, namely, on her stomach with head raised, resistive towards +any interference, immobile face, totally inaccessible.</p> + +<p><i>Nov. 15.</i> Freer. She said: "One day I was in a coffin, that's +the day I went to Heaven." She also said she used to see "the +crucifix hanging there" (on the ceiling)—"not now but when I +was going to Heaven." (When was that?) "Over in that bed" +(her former bed). Later she added, "The place changed so ... +things used to be coming up and down (dreamily)—that was the +day I was coming up on the ship or going down." She is quite +oriented.</p> + +<p><i>Nov. 17.</i> Usually stands about with immobile face, preoccupied, +but she eats voluntarily.</p> + +<p><i>Nov. 24.</i> When the husband and sister came a few days ago +she said she was glad to see them, embraced them, cried and is +said to have spoken quite freely. To-day she speaks more freely +than usually. When asked why she had answered so little, she +said she could not bring herself to say anything, though she +added spontaneously, "I knew what was said to me." When +shown a picture of her cataleptic attitude with hands raised, she<!-- Page 89 --><span class='pagenum'><a name="Page_89" id="Page_89">[89]</a></span> +said dreamily, "I guess that must have been the day I went to +Heaven, everything seemed strange, things seemed to be going up +and down." (Did you know where you were?) "I guess that +was the day I thought I was on the ship." When the sister +spoke to her, she seemed depressed and said, "If only I had not +done those things I might be saved, if I had only gone to church +more."</p> + +<p><i>Dec. 3.</i> Seems depressed. She weeps some, says she is sad, +"There seems to be something over my heart, so I can't see my +little girls." Again: "I should have told you about it first—I +should not have bought it"—(refers to buying carbolic acid). +She wrote a natural letter but very slowly.</p> + +<p>4. There followed then a state lasting for six months, during +which the patient was rather inactive, preoccupied, even a little +tense at times. Sometimes she did not answer, again at the same +interview spoke quite promptly. For the most part the affect +was reduced, at other times she appeared a little uneasy, bewildered, +or again depressed. She said that sometimes a mist +seemed to be over her. Now and then spoke of things looking +queer and she asked, when the room was cleaned, "Why do they +move things about?" and she added irrelevantly: "I thought the +robbers broke into my house and stole my wedding dress and my +children's dresses" (refers to the condition during the onset of +her psychosis). In the beginning of this state, when asked +about the stupor, she spoke again of the "ship" and about going +"down, down," but also said that on one occasion she heard beautiful +music, was waiting for the last trumpet and was afraid to +move. Moreover, she had some ideas referring to the actual +situation which were akin to those in the more marked stupor +period. Although she admitted she was better, she said on December +8 that she still had queer ideas at times, "I sometimes think +the doctor is Uncle Jim" (long dead). She also spoke of other +patients looking like dead relatives, and added, "Are all the +spirits that are dead over here?" "We never die here, the spirits +are here." But after that date no such ideas recurred, in fact +this whole period seems to have been remarkably barren of delusions. +Exceptionally isolated ones were noted. Thus, on January +28 it is mentioned that she stated she sometimes felt so lonely, +and as though people were against her; and on February 13 she<!-- Page 90 --><span class='pagenum'><a name="Page_90" id="Page_90">[90]</a></span> +said she felt as though the chair knew what she was talking about. +It is also mentioned in January that she wept at times, but this +seems not to have been a leading feature at all. In March, when +asked why she was not more active and cheerful, her lips began +to quiver and she said, "Oh, I thought my children would be cut +up in Bellevue." "I don't know why I feel that way about them." +She sometimes cried when her friends left her.</p> + +<p>5. Then followed a week of a rather faultfinding, self-assertive +state, during which she demanded to be allowed to go home, saying +indignantly that she was not a wicked woman, had done nothing +to be kept a prisoner here; she wanted justice because another +patient had called her crazy. But in this period also she said +that after the robbery (at home) she felt afraid that her honor +would be taken away. When told that her husband had been +with her, she said "Yes, but I was afraid they would get into a +fight." (You mean you were afraid the other man would kill +him?) "No, he is not dead." She further talked of a disagreement +she had at that time with her husband, and that she felt +then like running away and leading a bad life, but thought of +the children. With tears she added: "I would not do anything +that is wrong. I have my children to live for." Quite remarkable +was the fact that she then told of various erotic experiences +in her life, though with a distinctly moral attitude and minimizing +them.</p> + +<p>6. On <i>June 16</i> another state was initiated with peculiar ideas, +the setting of which is not known, as she told them only to the +nurses. She said that she was not Mrs. W. but the Queen of +England, again that she was an actress, or again the wife of a +wealthy Mr. B., and that she was going to have a baby. But at +night she is said to have been agitated and afraid she was to be +executed. She asked to be allowed to go to bed again, then +stopped talking, and remained in this mute condition for about +a week. She often left her bed and went back again, remained +much with a perplexed expression. On one occasion she put +tinsel in her hair saying it was a golden crown.</p> + +<p>7. At the end of that time she became freer and more natural, +and remained so for three weeks. She occupied herself somewhat. +When asked what had happened in the condition preceding, +said she thought she was a queen or was to be a queen.</p> + +<p><!-- Page 91 --><span class='pagenum'><a name="Page_91" id="Page_91">[91]</a></span> +8. Towards the end of this period she had again three more +absorbed days, but when examined on the third of these days got +rather talkative and somewhat drifting in her talk on superficial +topics.</p> + +<p>9. Two days later she began to sing at night, kissed everybody, +said it was the anniversary of her meeting her husband, +again cried a little, and on the following morning began to sing +love songs, with a rather ecstatic mood, and at times stood in an +attitude of adoration with her hands raised. This passed over +to a more elated state, during which she smiled a good deal, often +quite coquettishly; she sang love songs softly; on one occasion +put a mosquito netting over her head like a bridal veil; or she +held her fingers in the shape of a ring over a flower pinned to +her breast. But even during this state she said little, only once +spoke of waiting for her wedding ring, and again, when asked +why she had been singing, said "I was singing to the man I love." +(Why are you so happy?) "Because I am with you" (coquettishly).</p> + +<p>This, however, represented the end of the psychosis. She improved +rapidly. At first she smiled rather readily, but soon began +to occupy herself and made a perfect recovery.</p> + +<p>She gave a rather shallow retrospective account about the last +phase: at first she said it was natural for people to feel happy +at times, and that she did not talk more because the inclination +was not there. The only point she added later was that she +held her fingers in the shape of a ring because she was thinking +of her wedding ring.</p> + +<p>She was discharged on <i>October 11</i>.</p> + +<p>The patient was seen again in <i>September, 1915</i>. She then stated +that she had been perfectly well until 1912, when she had a +breakdown after childbirth. (A childbirth in 1910 had led to +no disorder.) The attack lasted six months. She slept poorly, +lost weight, and felt weak, depressed, "my strength seemed all +gone." In <i>July, 1915</i>, following again a childbirth, she was for +about six weeks "despondent, weak and tired out."</p> + +<p>At the interview she made a very natural, frank impression, +and displayed excellent insight.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 13.</span>—<i>Johanna S.</i> Age: 47. Admitted to the Psychiatric +Institute January 23, 1904.</p> + +<p><!-- Page 92 --><span class='pagenum'><a name="Page_92" id="Page_92">[92]</a></span> +<i>F. H.</i> It was claimed that there was no insanity in the +family.</p> + +<p><i>P. H.</i> The patient was said to have been bright and rather +quick-tempered. She came to the United States from Ireland at +the age of 20, worked as a servant, was well liked, and retained +her position well.</p> + +<p>She was married at 24. After a second confinement, at the age +of 26, the patient had her first attack of manic excitement, from +which she recovered in four months. She had, subsequently, at +the ages of 28, 30, 32, 35, 43, and 45, other attacks of the same +nature, each one lasting about four months. No precipitating +cause was known for any of them. Only one of the attacks, the +fifth, (none were well observed) seems to have shown features +different from an elated excitement with irritability. At the end +of this attack she was said to have been "dull" for a month.</p> + +<p>Her husband died four years before the present admission, evidently +soon after her sixth attack.</p> + +<p>The present attack:</p> + +<p>About two months before admission the patient began, without +appreciable cause, to be sleepless, complained of headaches and +appeared downhearted and sad. She sat about.</p> + +<p>After a week she would not get out of bed and remained in +bed until she was sent to the Observation Pavilion, getting up +only to go to the closet. She said very little and would not eat +much. About a month before admission she began to say that +she did not want to live, begged her daughter to throw her out +of the window. About two weeks before admission she began +to insist that she heard the voice of her brother (living in Ireland) +calling her. She got out of bed to look for him.</p> + +<p>At the <i>Observation Pavilion</i> she was described as slow, looking +about in an apprehensive manner, bewildered, dazed, saying "I +am dead—there is poison in it (not clear in what)—I am dead, +you are dead."</p> + +<p><i>Under Observation:</i> 1. On admission the patient had a coated +tongue, foul breath, constipation, lively knee-jerks and a pulse +of 110. She appeared dull, inactive, lay in bed with her eyes +closed. She would open them when urged but appeared drowsy +and her face was strikingly immobile. At times she moaned a +little. She could be made to respond in various ways such as<!-- Page 93 --><span class='pagenum'><a name="Page_93" id="Page_93">[93]</a></span> +shaking her head, or making some motions as though to indicate +that she could not give any explanations. All movements were +slow. She also responded to a few questions by "I don't know."</p> + +<p>Two days after admission the condition was not essentially +different except that she was a little uneasy when urged to speak, +corrugated her forehead, said "Everything is dark," again "I am +very sick," or she turned away her head.</p> + +<p>On the fourth day, i.e., January 26, the picture altered, inasmuch +as she was much more responsive. She was found sitting up +in bed and, at times, a little uneasy. She was slow in her movements +and answers, speaking in a whisper and sometimes a little +fretfully. The answers, though slow, were, however, by no means +given in the shortest possible manner, but with variations, e.g., +from "I don't know," to "I could not tell you," or "I can't tell +that either." She said herself that everything had "been so dark—it +is light now, but it gets so dark sometimes." She denied +knowing where she was, even in what city, also denied knowing +the month, adding to the latter answer "the nurse can tell you." +She could not tell where she had been before coming to the hospital, +or how she came. Finally, she also claimed not to know +her age, her birthday or the date of her marriage; but she gave +the current year correctly, the place where she went to school, +the names of some of her teachers, and the year of her arrival +in the United States. She also stated in answer to questions that +she came to the hospital "to get well." She repeatedly said "I +am so sick," or "I am so stupid," or "My mind is mixed up, +twisted," or "My mind is not so good," or "I am so tired." +What could be obtained of a content was as follows: When she +spoke of being "twisted," she said, "I got all kinds of medicine." +(How does it affect you?) "Through my head and it made me hot +inside." Again, when asked whether anybody had done anything +to her, she said "No, I have done wrong myself, by speaking +bad of my neighbors." She claimed to hear voices "all over," +but could not tell what they said. When, in the evening of that +day, the nurse asked her why she did not talk more, she said, +"God damn it, I am all twisted, my brain is mixed up, my system +is all upset, the doctor made me stupid with questions, and +the medicine I have taken made me all stupid and I am inhaling +gas now." Then she again settled into a dull state and was found<!-- Page 94 --><span class='pagenum'><a name="Page_94" id="Page_94">[94]</a></span> +by the physician with immobile expression, slow motions and +mute.</p> + +<p>2. For about ten days, i.e., from January 27 to February 8, +her condition was of a more pronounced character. For the +most part she lay in bed with often quite immobile face and with +eyes closed, or she looked about in a bewildered manner. She +was very inactive, presented a marked resistance in her arms and +jaw when passive motions were attempted, or, again, exhibited +decided catalepsy. She had to be tube-fed. Once on the 27th of +January, when the nurse tried to feed her, she pushed her away +and said, "I am dead—I am not home." Sometimes she turned +her hands about with slow tremulous movements, looking at them +in a bewildered manner.</p> + +<p>She usually was mute, except on the few occasions to be mentioned +later, as well as on February 3, when she was generally +a little more responsive. At that time she could be made to open +her eyes, and then replied to a few questions slowly and in a +low tone; others were left unanswered. (To the questions where +she was and how long she had been here, she replied with "I +don't know," but to questions about who the physician and the +nurse were, by saying "You are a doctor," and "she is a nurse.")</p> + +<p>In the general setting just described there occurred at various +times changes in behavior which were as follows: On the evening +of the 27th of January she got out of bed and walked about +with slow restlessness, saying: "They say I am going to be cut +up." On February 1, she was seen for a time making peculiar +slow swimming motions with her hands. Again on the 3d of +February she got out of bed, walked about slowly, with peculiar +steps, as though avoiding stepping on something. Next day (the +4th) she sat up in bed—again made at times her peculiar slow +swimming motions. She presented at the same time a peculiar +dazed bewildered uneasiness and, when questioned what was the +matter, said: "I am—I am—at the bottom of the deep—deep +water—oh—oh—the deep—deep—dark water." And when further +urged she added with the same manner, "I can't swim—I +don't know—but the place"—She did not finish but later again +muttered "the deep—deep—dark water." (Do you really think +you are in the water?) "I don't know—my head is so bad."</p> + +<p>For the following five days this behavior was repeated from<!-- Page 95 --><span class='pagenum'><a name="Page_95" id="Page_95">[95]</a></span> +time to time, when she would sit up and with bewildered uneasiness +make slow swimming motions and mutter when questioned, +"I am in the deep, dark water."</p> + +<p>Some other emotional responses in reaction to external events +must still be mentioned. They were rare. On February 1 the +patient's daughter came while she was lying motionless in bed. +She slowly extended her hands, tried to speak, and then her eyes +filled with tears. Again, at the end of the interview of February +3, after she had made a few replies, she settled down to her +usual inactivity and, when further urged to answer, her eyes +filled with tears.</p> + +<p>3. From about February 9 to February 24 the condition again +presented a different aspect, inasmuch as while there was still +a marked reduction of activity, she showed this to a decidedly +lesser degree. Moreover, there was no bewilderment at any time. +No resistance, but cataleptic tendencies were still seen occasionally. +There was at no time the peculiar dazed uneasiness and +slow restlessness associated with the idea of being in the deep, +dark water.</p> + +<p>She now dressed herself very slowly, ate slowly but of her own +accord, and spoke, though her voice was consistently slow, in a +low tone and her words were few.</p> + +<p>At the beginning of this period on February 9, when asked +how she was, she said "I—I am sick." To the questions as to +where she was, how long she had been here and how she had been +taken sick, she replied by saying "I don't know." But she knew +she was in a hospital, had been here before "many times." (Correct.) +She was then again asked for the name of the hospital, +but replied "I don't know." So the physician pointed out of +the window and asked her what it was that she could see there +(the East River). She replied, "It is the dark water. Sometimes +I go there and don't come back again—and—something +throws me up and I come back." (What has been the matter +with you?) "I have been sick all this time." Again, "I can't +tell—I am not a good woman—I am very sick." (Why do you +say you are not a good woman?) "Oh, I did not do things +right."</p> + +<p>At a later interview, during the same period, she knew the +doctor's name, knew she had seen him at Ward's Island, knew<!-- Page 96 --><span class='pagenum'><a name="Page_96" id="Page_96">[96]</a></span> +she was in a hospital, but somehow could not connect the present +place with Ward's Island. She said she didn't know, when asked +where she was, and when questioned about the season, said, after +a pause "Summer" (February 15).</p> + +<p>We have seen above that she once spoke of not having been a +good woman. She repeated this on February 10, said "I have +done lots of harm, I have been a bad woman all my life." Again: +"I had bad thoughts." (What kind?) "I have forgotten all +about them." It should be added that at this interview she also +said, "My mind is better now."</p> + +<p>On February 25 there was a sudden change. She laughed +when a funny remark was made on the ward. Later, when the +physician came to her, she still lay in bed inactive and had to be +urged considerably at first, but presently began to laugh good-naturedly +and quite freely commented on the funny remark she +had heard earlier in the morning, and on peculiarities of some +patients. She spoke quite freely and without constraint. But it +was striking how little account of the condition she had gone +through could be obtained from her. She either turned the +questions off by flippant remarks, or said she did not know. The +only information obtained was that she had been sick since +Christmas, felt like a dummy, that she had lost track of time, +and did not know how she had felt during that period. When +asked why she had not spoken, she said, "I couldn't, I had a +jumping toothache," or she said, "Ask the nurse, she put it down +in the book." Or again she said, "Did you ever get drunk? +That is the way I felt. I felt like dead."</p> + +<p>She soon developed a lobar pneumonia and died.</p></div> + +<p>The following typical case of partial stupor is +quoted as an example of delusions appearing only +during the onset.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 14.</span>—<i>Maggie H.</i> Age: 26. Admitted to the Psychiatric +Institute February 8, 1905.</p> + +<p><i>F. H.</i> The father died when 33. The mother was living. +Psychopathic tendencies were denied.</p> + +<p><i>P. H.</i> The husband and brother stated that the patient was<!-- Page 97 --><span class='pagenum'><a name="Page_97" id="Page_97">[97]</a></span> +natural, capable, rather jolly. She married about a year before +admission and shortly became pregnant. During the pregnancy +she was rather nervous and had various forebodings, among +which were that the child might be born deformed, or that she +would die in childbirth.</p> + +<p>The baby was born three weeks before admission. The patient +seemed much worried immediately after the childbirth, fretted +about not having enough milk, was quite concerned about her +husband and did not want him to leave her side. The brother +stated that about this time the patient heard that the husband +was out of work. She worried about this and told her sister so. +She also began to say that her head was getting queer. On the +fifth day after childbirth, a change came over the patient. She +cried and said she was going to die. She also spoke of poison +in the food and accused the husband of unfaithfulness. The +next day she became silent, "did not seem to want to have anything +to do with anybody," lay in bed, had a tendency to pull +the covers over her head and scarcely ever spoke. But during +this period she continued to look after the baby faithfully. +Sometimes she clung to her husband, saying she was afraid he +was going to die.</p> + +<p>After recovery the patient said that while she was at home she +thought she saw bodies lying about.</p> + +<p>At the <i>Observation Pavilion</i> she was quiet and apathetic, indifferent +to environment and could not be induced to speak. +She soiled, refused food, and was resistive when anything was +done to her.</p> + +<p><i>Under Observation:</i> 1. On admission the patient was fairly +well nourished but looked rather anemic and weak. The temperature +was normal, the pulse a little irregular but of normal frequency, +the tongue coated. She lay inactive but looked about, +and the facial expression sometimes changed as she did this. Any +interference met with intense resistance. There was no catalepsy. +In contradistinction to this inactivity and resistance, natural, +free motions were observed at times, as, for example, when she +arranged her pillows. She did not speak and could not be made +to answer.</p> + +<p>For the rest of the first week she made no attempt to speak, +except once when she seemed to attempt to return a "good morn<!-- Page 98 --><span class='pagenum'><a name="Page_98" id="Page_98">[98]</a></span>ing," +or on another occasion, when the nurse tried to feed her, she +said, in quite a natural tone, "I can feed myself." The resistance +to interference remained in a variable degree, and was +at times quite strong. It was largely passive, though not infrequently +associated with a scowl, or she moved away when approached. +She sometimes looked dull and stared, again she +looked determined, "disdainful," or scowled; or she looked about +watching others, sometimes only out of the corners of her eyes. +She had to be spoon-fed at times, again she ate naturally when +the food was brought. Repeatedly, when taken out of bed, +though she resisted at first, she dressed with natural free motions. +She always retracted promptly from pin pricks.</p> + +<p>Towards the end of the week she even complied at times with +a request to do some work, but on the same day she would remain +passive, with a look of disdain, or resist intensely when interfered +with, e.g., when an attempt was made to make her sit +down. She never soiled and never showed any catalepsy.</p> + +<p>2. Then the condition changed, inasmuch as the marked resistance +ceased entirely, and the mutism gave way first to slow and +low answers, and later to much freer speech, though the inactivity +improved only gradually. Thus at the examination on +February 19, though she was quite inactive, she answered some +questions, albeit in whispers and briefly. This was the case +when questioned about the year, month and date, which she gave +correctly, but she merely shook her head when asked how long +she had been here, why she was here, what was the matter with +her. Once she smiled appropriately. Later she became freer in +speech, with a more natural tone, although her answers continued +to be short. Not infrequently, when asked to calculate or to +write, she would not coöperate, saying "This has nothing to do +with my getting well," or (later) "What has that got to do with +my going home?" or she would simply say she did not want to. +Improvement in her listlessness and inactivity was more gradual.</p> + +<p>The prevailing affective state was indefinite. She denied repeatedly +that she was depressed, though later she admitted once +being downhearted, yet it seems that even then her mood was not +so much one of sadness as of a slight resentment. On one occasion, +however, she showed some tears when asked about the baby. +She repeatedly expressed the wish to go home, but not in a plead<!-- Page 99 --><span class='pagenum'><a name="Page_99" id="Page_99">[99]</a></span>ing, +rather in a resentful, way, saying she would never be better +here, that the questions which were asked had nothing to do with +her going home, that she would be all right if she went home. +She never admitted that she had ever been sick enough to be +taken to a hospital, though she quite appreciated that there had +been something the matter with her head at home and in the hospital. +She stated, in answer to questions, that she had a peculiar +feeling in the head which she could not explain, that she could +not remember so well as formerly. Once she said, "I hear so +much around here that my head gets so full."</p> + +<p>When towards the end she was questioned about her condition, +i.e., the reason for her resistance, her mutism, and her refusal +of food, she said that then she "wanted to be left alone"; that +she did not eat "because she did not want food," and she also +spoke of not having had any interest.</p> + +<p>She was discharged on April 29, i.e., about ten weeks after +admission before she had become entirely free.</p></div> + +<p>The last case is interesting in that a depressive +onset to a deep stupor was observed in the Institute. +It was characterized by constant repetitions of a request +to be killed.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 15.</span>—<i>Meta S.</i> Age: 16. Admitted to the Psychiatric +Institute June 26, 1902.</p> + +<p><i>F. H.</i> The father was dead, and the mother living abroad. +Not much could be learned about them and the immediate family.</p> + +<p><i>P. H.</i> An aunt who gave the anamnesis had known the patient +only since she came to the United States, a year before admission. +After her arrival the patient at once went to work as a +servant. It was claimed that her employer liked her, but that she +was rather slow about the work. The only trouble known was +that she sometimes complained of indigestion. She went to see +her aunt about once every two weeks.</p> + +<p>Three weeks before admission, when the patient visited her +aunt, she seemed quieter than usual. Further, she spoke about +sending money home on the <i lang="de">Kaiser Wilhelm der Grosse</i>, which +was thought peculiar because she had no money, and on a walk<!-- Page 100 --><span class='pagenum'><a name="Page_100" id="Page_100">[100]</a></span> +through a cemetery said "I would like to be here too." At the +time this did not impress the aunt as very peculiar. The patient +continued to work until nine days before admission. The employer +then sent for the aunt and said the patient had been very +quiet for about two weeks, and that she now had become more +abnormal. She suddenly had begun to cry, said the police had +come, claimed, without foundation, that she had "stolen," and +kept repeating "I have done it, I will not do it again." The +aunt took her home with her. There she was quite dejected, +cried, spoke of killing herself (wanted to jump out of the window, +wanted to get a knife). On the whole, she said very little, but +when the aunt pressed her to say why she was so worried, she +said she had allowed men to kiss her and had taken money from +them. It is claimed that she never menstruated.</p> + +<p>After recovery the patient herself described the onset as follows: +Ever since she came to this country she had been homesick, +and felt especially lonesome for some months before admission. +She knew, however, of no precipitating cause, in spite of what +she had said to the aunt and what she said at first under observation. +She consistently denied that anything had happened with +young men. A short time before she left her place (she left +it nine days before admission) she could not work, began to accuse +herself of being a bad girl and of having stolen. Then +she was taken to the aunt's house. There she wanted to die.</p> + +<p><i>Under Observation:</i> 1. On admission the patient appeared depressed, +sat with downcast expression, looking up rarely. She +spoke in a low tone and slowly. But, in spite of delay, she answered +all questions, knew where she was and gave an account of +the place where she had worked. When questioned about trouble +with men, she claimed that a man who lived in the same house +where she worked had tried to make her "lie on the bed," but that +she refused; that later a man had assaulted her and had after +that repeatedly come to her room when she was alone. Yet when +asked whether she worried about this, she denied it.</p> + +<p>2. For eight days her condition was sometimes one of marked +reduction of activity, with preoccupation. She sat in a dejected +attitude, and had to be urged to do anything. Sometimes she +was very slow in greeting and slow in answering, and said very +little. But whenever spoken to she was apt to cry and this might<!-- Page 101 --><span class='pagenum'><a name="Page_101" id="Page_101">[101]</a></span> +lead to such distress that the reduction of activity was no longer +to be seen. Thus on June 28, when greeted, she began to cry +and say, "Oh, what have I done!—Oh, just cut my head off—Oh, +please what have I done—I have given my hand." (Tell me the +whole story.) Imploringly and with hands clasped: "No, I can't +do it—just cut my head off, please, please." (Why can you +not tell me?) "Oh, what have I done!" The imploring to cut +her head off was then several times repeated, and she could not +be made to answer orientation questions. On June 29 she became +agitated spontaneously and cried loudly, saying, "Oh, let me +go home and die with my father." She was then put to bed, and +when seen she could not be made to answer orientation questions. +But when asked whether she had seen the physician before, she +said, "I saw you yesterday." She could not be made, however, +to say how long she had been here, "I think a"—not finishing +the sentence. Although she would not answer further, she presently +began to say "Oh, cut my head off—oh, where is my papa +and mamma?" When told that her people were in Germany +and that she could go back to them, she said "I haven't any +money to pay it." Then she wanted to know if she was to pay +for her board and bed and said she could not do it.</p> + +<p>Again, on July 1, although she had been quite preoccupied, +inactive and silent, she began to say when greeted, "Oh, please +cut my head off." But she then answered some questions, said +she had not worked enough. On questioning, she explained it +was not that the work had been too much, but that she had been +nervous, had tried to work as much as the servant next door, +but could do only half as much, "Oh, I ought to have worked."</p> + +<p>Repeatedly on other occasions she begged, with distress, to +have her head cut off or to be killed. Frequently there were +statements of self-blame: she ought to have worked more, was +lazy or "I am not worthy"; or she said she had lied and stolen; +or again, "I have not paid for these beds and I cannot," or "I +am a bad girl."</p> + +<p>3. For a month she presented a more marked reduction of activity. +She sat about with a dejected look, often gazed in a preoccupied +manner, or she stood or walked around slowly. Sometimes +she had to be spoon-fed. At other times she ate slowly. +Toward the latter part of this period, a distinct tendency to<!-- Page 102 --><span class='pagenum'><a name="Page_102" id="Page_102">[102]</a></span> +catalepsy appeared. During this period, too, as a rule (though +not always), she would cry when spoken to. A few times she +would make some ineffectual motions when questioned, but she +scarcely ever spoke.</p> + +<p>4. Then followed a period again lasting about one month in +which the picture was at times one of still greater inactivity. She +would retain uncomfortable positions, allow flies to crawl over +her face. She presented resistance in the jaws, did not react +to pin pricks. She sometimes sat with eyes closed or, with an +immobile face, the eyes stared with little blinking. The catalepsy +was more decided. She often would not swallow solid food but +swallowed fluid. Again she held her saliva, sometimes drooled. +Once she held her urine and had to be catheterized. When +spoken to she once smiled at a joke, sometimes there was no +response, but as a rule there were tears or flushing of the face. +On the physical side, there were marked dermatographia and, +for a time, towards the end of the period, profuse sweating. +Throughout the stupor proper her temperature was between 99° +and 100° as a rule.</p> + +<p>5. The period which followed and which lasted about two +months was characterized, like the one just described, by marked +stupor symptoms, associated, however, with more resistance, +while the crying practically disappeared. On the other hand, a +number of plainly angry reactions were seen and, towards the +end, smiling and laughing. She lay in bed, on her back, staring, +allowing the flies to crawl over her face; retained uncomfortable +positions without correcting them, and her arms often showed a +decided tendency to catalepsy. Sometimes she soiled. She constantly +held saliva in her mouth, though she did not often drool. +She was totally mute, did not respond in any way except in the +manner to be presently indicated. She had to be tube-fed a +good part of the time, was quite resistive when an attempt was +made to open her mouth. When attended to by the nurse, she +was apt to make herself stiff. But as a rule, she was not resistive +to passive motions when tested. On a few occasions she had, as +was stated, marked angry outbursts. Thus on one occasion when +her temperature was taken she angrily pushed the nurse away +and then struggled vigorously. On another occasion, when the +bed-pan was put under her, she threw it away angrily and struck<!-- Page 103 --><span class='pagenum'><a name="Page_103" id="Page_103">[103]</a></span> +the nurse; once she did the same with the feeding tube. She +struck a patient, on another occasion, when the latter came to +her bed. On two occasions she suddenly threw herself headlong +on the floor. Towards the end of the period, when the blood-pressure +was taken, she smiled and then laughed out loud. She +could be made to smile again later.</p> + +<p>6. The last period, before the more definite improvement, lasted +about a month. She was inactive and slow, ate slowly (feeding +no longer necessary), and was mute. But she did not stare, was no +longer resistive, no longer held saliva. She appeared indifferent, +but could be made to smile quite readily when spoken to. +On one occasion she laughed out loud when a comical toy was +shown her, again was amused at a party. In the beginning of +the period she was once seen to cry a little when sitting by herself, +and at the same time wept a little when spoken to, but this +was now isolated. Towards the end of the period she spoke a +little, asked for paper and pencil and wrote: "Dear Mother.—I +only take up the pencil in order to write you a few lines. We +are all cheerful and in good health and hope that you are the +same and we congratulate you on your birthday 19th of December +that I have not written to you for a long time were in the same +..." (Translated.) This was written very slowly.</p> + +<p>On the day after this letter she was distinctly freer, talked a +little to the nurse and then improved rapidly. A week after +this, January 16, she is described as quite free in her talk and +activity, but when asked about the psychosis she merely shrugged +her shoulders. However, mere extensive retrospective accounts +were taken later.</p> + +<p>The retrospective accounts were obtained on January 24 and +March 13. As these two accounts do not seem to be fundamentally +different for the period of the psychosis, they may here +for the sake of brevity be combined.</p> + +<p>She remembered clearly going to the Observation Pavilion, +and feeling frightened, as she did not know where she was going +and what they were going to do with her. She knew when she +was in the Observation Pavilion and had a good recollection of +the place, also of the transfer to the hospital, the ward she came +to, who spoke to her, etc. She did not know what the place was +until the doctor told her a day or two after admission. Unfor<!-- Page 104 --><span class='pagenum'><a name="Page_104" id="Page_104">[104]</a></span>tunately +definite incidents were inquired into only for the first +part (July). But she remembered those clearly. She also +claimed to remember all visits which were made to her by her +friends, but it was not specifically determined whether there was +a period of less clear recollection or not. However, she remembered +the tube-feeding, which occurred only during the more +marked stupor. Her desire to be killed, to have her head cut +off, she recalled but claimed not to know why she wanted to be +killed. However, she remembered worrying about being bad, +about the fact that she could not "pay for the beds," etc.</p> + +<p>Her mutism and refusal of food she was unable to account +for. She could not talk, her "tongue would not move." As regards +ideas during the more stuporous period, she claimed that +(when quite inactive) she heard voices but did not recall what +they said. But she remembered having dreams at that time "of +fire," "of her dead father and of home."</p></div> + +<p>In a survey of thirty-six consecutive cases of +definite stupor, literal death ideas were found in all +but one case. They seem to be commonest during the +period immediately preceding the stupor, as all but +five of these cases spoke of death while the psychosis +was incubating. From this we may deduce that the +stupor reaction is consequent on ideas of death, or, +to put it more guardedly, that death ideas and +stupor are consecutive phenomena in the same fundamental +process. Two-thirds of these patients +interrupted the stupor symptoms to speak of death +or attempt suicide, which would lead us to suppose +that this intimate relationship still continued. One-quarter +gave a retrospective account of delusions of +being dead, being in Heaven, and so on. From this +we may suspect that in many cases there may be a +thought content, although the patient's mind may<!-- Page 105 --><span class='pagenum'><a name="Page_105" id="Page_105">[105]</a></span> +seem to be a complete blank. It is important to note +that when a retrospective account is gained, the +delusions are practically always of death or something +akin to it, such as being in prison, feeling +paralyzed, stiff, and so on.</p> + +<p>In the one case of the thirty-six who presented no +literal death ideas, the psychosis was characterized +essentially by apathy and mild confusion, a larval +stupor reaction. It began with a fear of fire, smelling +smoke and a conviction that her house would +burn down. It is surely not straining interpretation +to suggest that this phobia was analogous to a death +fear. When one considers the incompleteness of +anamneses not taken <i lang="la">ad hoc</i> (for these are largely +old cases) and that the rule in stupor is silence, the +consistence with which this content appears is +striking.</p> + +<p>To exemplify the form in which these delusional +thoughts occur we may cite the following: Henrietta +H. (Case 8) said, retrospectively, that she +thought she was dead, that she saw shadows of dead +friends laid out for burial, that she saw scenes from +Heaven and earth. Annie K. (Case 5) claimed to +have had the belief that she was going to die, and to +have had visions of her dead father and dead aunt, +who were calling her. She also thought that all the +family were dead and that she was in a cemetery. +Rosie K. (Case 11) said she had the idea that she +wanted to die and that she refused food for that +purpose, and during the stupor she sometimes held +her breath until she was cyanotic. Mary F. (Case<!-- Page 106 --><span class='pagenum'><a name="Page_106" id="Page_106">[106]</a></span> +3), before her stupor became profound, spoke of the +hereafter, of being in Calvary and in Heaven. In +this case, as well as in the above-mentioned Henrietta +H., we find, therefore, associated with "death" the +closely related idea of Heaven. Whether Calvary +merely referred to the cemetery (Mt. Calvary Cemetery) +or leads over to the motif of crucifixion, cannot +be decided. It is, however, clear that this latter +motif may be associated with that of death, as is +shown in Charlotte W. (Case 12), who, during intervals +when the inactivity lifted, spoke of having been +dead, of spirits having told her that she must die, of +having gone to Heaven, of God having told her that +she must die on the cross like Christ. But this patient +also showed in a second subperiod of her +stupor another content. She said: "It was like +water. I was going down." Or again, she spoke +of having gone "under the ground"; "I went down, +down in a coffin." She spoke of having gone down +"into a dark hole," "down, down, up, up"; again, of +having been "on a ship." We shall see in the further +course of our study that this type of content +occurs not at all infrequently.</p> + +<p><i>The internal relationship among the different +ideas associated with stupor:</i> Before we go any +further it may be advisable to examine the meaning +of such ideas when they arise in other settings than +those of the psychoses. If we consider these ideas +of death, Heaven, of going under ground, being in +water, in a boat, etc., we are impressed with the +similarity which they bear to certain mythological<!-- Page 107 --><span class='pagenum'><a name="Page_107" id="Page_107">[107]</a></span> +motifs. This is, of course, not the place to enter +into this topic more than briefly. We are here concerned +with a clinical study, and therefore, among +other tasks, with the interrelationship of symptoms, +but for that purpose it is necessary to point out how +these ideas seen in stupor can be shown to have, not +only a connection amongst each other, when viewed +as deep-seated human strivings, but also are closely +related to, or identical with, ideas found in mythology.</p> + +<p>To one's conscious mind death may be not only +the dreaded enemy who ends life, but also the friend +who brings relief from all conflict, strife and effort. +Death may, therefore, well express a shrinking from +adaptation and reality, and as such may symbolize +one of the most deep-seated yearnings of the human +soul. But from time immemorial man has associated +with this yearning another one, one which, +without the adaptation to reality being made, yet +includes a certain attempt at objectivation, the desire +for rebirth. We need not enter further into +possible symbols for death <i lang="la">per se</i>, but it is quite +necessary to speak briefly of the symbolic forms in +which the striving for rebirth has ever found expression. +The reader will find a large material collected +in various writings on mythology, for the psychological +interpretation of which reference may be +made to Jung's "Wandlungen und Symbole der +Libido" and Rank's "Mythos von der Geburt des +Helden." From them it appears how old are the +symbols for rebirth, and how they deal chiefly with<!-- Page 108 --><span class='pagenum'><a name="Page_108" id="Page_108">[108]</a></span> +water and earth, and the idea of being surrounded +by and enclosed in a small space. Thus we find a +sinking into the water of the sea, enclosure in something +which swims on or in the water, such as a casket, +or a basket, or a fish, or a boat; again, we find +descent into the earth. The striving for rebirth +might be assumed to have adopted these expressions +or symbols on account of the concrete way in which +the human mind knows birth to take place. The +tendency for concrete expression of abstract notions +causes the desire for another existence to appear, +first as a rebirth fantasy and then as a return to the +mother's body. One thinks of Job's cry, "Naked +came I from my mother's womb and naked shall I +return thither," as an example of the literal comparison +of death with birth. We need only refer to +the myths of Moses and the older one of Osiris, and +the many myths of the birth of the hero, to call to the +mind of the reader the examples which mythology +furnishes. There is probably not one of the ideas +expressed by these patients which cannot be duplicated +in myths. We have, therefore, a right to speak +of these ideas as "primitive," and to see in them, +not only deep-seated strivings of the human soul, but +to recognize in them an essential inner relationship. +It is especially this last fact to which at this point we +wish to call attention: that without any obvious connection +the fantasies of our forefathers recur in the +delusions of our stupor cases. We presume that in +each case they represent a fulfillment of a primitive +human demand. In one of our cases a vision of<!-- Page 109 --><span class='pagenum'><a name="Page_109" id="Page_109">[109]</a></span> +Heaven and a conscious longing to be there was followed +by a stupor. On recovery the patient compared +her condition to that of a butterfly just +hatched from a cocoon. No clearer simile of mental +rebirth could be given.</p> + +<p><i>Brief survey of the ideas associated with the +states preceding the stupor:</i> If we now return to +the study of the further occurrence of such ideas in +the cases described, we find motifs, similar to those +seen in the stupor, in the period which immediately +precedes the more definite stupor reaction. Indeed +we find the ideas there with greater regularity. In +Meta S. (Case 15) the stupor followed upon six days +with reduced activity and crying, with self-accusation, +but also with entreaties to be allowed to go +home and die with her father. At the very onset of +her breakdown, the desire for death had also occurred. +Anna G. (Case 1) expressed a wish to be +with her dead father, and, at the visit of a cousin, +she had a vision of the latter's dead mother. A second +attack of this same patient began with the idea +that the dead father was calling her. Maggie H. +(Case 14) saw dead bodies, and during outbursts of +greater anxiousness, she thought her husband was +going to die. In Caroline De S. (Case 2) the psychosis +began with a coarse excitement, with statements +about being killed, with entreaties to be shot, with +the idea of going to Heaven, again with frequent +calling out that she loved her father (who was dead +since her ninth year), while immediately before the +stupor the condition passed into a muttering state<!-- Page 110 --><span class='pagenum'><a name="Page_110" id="Page_110">[110]</a></span> +in which she spoke of being killed. Mary D. (Case +4) began by worrying over the father's death (dead +four years before), had visions of the latter beckoning, +and she heard voices saying, "You will be +dead." Mary F. (Case 3) had a vision of "a person +in white," and thought she was going to die. In +Henrietta H. (Case 8) the stupor was preceded by +nine days of elation, with ideas of shooting and of +war, but this had commenced with hearing voices +of dead friends, and with ideas that somebody +wanted to kill her family. In the case of Annie K. +(Case 5) we find before the stupor a state of worry, +with reduction of activity, and then a vision of the +dead father coming for her. In Charlotte W. (Case +12) the stupor was preceded by a state of preoccupation, +with distress and entreaties to be saved, +partly from being put into a big hole, partly from +the electric chair.</p> + +<p>We see, therefore, in the introductory phase of the +stupor in almost every case ideas of death, and in +one case an idea belonging to the rebirth motif, +namely, of being put into a dark hole. In well-observed +cases apparently we do not find the stupor +reaction without either coincident or preceding ideas +of death.</p> + +<p><i>Relation of death and rebirth ideas with affect:</i> +In order to investigate the relation of these ideas to +the affective condition associated with them, it will +be necessary to study not only the abstract ideational +content but the special formulation in which +the content appears. In looking over the enumera<!-- Page 111 --><span class='pagenum'><a name="Page_111" id="Page_111">[111]</a></span>tion +of the ideas given above, it is very clear that +these formulations differed considerably from each +other. A priori we would say that it is, psychologically, +a very different matter whether a person expresses +a desire to die, or has the idea that he will +die or is dead, or says he will be killed. We associate +the first with sadness, the last with fear, while +our daily experience does not give us so much information +about the delusion of being dead. A vivid expectation +of death is usually accompanied by either +fear or resignation.</p> + +<p>In studying the ideas which we obtained from the +patients by retrospective account after the psychosis +or from a retrospective account during freer intervals, +it is, of course, difficult, especially in the former +case, to say whether they have persisted for any +length of time. Probably in most instances this was +not the case, and we must remember in this connection +that in a considerable number of cases the patients +recalled no ideas whatever.</p> + +<p>Of the five cases which we may consider as types, +Henrietta H. (Case 8) and Mary F. (Case 3) formulated +their ideas simply as <em>accepted facts</em> during the +stupor. The former thought she was dead, saw dead +friends laid out for burial, and scenes from Heaven +and earth. The latter spoke, during the stupor, of +being in "Calvary," "the hereafter," or "Heaven." +We have seen that these stupors were essentially +affectless reactions and we can therefore say that, +so far as these two cases are concerned, the ideas +thus formulated were not associated with any affect.</p> + +<p><!-- Page 112 --><span class='pagenum'><a name="Page_112" id="Page_112">[112]</a></span> +Annie K. (Case 5) was a little different. During +the stupor she made a few utterances about priests +and "all being dead," and retrospectively she said +that she had thought she was in the cemetery, was +going to die, that she had repeated visions of her +dead father and once of a dead aunt calling her; that +she had thought her family were dead, again that +the baby (who was born just before the psychosis) +was dead. The formulation is therefore less one of +fact than of something prospective, something which +is coming—the <em>going</em> to die. Correlated, perhaps, +with this anticipation were slight modifications of +the usual apathy. The patient often had an expression +of bewilderment. She was also more in contact +with her environment than many stuporous patients +are, for, not infrequently, she would look at what was +going on about her. Her apathy was also broken +into in a marked degree by her active resistiveness, +which was sometimes accompanied by plain anger. +It seems that a prospect of death may occur in other +instances in a totally affectless state. We have recently +seen it in a partial stupor during which the +patient spoke and had this persistent idea in a setting +of complete apathy. We see here also, as in +one of the former cases, the idea of other members +of the family being dead.</p> + +<p>More difficult and deserving more discussion are +the two remaining cases, Rosie K. (Case 11) and +Charlotte W. (Case 12). Rosie K. showed a peculiar +condition. She said, retrospectively, that during +the stupor she had the desire to die and that for this<!-- Page 113 --><span class='pagenum'><a name="Page_113" id="Page_113">[113]</a></span> +purpose she refused food. Moreover, she was repeatedly +seen to hold her breath with great insistence, +though without affect. This is worth noting. +We are in the habit in psychiatry to say in a case +like this that "there is no affect," and yet there is +evidently a considerable "push" behind the action. +We shall later have to mention in detail a patient +whom we regard as belonging in the group of stupor +reactions, and who for a time made insistent, impulsive +and most determined suicidal attempts, yet +with a peculiar blank affectless facial expression and +with shouting which was more like that of a huckster +than one in despair. Here also, then, there was a +great deal of "push," yet not associated with that +which we call in psychiatry an affect. In both instances +we see acts which we are in the habit of +calling for this very reason "impulsive." Evidently +this is an important psychological problem which +leads directly into the psychology of affects and +deserves further study. For the present it is +enough to say that with a different formulation—that +of wishing to die—there is here not, as in other +psychoses, a definite affect, such as sadness or despair, +but no affect, though there may be a good +deal of "push" or impulsiveness.</p> + +<p>The case of Charlotte W. (Case 12) is a complicated +one, for she had short stupor periods with +inactivity, catalepsy, resistiveness, etc., which were +interrupted with freer spells. A careful analysis of +her history has been instructive and justifies a detailed +and lengthy discussion. For the purpose in<!-- Page 114 --><span class='pagenum'><a name="Page_114" id="Page_114">[114]</a></span> +hand it is necessary to separate the ideas which she +expressed only in the freer periods (during which +some affect was at times seen) into those which referred +retrospectively to the stupor phase and those +which referred to the freer periods themselves.</p> + +<p>We find that the time during which more marked +stupor symptoms appeared may be divided into two +subperiods. This is not possible in regard to the +manifestations belonging to the general reaction, +which seem to have undergone no decided change, +but only in regard to the form of the delusions. In +this we find there was a first phase in which ideas of +death and Heaven (and crucifixion) occurred, and a +second phase in which ideas were present which belonged +essentially to the motif of rebirth but which +were also associated with ideas of Heaven.</p> + +<p>About the first subperiod she said: "I was mesmerized," +or "I thought I was dead," or "God told +me I must die on the cross as He did," or "I went +to Heaven in spirit." About the second subperiod +she said retrospectively: "We were on a ship and +we were 'most drowned." "It was like water, I was +going down, down." She said she saw the people +of the hospital and "it was all full of water"; or +again, "I went under the ground and it was full of +water and every one got drowned and a sharp thing +struck me"; or "I was out on a ship and I went +down in a coffin." She claimed she put up her arms +to save the ship. Again she spoke of having gone +into a dark hole. She also said: "One day I was +in a coffin—that was the day I went to Heaven."<!-- Page 115 --><span class='pagenum'><a name="Page_115" id="Page_115">[115]</a></span> +"They used to be coming up and down, that was the +day I was coming up in a ship or going down." And +when shown her picture in a cataleptic attitude, she +said: "That must have been when I went to Heaven—everything +seemed strange, things seemed to go +up and down—I guess that was the day I thought I +was on the ship." Finally she also said: "Once I +heard beautiful music—I was waiting for the last +trumpet—I was afraid to move."</p> + +<p>We see, therefore, that most of the ideas which she +thus spoke of retrospectively as having been in her +mind during this stupor, and which belonged both +to the death and the rebirth motifs were formulated +as facts (as in the cases of Henrietta H. and Mary +F. above mentioned). It was, moreover, a condition +which was accepted without protest. Here again an +affect was not associated with these ideas, and when +the patient was asked whether she had not been +frightened, she said herself, "No, I just lay there." +The idea that God told her she would have to die on +the cross like Christ, is, in the religious form, like +the beckoning of the father with Henrietta H. The +only exception to the claim that the ideas were +formulated as facts and accepted as inevitable seems +to be the statement that she held up her arms to save +the ship. This would seem to be, in contradistinction +to the rest, a formulation as a more dangerous situation. +However, this was isolated and we can do no +more than to determine main tendencies. We must +expect, especially in such variable conditions as we +see in this patient, to find occasional inconsistencies.</p> + +<p><!-- Page 116 --><span class='pagenum'><a name="Page_116" id="Page_116">[116]</a></span> +In summing up we may say, therefore, that so far +as the stupor itself is concerned, the ideas are +formulated as a rule:—</p> + +<ol> +<li>As accepted facts (being dead, being in a ship, +etc.).</li> +<li>As accepted prospects (going to die).</li> +<li>As the wish to die.</li> +</ol> + +<p>In the first two types the ideas are not associated +with affect; in the third, though not associated with +affect, they are combined with "impulsive" suicidal +attempts.</p> + +<p>In order not to tear apart the analysis of Charlotte +W. (Case 12) too much, we may begin our study +of the intervals and the conditions preceding the +stupors with the ideas which this patient produced +when the stupor lifted somewhat. We shall see that +the ideas are closely related to those mentioned +above but formulated differently.</p> + +<p>It will be remembered that Charlotte W. had freer +intervals when she responded and was less constrained +generally, and that it was in these that the +ideas above mentioned were gathered. Since they +were spoken of in the past tense, we regarded them +as not belonging to the actual situation but to the +more stuporous period. It seems tempting now to see +whether the ideas which are expressed in the present +tense are different in character, the general aim being +to discover whether any tendencies can be found +in regard to the types and formulations of delusions +associated with different clinical pictures. We see<!-- Page 117 --><span class='pagenum'><a name="Page_117" id="Page_117">[117]</a></span> +that on November 2 the patient, when speaking much +more freely than before, said she had felt that she +was mesmerized, was dead, and that she had gone +to Heaven, ideas which we have taken up above as +belonging to the stupor period. In addition to +speaking much more freely in these intervals, she +showed at times some affect. Thus to the physician +whom she called Christ, she said, with tears, "You +came to tell me what was right," or again with +tears, "I will have to be crucified," or she spoke in +a depressed manner about her children, "I can't see +them any more," "I must stay here till I die," and +she spoke of having to stay here till she picked her +eyes and her brains out; or she claimed her husband +or her children had to pick them out. Once she exclaimed +crossly and with tears, "You are trying to +keep me from Jim" (husband). Another idea was +not plainly associated with affect. She said she +had come back from Heaven, "The wedding ring +kept me on Earth." What strikes one about these +formulations is that they are, on the one hand, sometimes +associated with an affect, and that, on the +other hand, they refer much more to her actual life, +her marriage, her husband, her children. At least +this seems to be a definite tendency. A similar tendency +may be seen later: On November 4, while generally +stuporous, this suddenly lifted for a short +time, and with feeble voice she uttered some depressive +ideas. She said she wanted to go to a convent, +that it would be better if she were dead, that she<!-- Page 118 --><span class='pagenum'><a name="Page_118" id="Page_118">[118]</a></span> +could not do anything right. On November 5 and +6 she said she wanted to go to Jim in Heaven (in +contradistinction to the retrospective statements +that she had gone to Heaven), and on the 8th, when +she had the idea of being in a boat, she said with +some anger that she had wanted to get her husband +into the boat, but that the doctor kept him out and +took his place.</p> + +<p>Later there were at times ideas expressed which +referred to the actual situation or essentially depressive +ideas in a depressive setting. Thus on December +3 she appeared sad, retarded, and spoke of not +being able to see her children and that she had done +wrong in buying carbolic acid (her suicidal attempt). +So far as this case is concerned, therefore, we do +find a distinct tendency for the ideas which refer +to the more stuporous condition to differ from those +which refer to the actual situation in the freer intervals, +a difference which we may formulate by +saying that, though primitive ideas are expressed, +the tendency seems to be to connect them more with +actual life, or that the primitive character is lost +and the ideas take on a more depressive character +with a depressive affect. A few words should be +added in regard to the peculiar ideas that she or her +husband or her child had to pick out her eyes (or +her brain). It is probable that this idea belongs +to the motif of sacrifice (the <i lang="de">Opfer motiv</i> of Jung) +into which we need not enter further, except to say +that in this instance it was plainly connected, like<!-- Page 119 --><span class='pagenum'><a name="Page_119" id="Page_119">[119]</a></span> +some of the other ideas just spoken of, with the real +situation of her life (husband, children).</p> + +<p>It will now be necessary to examine the earlier +state of Charlotte W. The condition preceding the +stupor set in with pre-occupation, slow talk and +slight distress. During the time she asked to be +given one more chance, she said to the husband she +would not see him again. Then followed a day +when she was very slow and with moaning said she +was going to be put into a dark hole. Again on the +next, when speaking more freely, she begged to be +saved from the electric chair, and also said, "Don't +kill me, make me true to my husband," etc. [Again +the connection with real life!] We see here the +idea of death and especially an idea pertaining to +the rebirth motif in a setting of distress and slowness, +as an introduction to the stupor which had in it +both of these motifs. We must leave it undecided +whether it is accidental or not that the distress was +associated with more slowness (i.e., more marked +stupor traits) when she spoke of the dark hole than +when she spoke of the electric chair or death. But +what interests us is that distress and reduction of +activity (not sadness and reduction of activity, +which seems as a rule to have a different content) +are here associated with ideas seen in stupor but +formulated as prospective dangers. We know from +experience that we often find associated with the +fear of dying considerable freedom of action, and +we see at times in involution states conditions with +freedom of motion and marked anxiety, whereas the<!-- Page 120 --><span class='pagenum'><a name="Page_120" id="Page_120">[120]</a></span> +ideas seem to belong to the motif of rebirth; e.g., +the fear of being boiled in a tank.<a name="FNanchor_A_7" id="FNanchor_A_7"></a><a href="#Footnote_A_7" class="fnanchor">[A]</a></p> + +<p>In this connection, however, two other cases +should be taken up which show a condition which reminds +one somewhat of that we have just discussed, +but in which the rebirth motif appeared, not as prospective, +but, as in the stupor, as an actual situation. +At the same time this situation was not passively +accepted but conceived as a dangerous situation. +The significant phenomenon in both these conditions +was that there was not anxiety with freedom of action +but a bewildered uneasiness with marked reduction +of activity.</p> + +<p>The first case is that of Johanna S., whose history +has been given in this chapter. It will be observed +that in the fourth period the patient presented +two days of typical stupor with the idea that +she was dead. We are familiar with this. But this +was followed by several days of bewildered uneasiness +and slow restlessness, with ideas that she was +at the bottom of the deep, dark water and for a time +she made attempts at stepping out of the water or +swimming motions. All of this was in a general +setting of reduction of activity with bewildered uneasiness. +In the ideas about being at the bottom +of the deep, dark water, we recognize again the re<!-- Page 121 --><span class='pagenum'><a name="Page_121" id="Page_121">[121]</a></span>birth +motif, yet the situation is not accepted but +attempts are made by the patient to save herself, +i.e., the attitude is one in which the situation is taken +to be one of danger. It is interesting in this connection +that immediately following this state there +was one day of ordinary retardation with sadness +and ideas of being bad and sick. That is, when the +element of anxiety, the uneasiness, disappeared and +sadness supervened, the rebirth ideas were no +longer present.</p> + +<p>In Mary C. (See <a href="#ChapII_Case7">Chapter II, Case 7</a>) we have, unfortunately, +not a direct observation, but we have, +at any rate, a description from the Observation Pavilion +which seems so plain that we should be justified +in using it here. The condition we refer to is +described as a dazed uneasiness, with ideas of being +shut up in a ship, of the ship being closed up so that +no one could get out, of the boat having gone down, +of the people turning up. We should add here that +the condition was not followed by a typical stupor. +Essentially it was a retardation, in which only on +one occasion was a definite akinesis observed. During +this phase she soiled her bed. Perhaps the persistent +complaint of inability to take in the environment +belonged also more to the retardation of stupor +than to that of depression. We have again, therefore, +in this initial phase, a similar situation, +namely, ideas belonging essentially to the rebirth +motif, formulated as of a threatening character if +not as actually dangerous.</p> + +<p>We can say, therefore, that what characterizes<!-- Page 122 --><span class='pagenum'><a name="Page_122" id="Page_122">[122]</a></span> +these three cases, and brings them together, is the +fact that all three had ideas belonging to the rebirth +motif, but formulated as dangerous situations. Associated +with this there was not a typical anxiety +with the relative freedom of activity belonging to +this state, but an anxiety or distress or uneasiness +with traits of stupor reaction, namely, slow movements, +lack of contact with the environment, and a +dazed facial expression. It would seem that these +facts could scarcely be accidental but that they +must have a deeper significance. As a discussion +of this belongs, however, more into the psychological +part of this study, we shall defer it for the present, +and be satisfied with pointing out here the clinical +facts of observation.</p> + +<p>In brief, then, our findings as to the ideational +content of the benign stupor are as follows: From +the utterances during the incubation period of the +psychosis, from the ideas expressed in interruptions +of the deep stupor, as well as from the memories +of recovered patients, we find an extraordinary paucity +and uniformity of autistic thoughts. They are +concerned with death, often as a plain delusion of +being no longer alive, or with the closely related +fancy of rebirth. The rule is a setting of apathy +for these ideas, but when they are formulated so as +to connect them with the real life and problems of +the patient, or when rebirth is represented as a +dangerous situation, some affect, usually one of distress, +may appear.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> Kirby, <i lang="la">loc. cit.</i>, pointed out that stupor showed resemblance to +feigned death in animals, that the reaction suggested a shrinking +from life and that ideas of death were common.</p></div> + +<div class="footnote"><p><a name="Footnote_A_7" id="Footnote_A_7"></a><a href="#FNanchor_A_7"><span class="label">[A]</span></a> We may mention that since this study was made we risked a +prediction of stupor, which events justified, in the case of a patient +who showed expectation of death without affect. Such opportunities +are rare, however, since we usually do not see these cases till +the stupor symptoms are manifest. It would be unsafe to dogmatize +on the basis of such meager material.</p></div> +</div> + +<p><!-- Page 123 --><span class='pagenum'><a name="Page_123" id="Page_123">[123]</a></span></p> + +<h2>CHAPTER VI<br /> + +<span class="sm">AFFECT</span></h2> + +<p>The most constant and significant symptom in the +stupor reaction is the change in affect. This extends +from mere quietness in the mildest phases of +the disease through the stage of indifference where +apathy replaces the normal reactions of the personality, +to the final condition of complete inactivity +in the vegetative stupor where all mental life seems +to have ceased. It seems as though there were, as +a pathognomonic sign of the morbid process, a lack +of energy and loss of the normal <i lang="fr">élan vital</i>.</p> + +<p>We may say, in fact, that the establishment of a +specific type of emotional change is justification for +classifying all milder stupor reactions with the deep +stupors. In other words, our reason for the enlargement +of the stupor group to include all apathetic +reactions (except those of dementia præcox) +is the belief that this dulling of the emotional response +is as specific a type of emotional change as +is anxiety, depression or elation. Perhaps it would +be more accurate to say that this clinical group is +founded on the symptom complex which is built +around apathy. There is never any resemblance +between apathy and the mood of elation or anxiety.<!-- Page 124 --><span class='pagenum'><a name="Page_124" id="Page_124">[124]</a></span> +A discrimination from depression is the only differentiation +worth discussion.</p> + +<p>The first point that should be made is that there +is a difference between marked depression and the +mood of stupor. In the former we get a retardation +with a feeling of blocking, rather than of an absence +of energy. The expression of the patient is one +of dejection, not of vacancy, which bespeaks a mood +of sadness, even when the patient is so retarded as +to be mute and therefore incapable of describing his +emotions. Running through all the stages of stupor, +however, there is an emptiness, an indifference that +is in striking contrast to the positive pain that is felt +or expressed by the depressed patient. It may be +objected, of course, that this apathy really represents +the final stage in the emotional blocking of +the depressed individual, but the development of +stupor and recovery from it shows an entirely different +type of process. A deep depression recovers +by changing the point of view from a feeling of unworthiness +and self-blame to one of normality. The +stuporous case, on the other hand, evidences merely +less and less indifference, and more and more interest +in his environment and in himself as he gets +well.</p> + +<p>The associated symptoms are no less dissimilar. +The difficulty in thinking which troubles the depressed +patient is slight in proportion to his emotional +gloom, and he feels himself to be much more +incompetent intellectually than examination proves +him to be. On the other hand, in the stupor reac<!-- Page 125 --><span class='pagenum'><a name="Page_125" id="Page_125">[125]</a></span>tion +we find that the thinking disorder runs hand +in hand with the apathy and that the intellectual +capacity of the patient is really markedly interfered +with, as can be shown by more or less objective tests. +A mere slowing of thought processes accompanied +by subjective feeling of effort is the limit reached +in true depression, while it is merely the beginning +of the intellectual disorder in stupor, for one meets +with retardation symptoms only in the partial stupors. +The slowing in these cases seems to represent +an early stage of the intellectual disturbance which +reaches its acme in the mental vacuity and complete +incompetence of the deep stupor, just as slow +movements in the partial stupors seem to represent +a diluted inactivity reaction. This actual thinking +disorder is not present in those forms of manic-depressive +insanity which are characterized by elation, +anxiety or depression but is seen only in stupors, +occasionally in absorbed manic states (manic +stupor) and sometimes in perplexity states. The +psychological mechanisms of this last group are +probably analogous to those of stupor, but this is +not the place for a discussion of this topic.</p> + +<p>Another associated symptom whose manifestations +differ in depression and stupor is that of unreality. +In the former there is frequently a feeling +of unreality that is purely subjective, whereas the +stupor case does not usually complain of this but +does exhibit a difficulty in grasping the nature of +his environment, which the typical depressive case +never has.</p> + +<p><!-- Page 126 --><span class='pagenum'><a name="Page_126" id="Page_126">[126]</a></span></p><p>The occurrence of other mood reactions than +apathy in the same patient is also characteristic. +Manic states (usually hypomanic) frequently occur +during the phase of recovery from the stupor. This +is an unusual, although not unknown, phenomenon +in recovery from severe retarded depressions. The +circular cases who swing from depression to elation +usually show the milder types of depressive reaction +which would never be confused with stupor. On +the other hand, deep stupors very frequently are +terminated by manic reactions, and if not by such +means, recovery seems to occur merely in virtue of +a gradual attenuation of the stupor symptoms. +Rarely do we see a change to depression or anxiety +heralding improvement. This tendency of the stupor +reaction to remain pure or change to hypomania +is a peculiarity which seems to put stupor in a class +by itself among the manic-depressive reactions, as +all the other mood reactions frequently change from +one to the other.</p> + +<p>Although apathy is the central pathognomonic +symptom of stupor conditions, there are other mood +anomalies to be noted. One of these is the tendency +for inconsistency in, as well as reduction of, the expression +of emotion. For instance, in the states +where one would expect anxiety during the onset +of stupor or in its interruptions, manifestation of +this anxiety is often reduced to an expression of +dazed bewilderment. In the anxiety states associated +with stupor one does not meet with the restlessness +and expressions of fear which would be ex<!-- Page 127 --><span class='pagenum'><a name="Page_127" id="Page_127">[127]</a></span>pected. +Quite similarly, when a manic tendency is +present, it occurs either in little bursts of isolated +symptoms of elation (such as smiling or episodic +pranks), or some of the evidences of elation which +we would expect are missing. For instance, Johanna +S. (Case 13) terminated her stupor with a +hypomanic state which was natural except for her +always wearing an expressionless face. Sometimes +laughter occurs alone and gives the impression of a +shallow affect, raising a suspicion of dementia præcox. +In fact, such evidences of affect as do appear +in the course of the stupor are apt to be isolated, +queer and "dissociated." It does not seem as if the +whole personality reacted in the emotion as it does +in the other forms of manic-depressive insanity. +For example, we may think of the resistiveness +which is so frequently present when the patient +seems in other respects to be psychically dead. One +may recall the case of Meta S. (Case 15), who, otherwise +inert, was occasionally seen with tears or smiles. +Anna G. (Case 1), too, was often seen smiling or +weeping. It was noted once of Charlotte W. (Case +12) that she ceased answering questions and remained +immobile with fixed gaze, but when some +mention was made of her going home she flushed +and tears ran down her cheeks, although no change +in the fixedness of her attitude or facial expression +was seen. When Johanna S. was visited by her +daughter and was lying motionless in bed, she +slowly extended her hands, apparently tried to +speak, and then her eyes filled with tears. Two days<!-- Page 128 --><span class='pagenum'><a name="Page_128" id="Page_128">[128]</a></span> +later, at the end of an interview when she had made +a few replies, she settled down into her usual inactivity +and, when further urged to answer, her eyes +filled with tears. Similarly, too, in fairly deep stupor +pin pricking may result in flushing, in tears or +an increased pulse rate without the patient giving +any other evidence of the stimulus being felt. These +examples seem to show a larval effort at normal human +response which, failing of complete expression, +appeared as single isolated features of emotion suggesting +true dissociation. We should also in this +connection bear in mind the impulsive suicidal acts +which occur either as unexpectedly as the impulsiveness +in a true dementia præcox patient, or in a setting +of coarse animal-like excitement that seems +quite unrelated to the personality. One is reminded +of the patient who made suicidal attempts during +the period when she shouted like a huckster, giving +no evidence whatever by her expression or the tone +of her voice of feeling anxiety, sorrow or any other +normal emotion.</p> + +<p>All these queer and larval affective reactions remind +one strongly of dementia præcox. The resemblance +of the benign stupor to certain dementia præcox +types is not merely a matter of identity with +catatonic features (catalepsy, negativism). In +these anomalous mood reactions it seems as if there +were a definite dissociation of affect, and so there is. +How then can we differentiate these emotional symptoms +from the "dissociation of affect" which is regarded +as a cardinal symptom of dementia præcox?<!-- Page 129 --><span class='pagenum'><a name="Page_129" id="Page_129">[129]</a></span> +The answer is that this term is used too loosely as +applied to the latter psychosis. It is a particular +type of dissociation which is significant of the schizophrenic +reaction, for in it there is an acceptance +of what should be painful ideas evidenced either by +incomplete manifestations of anxiety or depression +or actually by smiling. We never see in dementia +præcox the reverse—a painful interpretation of +what would normally be pleasant. It is the pleasurable +interpretation of what is really unpleasant +that gives the impression of queerness in the mood +of these deteriorating or chronic cases. In stupor, +on the other hand, although this dissociation takes +place, the mood is never inappropriate, merely incomplete +in that all the components or the full expression +of the normal reaction are not seen.</p> + +<p>Our description of the mood reactions in stupor +would be incomplete if we omitted to mention the +occasional appearance of an emotional attitude not +unlike that seen in many cases of involution melancholia, +which reminds one in turn of the reactions +of a spoiled child. The commonest of these manifestations +is resistiveness that may occur when an +examination is attempted, feeding is suggested, or a +sanitary routine insisted upon. One also meets +with resentfulness. One patient, who frequently +showed this reaction, explained it retrospectively by +saying that she wanted to be left alone. Quite analogous +to this is sulkiness that occasionally appears. +Then we have, particularly as recovery begins, other +childish tricks, such as flippancy in answering ques<!-- Page 130 --><span class='pagenum'><a name="Page_130" id="Page_130">[130]</a></span>tions +or the playing of pranks. Such tendencies +naturally lead over to frank hypomanic behavior.</p> + +<p>Finally, a peculiar characteristic of the stupor +apathy must be mentioned. This is its tendency to +interruptions, when the patient may return to life, +as it were, for a few moments and then relapse. +Such episodes occur mainly in milder cases or towards +the end of long, deep stupors. It is interesting +that the occasion for such reappearance of affect is +frequently obvious. We usually observe them in response +to some special stimulus, particularly something +that seems to revive a normal interest. Visits +of relatives are particularly common as such stimuli, +in fact recovery can often be traced to the appearance +of a husband, mother or daughter. It is also +important to recognize that with this revived interest, +other clinical changes may be manifest, that the +thinking disorder may, for instance, be temporarily +lifted. Helen M., for example, when visited by her +mother was so far awakened as to take note of her +environment, and remembered these visits after recovery +like oases in the blank emptiness of her stupor. +She further remembered that definite ideas +were at such a time in her mind that ordinarily was +vacant. She then had delusions of being electrocuted.</p> + +<p>In summary, then, we may say that the <i lang="la">sine qua +non</i> of the stupor reaction is apathy in all gradations, +and that this apathy is as distinct a mood +change as is elation, sorrow or anxiety. Incidental +to this loss of affect there is a dissociation of emo<!-- Page 131 --><span class='pagenum'><a name="Page_131" id="Page_131">[131]</a></span>tional +response whereby isolated expressions of +mood appear without the harmonious coöperation of +the whole personality which seems to be dead. +Thirdly, there tends to be associated with the stupor +reaction a tendency to childish behavior. Finally, +the apathy and accompanying stupor symptoms may +be suddenly and momentarily interrupted. An explanation +of these apparently anomalous phenomena +will be attempted in the chapter on Psychology of +the Stupor Reaction.</p> + +<p><!-- Page 132 --><span class='pagenum'><a name="Page_132" id="Page_132">[132]</a></span></p> + +<h2>CHAPTER VII<br /> + +<span class="sm">INACTIVITY, NEGATIVISM AND CATALEPSY</span></h2> + +<p><b>1. Inactivity.</b> We must now turn our attention to +the other cardinal symptoms of the stupor reaction, +and quite the most important one of these is the +inactivity. It is convenient to include under this +heading both the reduction of bodily movement and +the diminution or absence of speech. This inactivity +is, of course, related to the apathy which we have +just been discussing, in fact it is one of the evidences +of the loss of emotion. We presume that a patient +is apathetic when there is no expression in the face +and when he does not respond to external stimuli, +whether these be physical or verbal, by movement +or by word.</p> + +<p>Bodily inactivity is present in all degrees, and in +some forty consecutive cases was recognizable in +every one. In its most extreme form there is complete +flaccidity of all the voluntary muscles, and +relaxation of some sphincters. As a result of +the latter we see wetting, soiling and drooling. +Even those reflexes which are only partially under +voluntary control, like those of blinking and swallowing, +may be in abeyance; for instance, saliva may +collect in the mouth because it is not swallowed, and<!-- Page 133 --><span class='pagenum'><a name="Page_133" id="Page_133">[133]</a></span> +tube-feeding is frequently necessary on account of +the failure of the patient to swallow anything that is +put into his mouth. The eyes may remain open for +such long periods of time that the conjunctiva and +sclera may become quite dry and ulcerate. In these +extreme cases there is, of course, no response to +verbal commands. What is more striking, no reaction +appears to pin pricks, so that it seems as if consciousness +of pain were lost.</p> + +<p>This deep torpor does not usually persist indefinitely. +The commonest evidence of some form of +consciousness persisting is probably to be seen in +blinking when the eye is threatened or the sclera or +cornea actually touched. A very large number of +patients, when otherwise quite inactive, showed considerable +response in their muscular resistiveness, +the phenomena of which will be discussed shortly. +The relaxation of the sphincters is apt to persist +even after control of the rest of the body is exercised +to the point of permitting the patient to stand or +walk about.</p> + +<p>The first phase of obvious conscious control is +seen in those patients who will retain a sitting posture +in bed or in a chair. The next stage is reached +where the stuporous case can be stood upon his feet +but cannot be induced to walk. The next degree is +that of walking only when pushed or commanded. +Finally spontaneous movement is observed in which +the inactivity is evidenced merely by a great slowness.</p> + +<p>No correlation can be established between restric<!-- Page 134 --><span class='pagenum'><a name="Page_134" id="Page_134">[134]</a></span>tions +of speech and motion other than that present +in the extremes. With complete inactivity there is almost +always consistent mutism, and perfect freedom +of speech does not, as a rule, appear until the movements +are free. In between these extremes all variations +are possible, even the deepest stupors are +occasionally interrupted by one or two words; for +instance, a patient may remain comatose, as it were, +and absolutely mute for six months, then to every +one's surprise say one or two words and relapse into +a year of silence. Again one sees cases where movements +have become fairly free and yet the patient +says nothing. This is another example of that inconsistency +in reaction which we have already noted +in connection with the mood or affect.</p> + +<p>In so far as inactivity is merely an expression of +apathy, its causation will be considered in connection +with the psychology of the stupor reaction as a +whole. In so far as there may be specific factors, +however, it may be of interest to consider what information +the patients themselves give us from time +to time as to what determined their inactivity. It +is really surprising how frequently something can +be gained either from careful notes taken during the +stupor or from the retrospective accounts of the +psychotic experiences. Of course when one considers +the degree of amnesia which is usually present +and the extent of the intellectual defect in general, +it becomes obvious that one cannot think of getting +anything like a complete explanation of the behavior +of any given case. Nevertheless this material is<!-- Page 135 --><span class='pagenum'><a name="Page_135" id="Page_135">[135]</a></span> +quite suggestive in the mass; it gives one some idea +of the mental state as a whole.</p> + +<p>Among 40 cases, 27 offered some explanation +either during or following the psychosis. Of these, +20 spoke of feeling dead, numb or drugged, or feeling +as if paralyzed or having lockjaw. This group, +just half of all the cases, apparently ascribed their +disability to something which seemed physical. +One might call them somatopsychic cases. The +other 7 gave more allopsychic explanations: 3 attributed +their inactivity to outside influence; 3 more +said they were afraid (one of these because she imagined +herself to be in prison), which is analogous to +the outside influence; the 7th case thought she would +injure people if she moved.</p> + +<p>The following are some examples of the statements +of the somatopsychic group: Laura A.: "I +can't move," and retrospectively, "My arms were +stiff." Bridget B. claimed retrospectively that she +felt dead or drugged, that her limbs were lifeless, +she felt as if she had lockjaw. Johanna B. remembered +being pricked with a pin on several occasions +but claimed that she did not feel the pain at any +time. This suggests a definitely hysterical mechanism. +Anna L. (Case 16) said retrospectively that +she felt as if she were dead, although walking +around, and also that she thought she was a ghost +and not supposed to speak. Anna M. said she had +tried to speak but everything stuck in her throat. +Alice R. said that she had no energy, did not want to +talk. Meta S. (Case 15) claimed that while stupor<!-- Page 136 --><span class='pagenum'><a name="Page_136" id="Page_136">[136]</a></span>ous +her tongue would not move. Isabella M. in intervals +claimed that during the stuporous periods +she felt as if dead and said retrospectively when +the whole psychosis was over that it was "an effort +to speak." Johanna S. (Case 13), while stuporous +when pressed with questions would say: "I can't +think," "I don't know," "I am twisted." When +food was offered her she protested, "I am dead." +Charlotte W. (Case 12), in reviewing her case, said: +"I was mesmerized," "I thought I was dead." +Anna G. (Case 1), in retrospect said: "I don't think +I could speak," again "I made no effort," or "I did +not care to speak." Henrietta H. (Case 8) said, "I +lost speech." She claimed that she did not move +because she was tired and had a numb feeling. +Mary C. (Case 7) said that her tongue had been thick +and that she felt dull. Rose Sch. (Case 6) said during +the psychosis that her head was upside down +and retrospectively that she had been mixed up, +could not remember well, did not feel like talking. +Mary D. (Case 4) said that she had been dazed, that +she had not felt like talking, and that her limbs +"were stiff like." We should probably also include +here as a delusion of death the statement of Annie +K. (Case 5) who wanted to die and thought she would +do so if she kept still enough.</p> + +<p>It is rather striking that among all the forty cases +only one spoke of being sick—"I am so sick." Only +one evaded questions with "that was my illness." +One would expect a priori that these patients would +offer some vague explanations or make complaints<!-- Page 137 --><span class='pagenum'><a name="Page_137" id="Page_137">[137]</a></span> +of weakness. If these stupors were purely physical +in origin, one would expect such explanations as +weakness or illness to be offered in accounting for +the inactivity. That there is a rather definite type +of explanation offered is, we think, distinctly suggestive. +If one tries to correlate and group the +death ideas, one sees that they are all delusions of +death or of loss of energy or complaints of hysterical +symptoms that look like sham death. If the +lack of energy complained of be looked upon as lifelessness, +one can conceive of these explanations being +variations of one theme, namely, that of death. +In the last chapter it has been shown that a delusion +of dying, being dead, or having been dead is +extremely frequent in the stupor group. It would +seem only natural then to regard the inactivity, in +so far as it may be specifically determined, as an expression +of some such delusion.</p> + +<p>Psychiatrists are more or less aware of there being +typical ideational contents in the different +manic-depressive psychoses. For instance, every +one is familiar with ideas of wickedness and inadequacy +in depression, ideas of violence in anxiety, or +expansive and erotic fancies in manic states. Quite +similarly we have seen that death is a dominant +topic in a stupor. Now in addition to these typical +ideas we often hear expressed what we might term +non-specific delusions, ideas that seem to have nothing +to do with a peculiar type of reaction which the +patient presents. It is therefore not surprising to<!-- Page 138 --><span class='pagenum'><a name="Page_138" id="Page_138">[138]</a></span> +find that inactivity is not consistently ascribed to +death or a related delusion.</p> + +<p>For instance, Henrietta B. had much talk of higher +powers that were controlling her, also said that +it was fear which kept her quiet. Josephine G. said +retrospectively that she had thought she would injure +people if she moved and that if she opened her +eyes she would murder the people around her. Johanna +B. was afraid to talk because she fancied she +was in prison. Laura A.: During her stupor was +more vague, saying, "I can't move, they won't let +me be," without betraying any suggestion of whom +"they" might be. Finally Mary C. (Case 7) was +still more indefinite, ascribing her immobility merely +to fear. When one considers, however, that these +five were the only ones who gave any atypical explanation +of their inactivity among the thirty-seven +cases, the preponderance of the death idea becomes +striking.</p> + +<p><b>2. Negativism.</b> The next of the cardinal symptoms +to be considered is negativism. This term, which is +often loosely used, we would define as perversity of +behavior which seems to express antagonism to the +environment or to the wishes of those about the +patient. Naturally it is only in the minor stupors +that we see it in well-developed form as active opposition +and cantankerousness. For example, Harriett +C., who stood about until her feet became +edematous, would spit out food when it was placed +in her mouth but would eat if she were left alone +with the food. Josephine G., in a milder state,<!-- Page 139 --><span class='pagenum'><a name="Page_139" id="Page_139">[139]</a></span> +would turn her back on people. When more inactive +once rolled out of bed and lay on the floor. At this +time also she tried to keep people out of her room. +Rarely, patients may have angry outbursts, as did +Annie K. (Case 5) who would strike at the nurses.</p> + +<p>Very often the failure to swallow and anomalous +habits of excretion seem to be negativistic in their +nature. One thinks at once of the necessity for tube-feeding, +which is so common even when patients +seem otherwise fairly active. Naturally this form +of treatment is necessary only when the patient refuses +to swallow. Quite frequently a refusal to +urinate is met with so that catheterization is necessary, +or a patient may never use the toilet when +led to it, but will defecate or urinate so soon as he +leaves it. These latter, like some other perversities, +suggest reactions of a petulant, spoiled child.</p> + +<p>By far the commonest manifestation is muscular +resistiveness, often spoken of as "resistiveness." +It was present in thirty-two out of thirty-seven of +our cases. Usually it takes the form of a contraction +of the whole system of voluntary muscles when +the patient is touched or the bed approached. Often +it appears only when any passive movement of the +limb is attempted. All muscles of the limb then +stiffen, making the member rigid. Sometimes the +negativism is expressed by quite isolated symptoms, +such as stiffness in the jaw muscles alone. One patient +showed no opposition except by holding her +urine for two days. Another kept her eyes constantly +directed to the floor. The reaction of an<!-- Page 140 --><span class='pagenum'><a name="Page_140" id="Page_140">[140]</a></span>other +showed no irregularity except for stiffness in +the neck and arms and wetting herself once after +she had been taken to the toilet. One displayed +merely a slight stiffness in her arms. An interesting +case was that of Annie G. (Case 1) who kept +one leg sticking out of bed. If this were pushed +in, she would protrude the other. Mary F. (Case +3) sometimes expressed her antagonism to the environment +by slapping other patients. She spoke +only twice in a year and a half, and each time it was +when interfered with. By far the commonest cause +of muscular movement in these inactive cases is resistiveness, +and as a rule the inactivity is interrupted +only by negativistic symptoms.</p> + +<p>If we look for some explanation or correlation of +these symptoms, we find that chance references to +conduct seem to point in the same direction, namely, +to the desire to be left alone. This resentment +against interference again reminds us of the reactions +of a spoiled child. For instance, Laura A., in +manic spells during which she was still constrained +and drooled, said, "I don't want to have my face +washed." In the intervals she showed an intense +muscular resistiveness. Mary G. used to say, "Leave +me alone," and covered her head or buried it in +the pillows. Maggie H. (Case 14) said in retrospect +that she had wanted to be left alone. Similarly Alice +R. thought she did not want to talk. Emma K. +thought that she was in prison and apparently resented +this. Henrietta B. combined in her behavior +tendencies both to compliance and opposition.<!-- Page 141 --><span class='pagenum'><a name="Page_141" id="Page_141">[141]</a></span> +When her arms were raised they retained the new +position for a minute. Then she dropped them and +said, "Stop mesmerizing me." But then she put +them up again of her own accord, and when she had +done this presented intense resistiveness to any +movement. Later she extended her arms in front +of her and said, "I am all right," in a theatrical +manner, and then added, "Why don't you go +away?"</p> + +<p>There seems to be some correlation between inaccessibility +and muscular resistiveness. For example, +Charlotte W. (Case 12), whose condition varied +a great deal, always lost the resistiveness when she +became accessible, during which periods she also +showed some facial expression. The resistiveness +would invariably return when the inaccessibility +reappeared. Caroline DeS. (Case 2) lost her resistiveness +as she became more accessible, although the +inactivity and apathy persisted. This tendency, +which is quite common, suggests that muscular resistiveness +represents a lower level of expression of +opposition which patients put into words or purposeful +actions when there is other evidence of some +contact with the environment. Sometimes one observes +both general resistiveness and specific acts. +For instance, Mary G., who said, "Leave me alone," +and covered her head or buried it in the pillows, +accompanied her muscular resistiveness with laughter. +This shows the affective nature of the apparently +purposeless muscular tension. The case of +Annie K. (Case 5) is more instructive. In the stage<!-- Page 142 --><span class='pagenum'><a name="Page_142" id="Page_142">[142]</a></span> +of deeper stupor she had the automatic type of resistiveness +but also outbursts of anger, particularly +toward the nurses, striking one of them she said, +"You are the cause of it all." When food was offered +her, she said, "I wonder people would not leave +me alone sometimes." Again, when her bed was approached, +she would clutch and hold the bed clothes +in an apparently aimless way as if the impulse to +resist never reached its goal. Retrospectively she +could not account for her muscular rigidity on the +basis of definite ideas, and could recall only that +she felt stubborn. In a later period when more accessible, +she felt cross and did not want to be bothered. +This emotional attitude was quite conscious +with her, whereas the acts and speech of the earlier +period, when her stupor was more profound, seemed +more automatic and impulsive. In other words, the +resistiveness looks like a larval attempt to express +an idea which is probably not fully conscious and +therefore gives the appearance of being aimless. +As another example of this we may cite the case of +Pearl F. (Case 9), who said when she recovered, "I +was stubborn." In addition to the muscular resistiveness +she had shown, she would often bite the bed +clothes or scratch herself when she was approached. +Mary F. (Case 3), while in a stupor, slapped at +nearby patients quite aimlessly. When somewhat +better, this conduct appeared in a more conscious +form, as sullenness, indifference and smearing of +feces (again the behavior of a naughty child). Here +one might quote Laura A. once more, whose resis<!-- Page 143 --><span class='pagenum'><a name="Page_143" id="Page_143">[143]</a></span>tiveness +when stuporous was intense but who in her +manic spells expressed her negativism in a definite +idea, "I don't want my face washed."</p> + +<p>To summarize, then, we may say that negativism +is apparently the result of a desire to be left alone, +and that muscular resistiveness is a larval exhibition +of the same tendency. But the appearance of +this attitude in such aimless, impulsive acts or +habits reminds us strongly of the dissociation of +affect, which was commented on in the previous +chapter. It would seem to be another example of +this rather fundamental tendency of the stupor reaction, +not merely to diminish conative reactions in +general, but to reduce their appearance to that of +isolated, partial and therefore rather meaningless +expression.</p> + +<p><b>3. Catalepsy.</b> The last of the cardinal symptoms +to be considered is catalepsy. It occurred in thirteen +of thirty-seven cases, although it was present only +as a tendency in three of these. If we define it as +the maintenance of position in which a part of the +body is placed regardless of comfort, we can see that +sometimes it is difficult to differentiate from the +phenomenon of resistiveness with its rigidity. It is +most frequently observed in the hands and arms, +perhaps because it is, as a rule, most convenient +to demonstrate the retention of awkward positions +in the upward extremities. But any part or even +the whole body may be involved; for example, +Charles O. retained standing positions even where +balance was difficult. This phenomenon is often<!-- Page 144 --><span class='pagenum'><a name="Page_144" id="Page_144">[144]</a></span> +accompanied by "waxy flexibility," where the joints +move stiffly but retain whatever bend is given them, +like a doll with stiff joints.</p> + +<p>The significance of catalepsy is best studied by +considering its relationship to other symptoms and +by noting remarks made by the patients in reference +to it. The most important observations which we +have made seem to indicate that it never occurs with +that degree of deep inactivity which suggests a complete +lack of mentation on the part of the patient. +One is therefore forced to conclude that back of this +phenomenon there must be some purpose, some kind +of an ideational content, although this may be of a +primitive order. This is demonstrably true in some +cases, at least such as that of Isabella M., who left +her arm sticking up in the air but took it down to +scratch herself and then put it back. Somewhat +similarly, Charlotte W. (Case 12), when she was +shown during convalescence a photograph of herself +in a cataleptic state, said that that was when she was +waiting to go to Heaven and was afraid to move. +Again she remarked, "I was mesmerized." Josephine +G., who showed only a tendency to catalepsy, +said that she feared the devil would get control of +those about her if she moved. Sometimes there is +a development of this symptom from others which +seem to be ideational in their origin. For instance, +Charles O. began making flail-like movements. +These passed over into slow circular motions which +finally subsided into the maintenance of fixed position.</p> + +<p><!-- Page 145 --><span class='pagenum'><a name="Page_145" id="Page_145">[145]</a></span></p><p>References to hypnotism are not infrequent, and +in many cases there is evidence of a delusion that +the posture is desired by those in charge of the +patient. Annie G. (Case 1) said so directly. In +retrospect she explained the holding of her arms in +the air by saying, "I thought you wanted me to have +them up." Henrietta B. at one examination kept +her arms raised in the position in which they had +been put for a minute and then dropped them, saying, +"Stop mesmerizing me." But she then put +them up again of her own accord and now presented +intense resistance to any motion. Later she extended +her arms in front of her and said, "I am all +right," in a theatrical manner. Some patients give +evidence in other symptoms of larval efforts at coöperation +with the actual or supposed wishes of the +physician and in such cases it is not impossible that +passive movements are interpreted as orders. One +must remember in this connection that the more +primitive are the mental operations of any individual, +the more important do signs, rather than +speech, come to be a medium of communication with +other people. As an example of this type we might +mention Rose Sch. (Case 6), who flinched from pin +pricks (showing that she felt them) but made no +effort to get away. When somewhat clearer she said +that she was "here to be cured." Similarly Mary +D. (Case 4), who showed no catalepsy from ordinary +tests, kept her head off the pillow for a long time +after it was raised to have her hair dressed. She +showed such perseveration in many constrained po<!-- Page 146 --><span class='pagenum'><a name="Page_146" id="Page_146">[146]</a></span>sitions. +She too flinched from pin pricks but not +only made no effort to prevent them but would even +stick out her tongue to have a pin stuck in it.</p> + +<p>The relationship of catalepsy to resistiveness is +interesting but unfortunately complicated and unclear. +In only one of our cases was catalepsy definitely +present without resistiveness, and in one +other a "tendency to catalepsy" was noted without +muscular rigidity being observed. In this latter +case, when the catalepsy became unquestionable, +resistiveness also appeared. It is one thing to note +this coexistence and another to explain it adequately. +All that we can offer are mere speculations +as to the real meaning of the association of these +phenomena. It may be that the tension of muscles +that occurs when resistiveness is present gives the +idea to the patient of holding the position. There +would be two possible explanations for this. We +might think there is a dissociation of consciousness, +like that of hysteria, where the feeling of tenseness +in the muscles that comes from the resistance to +gravity is not discriminated from the resistance to +the movements made by the examiner. On the other +hand, there might be a similar dissociation where +the perception of contraction in the antagonistic +muscles is interpreted as the action of the examiner +in placing the limb in a given position. This latter +view would seem, on the face of it, ridiculous, inasmuch +as its presumes the existence of two directly +opposed tendencies, namely, those of opposition to +the will of the physician and compliance with it. But<!-- Page 147 --><span class='pagenum'><a name="Page_147" id="Page_147">[147]</a></span> +ambivalent tendencies are frequently present in +psychopathic states, and moreover we find occasionally +some evidence in the behavior of the patient +to substantiate this view. For example, at one stage +of the stupor of Annie G. (Case 1), her arm could be +moved without resistance. Then the elbow would +catch and at this moment the position would be +maintained. Such observation is highly suggestive +of the resistance being signal for the catalepsy. In +Isabella M. the catalepsy appeared when resistance +to passive movements also developed. On the other +hand, when the resistance became extreme, the catalepsy +was reduced, and vice versa. This makes one +think of two tendencies: suggestibility on the one +hand, and opposition on the other. We might presume +that when both are present and equally strong, +stiffness with passive movements results as a kind +of compromise, but when there is a greater development +of one, the other is inhibited.</p> + +<p>Such speculations remind one strongly of the +psychology of conversion hysteria and of hypnotism. +In some cases of stupor hysterical symptoms are +quite definitely present. For instance, Celia G. +began her psychosis with hysterical convulsions +which would terminate with short periods of stupor. +Later the stupor became persistent and during this +stage she had catalepsy (and restiveness as well) +in her left arm only. On recovery from her stupor +she complained of stiffness in her hands, which +examination proved to be a purely hysterical difficulty.</p> + +<p><!-- Page 148 --><span class='pagenum'><a name="Page_148" id="Page_148">[148]</a></span></p><p>This whole subject is without question obscure +and many more and very careful observations are +needed before really satisfactory explanations can +be given for these phenomena. That it is a reaction +which is related to the primitiveness of the mental +content and the intellectual deficit in stupor would +seem to be a reasonable view, inasmuch as quite +similar phenomena have been observed in a large +number of animals, even among crustaceans. As a +result of our own observations the only thing we +feel at liberty to state with real confidence is that +catalepsy is presumably a phenomenon mental in +origin rather than somatic, because it always occurs +in conditions which show other evidence of mentation.</p> + +<p>Whatever may be the origin of the idea of the +posture assumed, there can be little doubt that its +indefinite maintenance is a phenomenon of perseveration. +The conception of the position being in +the patient's mind, it is easier to hold it than elaborate +another idea. This, of course, is part of the +intellectual disorder in stupor. In fact, it is difficult +to imagine any one whose critical faculty was functioning +coöperating in a test for catalepsy.</p> + +<p><!-- Page 149 --><span class='pagenum'><a name="Page_149" id="Page_149">[149]</a></span></p> + +<h2>CHAPTER VIII<br /> + +<span class="sm">SPECIAL CASES: RELATIONSHIP OF STUPOR TO +OTHER REACTIONS</span></h2> + +<p>We have described typical cases of benign stupor +and isolated certain interrelated symptoms which, +when they dominate the clinical picture, we believe +establish the diagnosis of stupor, regardless of the +severity of the reaction. These symptoms are +apathy, inactivity, a thinking disorder and, quite as +important as these, an absorbing interest in death. +It is typical that the patient contemplates his dissolution +with indifference or, at most, with mild or +sporadic anxiety. There seems little reason to doubt +that when these four symptoms occur alone, we are +justified in making a diagnosis of stupor. The next +problem is to consider the meaning and classification +of cases where these symptoms occur in conjunction +with others. This naturally introduces the subject +of relationship of stupor to other manic-depressive +reactions.</p> + +<p>It is probably best to begin with presentation of +three such cases.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 16.</span>—<i>Anna L.</i> Age: 24. Admitted to the Psychiatric +Institute August 21, 1916.</p> + +<p><i>F. H.</i> Maternal grandmother temporarily insane during illegitimate +pregnancy, thereafter a little odd. Mother high strung<!-- Page 150 --><span class='pagenum'><a name="Page_150" id="Page_150">[150]</a></span> +and emotional. Father high strung, impulsive and irritable.</p> + +<p><i>P. H.</i> As a child she was quick tempered, quite a spitfire and +given to tantrums. At the age of 14 she became a vaudeville +actress in Cleveland, which was the home of her childhood. +When 17 she married a Jew, although she was herself a Catholic. +Her husband noted that she was fretful, sensitive, resentful and +quick tempered, although apt to recover quickly from her rages. +Previously healthy, neurotic symptoms began with marriage, taking +the form of stomach trouble and a tendency to fatigue. +Shortly after marriage an abortion was induced. After being +married for two years she had a quarrel and separated from her +husband. They were reconciled later, but in the meantime she +had been having relations with another man. When 20 an abdominal +operation was performed in the hope of relieving her +gastric symptoms, but no improvement occurred. The patient +after recovery stated that she continued to be nervous, shaky and +dizzy, at times trembling when going to bed at night. Two years +later, however, she took up Christian Science and showed objectively +some improvement in her health, although according to her +later accounts she continued to feel somewhat nervous and fatigable. +Her husband stated that at this time she also began to +ponder much about such questions as the difference between life +and death, what "matter" was, and also studied "grammar" and +"etiquette." According to the patient some five or six months +before admission she began to have peculiar sensations following +intercourse—a feeling of bulging in the arms, legs and back of the +neck. One evening after an automobile ride there were peculiar +sensations on her right side like "electricity" or as if she were +inhaling an anesthetic. She gasped and thought she was dying. +Two months before her admission she went with her husband and +his family to a summer resort where she felt increasingly what +had always been a trouble to her, namely, the nagging of this +family.</p> + +<p>Just before her breakdown, because she went daily to the +Christian Science rooms in order to avoid the family, they suspected +her of immorality and accused her of going to meet other +men. Even her husband began to question her motive. Retrospectively +the patient herself said that she now felt she was losing +her mind and did not wish to talk to any one. At the time she<!-- Page 151 --><span class='pagenum'><a name="Page_151" id="Page_151">[151]</a></span> +told her husband that she felt confused and as if she were guilty +of something and being condemned. Repeatedly she said she +knew she was going to get the family into a lot of trouble. Once +she spoke of suicide, and for a while felt as if she were dying. +Finally she became excited and shouted so much that she was +taken to the <i>Observation Pavilion</i>, where she was described as +being restless and noisy, thinking that she was to be burned up +and that she had been in a fire and was afraid to go back.</p> + +<p><i>On admission</i> she looked weary and seemed drowsy. Questions +had to be repeated impressively before replies could be obtained, +when she would rouse herself out of this drowsy state. She +seemed placid and apathetic. She said that nothing was the +matter, but soon admitted that she had not been well, first saying +that her trouble was physical and then agreeing that it had been +mental. When asked whether she was happy or sad, she said +"happy," but gave objectively no evidence of elation. Her +orientation was defective. She spoke of being in New York and +on Blackwell's Island, but could not describe what sort of place +she was in, saying merely that it was "a good place," or "a nice +country place," again "a good city." Once when immediately +after her name L. had been spoken and she was asked what the +place was, she said "The L." She knew that she had arrived in +the hospital that day but said that she had come from Cleveland, +and to further questions, that she had come by train, but she +could not tell how she reached the Island. She claimed not to +know what the month was and guessed that the season was either +spring or autumn (August). She gave the year as 1917, called +the doctor "a mentalist," and the stenographer "a tapper," or +"a mental tapper." She twice said she was single. When asked +directly who took care of her, said "Mr. Marconi," who she +claimed at another time had brought her to the hospital. To the +question, who is he? she replied, "Wireless," and could not be +made to explain further. That night she urinated in her bed, +and later lay quite limp, again held her legs very tense.</p> + +<p>For five days she remained lying quietly in bed for the most +part, although once she called out "Come in, I am here," "Jimmie, +Jimmie" (husband's name). Several times she threw her bed +clothes off. Otherwise she made no attempt to speak and took +insufficient food unless spoon-fed. At one examination she looked +up rather dreamily but did not answer. When shaken she<!-- Page 152 --><span class='pagenum'><a name="Page_152" id="Page_152">[152]</a></span> +breathed more quickly and seemed about to cry but made no +effort to speak. When left to herself she closed her eyes and +did not stir when told she could go back to the ward. She was +then lifted out of her chair and took a step or two and stopped. +Such urging had to be repeated, as she would continue to remain +standing, looking about dreamily, although finally when taken +hold of she whimpered. When she got to the dining-table she +put her hand in the soup and then looked at it. So far there is +nothing in this case atypical of what we would call a partial +stupor. The cardinal symptoms of apathy, inactivity, with a +thinking disorder, are all present and dominate the clinical picture. +There is, further, the history of a delusion of death during +the onset of the psychosis. Had her condition remained like this, +there would be no difficulty in classifying the case, but other +symptoms appeared.</p> + +<p>Five days after admission she was restless, somewhat distressed, +and announced that she wanted to talk to the physician. When +examined, the distress, with some whimpering, continued. She +asked the doctor not to be harsh to her, frequently said there was +something wrong and began to cry. A normal interest appeared +only once, when she spontaneously said she wanted to see her +relatives. A most interesting feature, however, was a certain +perplexity that now appeared. She spoke of this directly: "I do +not know what it is all about. I know you are a doctor, that is all. +I don't know whether I passed out and came back again or +what—I don't know what to make of it." She also felt confused +about her marriage—"There is where all the mixup is. I was +married when I was 16." She was reminded that she had said +she was single, and replied "I am single." Then where is your +husband? she was asked. "He must be dead." She recalled the +examination on admission and remembered some of the questions +that she was asked then, also knew that she had been at the +Observation Pavilion and that she had reached this hospital by +boat. On the other hand she still claimed that the year was 1917, +and in connection with the delusion of having died was quite +unclear as to the time. She said that it seemed as if she had +died many years ago and that she had come to the hospital years +ago. She also spoke of having died at a summer resort the year +before. When asked for her age, she said that she must be very<!-- Page 153 --><span class='pagenum'><a name="Page_153" id="Page_153">[153]</a></span> +old, but on the other hand claimed that she was supposed to die +and to come to the hospital when she was 26 (two years more +than her actual age).</p> + +<p>Her psychosis continued from then on for about ten weeks. +She soon began to feed herself, but otherwise for most of this +period remained quietly in bed, looking about a good deal, +although showing no particular mood reaction until questioned, +when she was apt to make repeated statements about her perplexity—that +she did not know what it was all about, every one +had mixed her up, everything was so strange, "my head is mixed +up, I am trying to straighten things up." She frequently when +interviewed became lachrymose and often with her subjective +confusion there was considerable anxiety. Another unusual +phenomenon for a stupor patient was that she was frightened +at a thunder storm. On the whole, however, her apathy and +indifference were quite marked. For instance, during the latest +phase of her psychosis, when the nurses would sometimes make +her dance with them, she did so but without showing any interest +and not until immediately before her recovery did she begin to +speak spontaneously to any extent whatever. A marked difference +from the ordinary stupor was that this apathy was invariably +broken into when she was questioned and ideas came to her mind, +the nature of which seemed to be essentially connected with her +perplexity.</p> + +<p>Not only did ideas appear more frequently than one meets +them in stupor cases, but they were present in greater variety. +The dominant stupor death idea was, it is true, almost constantly +present, but it did not come to the direct and unequivocal expression +which we are accustomed to see in typical stupor. She +did not say "I am dead," or "I was dead," but it was always +"It seems as if I were dead," or "I think I must have died," or +some such dubious statement. Other ideas were that her mother +was dead and had been put into a box. She frequently gave her +maiden name and said that she lived in Cleveland with her mother +and that this was Cleveland. At times she thought she was engaged +and was going to be married to her husband shortly. +Again there were notions that her husband had married somebody +else or that some harm was going to come to him. Sometimes<!-- Page 154 --><span class='pagenum'><a name="Page_154" id="Page_154">[154]</a></span> +she thought that her mother's name was her own, that is, Mrs. L. +The hospital once seemed like a convent to her.</p> + +<p>Her subjective and objective confusion seemed quite definitely +to be connected with the insecurity and changeability of these +ideas. It appeared as if insight and delusion were struggling +for mastery in her mind, so that reality and fancy were alternately, +even simultaneously, possessing her, and that this gave her +the feeling of perplexity from which she suffered. Once when +she remarked "It seems as if I had been dead all the time," she +was questioned more about this and replied, "Well, sometimes I +thought I was dead, at other times it seemed as if I wasn't." +In answer to a direct question about her feeling of confusion she +said "I don't know. I know I have lots of good friends, they +all want to help me and it seems as if everything got mixed up +between the L.'s (her married name) and the G.'s (her maiden +name)." This was apparently an elaboration of the wavering +ideas she had about her singleness or her married state. Once +after referring to her husband as her sweetheart whom she was +to marry, and immediately thinking that perhaps he had married +somebody else, she added, with a sigh, "The more this goes on, +the more mixup." In short, any question, even on some apparently +neutral topic, seemed to start up conflicting ideas in her +mind, the inconsistency of which she recognized without being +able to control their appearance. Hence, whenever she was +spoken to, she became perplexed and distressed.</p> + +<p>Her orientation gradually improved so that, although it remained +vague, it was no longer glaringly inaccurate. Then quite +suddenly she one day came to a nurse and asked how long she had +been in the hospital. When told, she remarked that it seemed +as if she had spent the whole winter there. She was examined at +once and found to be quite clear and at first in good control of +her faculties. She remembered a good many of her ideas, in fact +was able to elaborate a little from memory on what had already +been reported from her utterances during the psychosis. The +recovery was not immediately complete, however, for at this +examination, when told that she had constantly given her maiden +name, she became distressed and said the physician was trying +to mix her up and was reluctant for this reason to discuss her +ideas. This soon passed, however, and within a few days she<!-- Page 155 --><span class='pagenum'><a name="Page_155" id="Page_155">[155]</a></span> +was quite normal and had remained so for some months after her +discharge from the hospital, when last seen. In fact, according +to the husband, she was in better mental and physical health +following the psychosis than she had been for years.</p></div> + +<p>Essentially, then, this case shows what was at +first a typical partial stupor, but soon became complicated +by a tendency for questioning to provoke +rather a free flow of ideas and a distressed perplexity. +This symptom of perplexity soon grew to +dominate the clinical picture, so that the psychosis +was really a perplexity ushered in by a brief stupor +reaction with a background of stupor symptoms +running through it. The second case shows similar +tendencies but different from the one whose history +has just been cited in that the perplexity was never +complained of by the patient herself and that her +emotional reactions were more marked and varied.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 17.</span>—<i>Celia C.</i> Age: 18. Admitted to the Psychiatric +Institute May 2, 1914.</p> + +<p><i>F. H.</i> Four years after this attack her mother was a patient +in the hospital with an atypical manic-depressive psychosis from +which she apparently recovered.</p> + +<p><i>P. H.</i> The patient herself was described by superficial observers +as being bright, sociable, well-informed and very ambitious.</p> + +<p>When 18 years of age she was working very hard preparing +for some examinations, and worried lest she should fail in them. +Some years later the patient accounted for her psychosis by +saying she had a quarrel with her sister, immediately after which +she began to feel depressed. The anamnesis states that she was +slow, complained of not being able to think and feeling as if she +had no brain. She was sent to a general hospital, where she was +apprehensive, wanted her mother to stay with her and one night +called out "Mother."</p> + +<p><!-- Page 156 --><span class='pagenum'><a name="Page_156" id="Page_156">[156]</a></span> +The case being recognized after a few days as a psychosis, +she was sent to the <i>Observation Pavilion</i>, where she was described +as jumping about in bed in a jerky, purposeless manner, resistive +when anything was done for her, and mute. Her sister reported +that when she visited her the patient said "Go away, I am dead."</p> + +<p><i>On admission</i> she looked dazed, stared vacantly and had a +tendency to draw the sheet over her. When put on her feet she +let herself fall limply. At times she became agitated, sobbed and +cried loudly, especially when attempts were made to examine +her physically, or, when she was asked questions, she scarcely +spoke.</p> + +<p>Her psychosis lasted but a little more than three months under +observation and was characterized by the following symptoms: +She was usually in bed, staring blankly or appearing otherwise +quite indifferent and apathetic, but not infrequently, especially +during the first few weeks, she was quite restless, resistive, +whined and suddenly appeared startled or distressed with no +occasion for this reaction in the environment. Rarely she was +suddenly assaultive. When attempts were made to examine her, +she was frequently mute or would repeat the question with a +rising inflection, not getting anywhere, or would say, "What shall +I say," or "I, I——" never finishing her sentence. After orientation +questions she might say "This is—this is—this is——" all +this, together with a rather perplexed appearance, gave the +impression of considerable bewilderment, but at no time did she +complain of autopsychic perplexity. It was difficult to judge of +her orientation on account of her failure to answer questions, +but it soon appeared that she knew the names of the nurses, for +she sometimes called them spontaneously by name. She always +ate reluctantly.</p> + +<p>During these examinations, however, other symptoms often appeared. +When she was talked to, she was apt to indulge in +depressive statements and show considerable distress. Such +remarks were: "I must confess my guilt," "I am a bad girl and +I have to face my guilt," or "I have sinned," or, standing up with +a dramatic air, "I must stand up and tell the truth." Once she +said, "It is too late to live now." She spoke of having lied and +usually would not say what about, but once on questioning replied +"I said I would not tell what happened here." She was asked,<!-- Page 157 --><span class='pagenum'><a name="Page_157" id="Page_157">[157]</a></span> +What do you mean? and answered "I took my oath not to tell +anything." Pressed further she said that the nurses poisoned +her. Another time she said she was in prison. To her aunt who +visited her she said, "I am a prostitute," and once she remarked +to the doctor, "I have killed my honor," and on another occasion +in the middle of the night she called out, "Chinatown Charlie, +come here." She thought the doctor was her brother.</p> + +<p>Most of these statements were associated with painful emotion, +but there were a few occasions when an element of elation +cropped out. Thus on one occasion she laughed, another time +gripped the doctor's pad and tried to read it. When the nurse +laughed, she made a funny grimace at her and said "Why do you +laugh?" Again she once sang two songs, but after the first verse +got stuck and kept repeating one word.</p> + +<p>At the end of three months she improved rather rapidly and +was in a condition for discharge as "recovered" a month later. +Retrospectively she said that she recalled feeling guilty, thinking +that her mother was dead, having been killed by the patient as a +result of worrying over the latter's failure in her examinations +and refusal to eat. She remembered, too, that at times she +thought the building was burning. Some things like "Chinatown +Charlie" she denied remembering, although she had a good recollection +for the external facts throughout the psychosis. Her +insight was superficially good, but she was reluctant to discuss her +psychosis, in fact claimed that she had been made more of a +lunatic by coming to the hospital than she was on admission.</p> + +<p>Some five years later she had another somewhat similar attack, +again following a quarrel, this time with a fellow employee. In +this second psychosis, however, manic elements were much more +prominent.</p></div> + +<p>Here again, then, we have the symptoms of apparent +apathy, inactivity, and similar ideas of death, +but the thinking disorder was possibly not very +profound, inasmuch as she had a good memory for +external events. Her ideas, too, are much more +florid than those which we customarily meet with in +stupor cases, but the most marked peculiarity was<!-- Page 158 --><span class='pagenum'><a name="Page_158" id="Page_158">[158]</a></span> +that this "stupor" was liable to constant interruption, +either spontaneously or as a result of questioning, +which always produced a mood reaction. She +was apathetic only so long as she was left alone. In +other words, whenever an effort was made to test +what seemed to be apathy, the evidences of it disappeared.</p> + +<p>The third case to be considered is somewhat like +that of the first, Anna L. (Case 16), in that with +the inactivity and apathy there was a coincident +subjective perplexity. The apathy, however, was +less marked than in the case of Annie L.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 18.</span>—<i>Catherine M.</i> Age: 24. Admitted to the Psychiatric +Institute November 10, 1913.</p> + +<p><i>F. H.</i> Information as to the family is confined to the two +parents. The mother, who was frequently seen, seemed to be a +natural, sensible woman. The father, on the other hand, had +been alcoholic all his life, had had two convulsions while drinking, +and had little respect from any member of the family, including +the patient.</p> + +<p><i>P. H.</i> The patient was said always to have been healthy, from +a physical standpoint, although never robust. She got on well +at school, and then worked first as a stock girl and later as clerk +in a department store, where her work was efficient and she +advanced steadily. As a child she played freely with other +girls but little with boys. As she grew older she moved about +socially a little more, made the acquaintance of men as well as +of girls, but never cared much for the former and had no love +affairs until she met her husband. She was never demonstrative +but always rather quiet and modest. Occasionally she spoke of +thinking that people talked about her, but the informant doubted +if she brooded over this, because she was not of a worrying +disposition. Considering the ideas which appeared in her +psychosis, it is striking that in her normal life she was rather<!-- Page 159 --><span class='pagenum'><a name="Page_159" id="Page_159">[159]</a></span> +antagonistic towards her father on account of his alcoholism and +the crudity of his speech and manners.</p> + +<p>When she met her husband she liked him from the first, +although she at no time became really demonstrative. They were +engaged for a year, during which time she agreed to a postponement +of three months for the marriage, which was suggested by +her mother. For some time before this event she was working +harder than usual and seemed a bit worn out. She ceased working +a month before marriage and improved physically, although she +became rather nervous, that is, she was more easily startled, an +accentuation of what had been a characteristic for some years. +Her husband stated that at this time she became fearful of the +approaching marriage relations and asked him to be kind to her +in this respect. She was married a year before admission. For +two and a half months she refused intercourse and visited her +mother's home a great deal. She finally submitted. She was +quite frigid but became pregnant at once. Her abnormality then +became apparent. She kept the fact of her pregnancy to herself +for several months and then when she told her mother wanted +to have an abortion performed. Neurotic symptoms appeared. +She became sensitive with her husband, correcting his grammar, +and cried easily. She also began to be anxious about the approaching +childbirth, and with this became more religious.</p> + +<p>For the first few days after the delivery, she was fussy with +the nurse so that two in succession had to be discharged. On +the fifth day she woke up and seeing a nurse lying on the couch +beside her bed thought the latter was colored. On the seventh +day she had a dream in which she thought she "nearly died in +childbirth." Then she began to talk of dying for her baby or +of having two babies, of dying herself and rising again after +Easter Sunday. She became antagonistic to her husband and +with this excited and confused so that she was taken to the +Observation Pavilion.</p> + +<p>On <i>admission</i> she looked pale and exhausted, had a slight temporary +fever and a coated tongue. Her orientation was usually +vague but sometimes she gave fair answers. Her verbal productions +were rather fragmentary and with the exception of some +repetitions there did not seem to be any special topics which +dominated her train of thought.</p> + +<p><!-- Page 160 --><span class='pagenum'><a name="Page_160" id="Page_160">[160]</a></span> +For some days the great weakness and the slight fever continued, +and then, as it gradually cleared up, there came a change +in her mental condition that settled into the state which characterized +the rest of her psychosis. She talked less and was often +quite inactive, frequently lying with her eyes closed for long +periods, or sat or stood about. Such movements as she made +were slow and languid. Her expression was either blank, absorbed, +or gave the appearance of peculiar appealing perplexity. +This last was not infrequently associated with a rather sheepish +smile. She was never resistive and always ate and slept well. +With the exception of a few times she did not soil herself. The +most interesting feature of her mood reaction was that in a +general setting of a slight perplexity there appeared at times +and evidently associated with definite ideas, changes in her emotional +state. Sometimes this was a matter of distress or of mild +ecstasy, sometimes she became markedly blocked. There was at +no time any frank elation, but often an appropriate smile, that +is, appropriate to the situation and to the thought to which she +was giving expression at the time. Then, rarely, there were +sudden bursts of peculiar conduct, such as throwing herself on +the floor or running down the hall. When questioned as to her +motive for these acts, she would flush, look perplexed and apparently +be unable to explain them.</p> + +<p>Her verbal productions dealt with a rather limited range of +topics which can be briefly summarized. As in the other cases, +the reader will notice that the bulk of these ideas are of a kind +not usually prominent in the typical stupor cases. Many of her +thoughts seemed centered around her husband. She always knew +him when he visited her, but in her thoughts there was a constant +change as to his personality. She persistently confused him +with the physicians, with her father, and with God, and one +remark is typical, "I thought he was God, priest, doctor, lawyer—well, +I wanted to go to Heaven; I thought he would still be my +husband; I always hoped that I would be home in Heaven." Not +unnaturally with this confusion there were doubts about her +marriage. People said her marriage was wrong and her husband +bad. Frequently she thought he was dead, or voices informed +her that she was not married to him, or that he was the devil in +Hell. In this connection she also said that people called her a<!-- Page 161 --><span class='pagenum'><a name="Page_161" id="Page_161">[161]</a></span> +whore, or it seemed as if she were accused of not being married.</p> + +<p>As prominently as appeared the ideas of the invalidity or impossibility +of her marriage, to the same extent did her father +assume an important rôle for her. As a rule he appeared in +religious guise as God, but often he was the doctor—"I knew my +father at home and my father in Heaven; which God do you +mean? did you say God or father?" At times she spoke of +being in Heaven and that God seemed to be God, doctor or priest. +In this connection there were ideas of being under the power of +some one, God, devil or father.</p> + +<p>As is usually the case where strong interest is expressed in +the father, ideas of the mother being dead occurred, although +in the frankest form she reported them as dreams; for instance, +one night she woke up screaming, said that she had dreamed that +her mother was dead and her sister dying. That, in the +psychoanalytic sense, this represented a removal of a rival, +making union with her father easy, appeared in the statement +that her father was dead but that she had dreamed he had +come to life again for some one else. When asked what she +meant, the question had to be repeated several times, then she +said "My mother died, my father and mother had a quarrel." +There is more than a suggestion here of a difference in the +significance of death, in so far as it concerned the two parents. +The mother dies and remains dead, that is, she is gotten rid of. +The father dies but takes on a spiritual existence and comes to +life again, a frequent method in psychoses for legitimizing the +idea of union with the parent by elimination of the grossly +physical.</p> + +<p>There were strikingly few allusions to the plainly sexual. She +spoke of being married to the doctor, and even went so far as +to say that they belonged together in bed. On another occasion +she called him "darling." Once she reported that it was said +that she was going to have babies and babies and babies. These +references were, however, quite isolated, so that the erotic formed +a very small part of her productions.</p> + +<p>Delusions of death, we have seen, are the most constant content +of true stupors. In this case they were present but distinctly +in the background. She spoke quite frequently of being in +Heaven. She also talked of being crucified. Once she said "I<!-- Page 162 --><span class='pagenum'><a name="Page_162" id="Page_162">[162]</a></span> +died but I came back again." This last utterance was rather +significant in that frankly accepted ideas of death were unusual; +for instance, she would say sometimes, "I think I am in Heaven, +again not. It confuses me, but I know I am in Heaven."</p> + +<p>In general, then, her ideas were, on the whole, not at all typical +of stupor but much more like those met with in other manic-depressive +conditions. Correlated with this was an unusual mood +picture. Quietness and apparent apathy of the patient were +interrupted by little bursts of emotion, and throughout the +psychosis there was a coloring of perplexity. Not only was this +last objectively noticeable, but she spoke very frequently of it +and always in connection with the inconsistency of the ideas in +her mind which puzzled her. For instance, in speaking to the +doctor she said "I think of you as Bill (her husband's name) +sometimes—I get confused thinking of Bill as God, doctor, lawyer, +priest." Again, referring to her husband, she made these curious +statements: "They seemed to speak of him as being in the +wrong—the right—it seems that the right devil is the wrong one +for me—they say he is not the right one for me; they say he +went wrong from the time we were married." Again, she said +that she did not know who her father was, and went on: "It +puzzles me, this father business, I knew my father at home and +my father in Heaven." Again, "Which God do you mean? Did +you say God or father?" A hint as to how this subjective +confusion made the environment seem uncertain comes from the +statement, "You looked like the devil and yet you were God."</p> + +<p>Distress and anxiety appeared not infrequently and always +appropriately. The distress was usually occasioned by an idea +of injury to others, as when she cried over the fancied accusation +of drowning her husband and mother; or in connection with +accusations of herself, such as when she reported "They called +me a whore." As has been stated, there was never any frank +elation, but an element of pleasurable expansive emotion was +frequently present in connection with her religious utterances. +This came particularly when she spoke of union with her father +as God. She seemed to swell with ecstatic emotion. It was +especially well marked once when she threw herself on the floor +and when asked what she was trying to do replied, "I want to +do what God wants me to do, drop dead or anything at all."<!-- Page 163 --><span class='pagenum'><a name="Page_163" id="Page_163">[163]</a></span> +Perhaps the most unusual affective reaction was a blocking which +occurred when certain topics appeared. This is a phenomenon +quite unusual for stupor, where speech seems to stimulate and +arouse the patient as a rule. One got the impression that ideas +tended to come into this patient's mind which were painful +enough to disturb her capacity for connected thought. A good +example of this reaction was when she was speaking of her +father having died and coming to life again. On being asked +what she meant, she became quite blocked and the question had +to be repeated several times, when finally the apparently unrelated +statements appeared: "I dreamed my mother died—they +had a quarrel." Who had a quarrel? she was asked, and replied +"My mother and father." Apparently her thinking about her +father coming to life for some one not her mother stimulated +deeply unconscious ideas concerning the separation of her mother +and father, and her taking the mother's place, and these ideas +were sufficiently revolutionary to upset her capacity of speech +for the time being.</p> + +<p>She recovered completely about six and a half months after +her admission.</p></div> + +<p>If we consider together the common features of +these three cases, we see that they resemble stupors +only in the presence of inactivity and apparent +apathy. It is true that death appears in the ideational +content but not with that prominence, bordering +on exclusiveness, which characterizes such delusions +in the true stupors. These three patients give +one the impression of being absorbed in thoughts +that have many variations. It seems as if they had +difficulty in grasping the facts of the environment, +while feeling at the same time the vividness of the +changing internal thoughts, hence a confusion develops +which is either subjective, objective, or both.<!-- Page 164 --><span class='pagenum'><a name="Page_164" id="Page_164">[164]</a></span> +It is probably the introversion of attention which +gives rise to the apparent apathy, because normal +emotions emerge as part of our contact with reality +around us. This lack of contact with the environment +leads also to inactivity. If one's attention and +interest is turned inwards, there can be no evidence +of mental energy exhibited until the patient is +roused to contact with the people or things about +him. It is noteworthy that in these cases emotional +expression emerged when the patients were stimulated +to some productiveness in speech.</p> + +<p>These conditions really constitute a different +psychosis in the manic-depressive group, essentially +they are perplexity states such as have recently been +described by Hoch and Kirby.<a name="FNanchor_7_8" id="FNanchor_7_8"></a><a href="#Footnote_7_8" class="fnanchor">[7]</a> Not infrequently +we see exhibitions of this tendency in what are +otherwise typical stupors. For example, Mary F. +(Case 3) (the third case to be described in the first +chapter), showed for a few days after admission a +condition when she was essentially somewhat restless +in a deliberate aimless way. At the same time +she looked dazed or dreamy. With this restlessness +she appeared at times "a little apprehensive." Although +she spoke slowly, with initial difficulty she +answered quite a number of questions. Her larval +perplexity was evidenced by the doubt expressed in +a good many of her utterances, such as, "Have I<!-- Page 165 --><span class='pagenum'><a name="Page_165" id="Page_165">[165]</a></span> +done something?" "Do people want something?" +"I have done damage to the city, didn't I?" When +asked what she had done, she said, "I don't know." +She asked the physician, "Are you my brother?" +and when questioned for her orientation said, "Is +not this a hospital?" The atmosphere of perplexity +also colored the information which she did recall +correctly; for instance, when asked her address, she +said, "Didn't I live at ——?" then giving the +address correctly.</p> + +<p>As stated in Chapter V dealing with the ideational +content of stupor, one has to look on the delusions +of patients as symptoms subject to analysis and +classification just as truly as the variations in mood +or intellectual processes, in fact they should be +subject to the same correlation as are the mental +anomalies which are usually studied, particularly if +we are to understand these psychoses as a whole. +Let us, therefore, consider the death ideas in the +three cases studied in this chapter. We find that, as +in the ordinary stupors, there are delusions of +death, also of mutual death (with the father), but +there is a tendency to elaboration so that the death +is only part of a larger Œdipus drama, the rest of +which is usually lacking in stupors. Here it is present. +So we have thoughts of the death of the mother +or husband, another rival, considerable preoccupation +with Heaven, and also erotic fancies.</p> + +<p>We find in manic-depressive insanity a tendency +for more or less specific ideational contents with dif<!-- Page 166 --><span class='pagenum'><a name="Page_166" id="Page_166">[166]</a></span>ferent +types of the psychoses.<a name="FNanchor_8_9" id="FNanchor_8_9"></a><a href="#Footnote_8_9" class="fnanchor">[8]</a> For example, there +are religious and erotic fancies or ambitious schemes +dominating the thoughts of manic patients, fears of +aggression and injury met with in anxiety cases, and +so on. In stupors, death seems to be a state of +non-existence with other meanings lacking or only +hinted at occasionally. When it tends to be elaborated, +it leads over to formulations suggesting personal +attachments and emotional outlet, and then +we are apt to find interruptions of the pure stupor +picture. For example, Charlotte W. (Case 12), +whose case has been described, thought much about +being in Heaven and ended with a hypomanic state. +Atypical symptoms appear just as constantly in +these cases, as do the atypical ideas. In other +words, the thought content is definitely correlated +with the clinical picture.</p> + +<p>As the clinical pictures show the relationship of +stupor to other psychoses, so there is also a correlation +with varying formulations of the death fancy. +We are now in a position to define more narrowly +what death means in stupor. It is an accepted fact, +a Nirvana state. When death means union with God +or appears in other religious guise, manic symptoms +tend to develop. When it is unwelcome and appears +as "being killed," we find anxiety symptoms. A +patient can conceive of death variously and have<!-- Page 167 --><span class='pagenum'><a name="Page_167" id="Page_167">[167]</a></span> +various clinical pictures. A knowledge of the metamorphoses +of ideas and their relationship to other +symptoms enables us to understand such cases, that, +without this key, seem confused and lawless jumbles +of symptoms. Such theories tend to justify the view +of essential unity of the manic-depressive group.</p> + +<p>It would be instructive at this point to consider +another case which illustrates beautifully how a +stupor reaction may crystallize out of other manic-depressive +states when attention has become focused +on personal death. This patient went +through four phases while under observation. First, +while showing a perplexed expression but with fair +orientation, she gave utterance to erotic and expansive +fancies. She was restless, somewhat intractable +and gave the impression of brooding over her imaginations +rather than luxuriating in them. In other +words, her condition seemed to be more that of absorbed +than active mania. Second, these same ideas, +somewhat reduced, continued in an apathetic state +while impulsive symptoms developed: She began +to shout like a huckster to be taken to Heaven and +made numerous affectless, suicidal attempts. Third, +came a true stupor and, fourth, a period of recovery +when the stupor symptoms all disappeared but insight +into the falsity of her ideas was lacking.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 19.</span>—<i>Celia H.</i> Age: 19. Admitted to the Psychiatric +Institute October 22, 1913.</p> + +<p><i>F. H.</i> The father was living; he always drank, and especially +in later years contributed little to the support of the family.<!-- Page 168 --><span class='pagenum'><a name="Page_168" id="Page_168">[168]</a></span> +The mother was living and said to be normal, while a brother +was coincidentally insane, with a recoverable psychosis.</p> + +<p><i>P. H.</i> The mother stated that the patient was bright at school, +enjoyed company and going out, had a droll wit, was not at all +seclusive, no dreamer, helped to support the family and was +efficient. She was very much attached to her brother and once +said that if anything should ever happen to him she thought she +would die. She also cared much for her older sister, with whom +she worked, and for her mother.</p> + +<p>Three months before the patient's admission her brother became +depressed, mute, seemed worried, cried at times. He was sent +to the country. Two months before admission, when the mother +and the patient went to bring the brother to town, and while +they were at the station, he suddenly tried to throw himself under +a train but was restrained just in time. The patient appeared +intensely frightened, but did not talk. In fact, she seemed somewhat +bewildered and at once became dull. "Her movement and +manner were much as at present."</p> + +<p>When the patient was able later to give a retrospective account +of the onset, she claimed that for some months before this +incident she saw that her brother was losing his mind. She +worried about this as well as about her work, and felt worn out. +She said that when the brother tried to throw himself under the +train she was terrified and could not speak or move, and that her +mind got upset at once, "I lost my memory." The others forgot +her and left her alone on the platform. Strangers put her on +another train and she knew nothing until she arrived at home.</p> + +<p>The mother added that at the time when the incident with the +brother happened, the patient was menstruating and that this +ceased at once.</p> + +<p>At home she sat about inactive and did not seem even to worry. +Whenever any one asked her about her brother she replied that +he was dead. For two weeks before admission she said she was +rich, that she owned all the property around. She also said she +was married to Mattie S. In this connection the mother says +that a foolish neighborwoman, the mother of Mattie S., told the +patient since her sickness, by way of encouragement, that she +should marry her son (the man mentioned). Finally, the patient<!-- Page 169 --><span class='pagenum'><a name="Page_169" id="Page_169">[169]</a></span> +also expressed the idea that her mother was a stranger, that her +real mother was dead.</p> + +<p>At the <i>Observation Pavilion</i> she was described as wandering +about in a perplexed manner, restless, resistive, answering few +questions and in a low tone. She said things were "changed," +also that she was married to S.</p> + +<p><i>Under Observation:</i> 1. For about ten days the patient's condition +may be described as follows: The most striking feature +was a certain restlessness with insistence on going out, with +complaints that this and that had been done to her and with +senseless struggling when interfered with. But all the motions +were slow, the whole restlessness aimless and impulsive. Although +the facial expression was somewhat perplexed, it changed remarkably +little, and whenever asked whether she felt worried or +anxious she denied it, and, indeed, there was only a suggestion +of perplexity in her face.</p> + +<p>The ideas which she expressed during this time referred to +a few topics only, namely, marriage, wealth, and State prison. +The remarkable fact was that all the ideas about marriage and +wealth were spoken of, often immediately, again after some +interval, now in the positive and again in the negative sense. +Thus she said she was "Mrs. S.," again "You kept me from +marrying Mattie S.," or "I am not supposed to be here—I am +a married person," but also "You kept me from getting married." +Or, "Take off that black dress, I am a bride," again "You have +taken my bridal crown off my head," "The steamboats (seen +from the window) are mine—I own the ships, the oceans, the land +and everything," or again, she said she owned a kingdom, was +Sh.'s wife, a wealthy woman, had millions. Sometimes she +connected the millions with Sh. "Sh. has millions." On the +other hand, she said: "I owned all this before I came. I have +nothing now," or "You have taken the regal crown from me," +"You have made a pauper of me," "They did it again, they took +my millions away," or "Let me out, they are taking my millions."</p> + +<p>Other ideas throughout this period were that this was a State +prison, that "bums" were around. On one occasion she said +"You can't put down all these things and make me out a lunatic." +At another time she pulled a patient's hair and then said without +fun: "I fixed the leading lady of the dump—she knows a lot,<!-- Page 170 --><span class='pagenum'><a name="Page_170" id="Page_170">[170]</a></span> +but she does not know enough to keep her soup cool." When +questioned about this woman (who at the time while cleaning had +moved the furniture), she said: "I don't know where I am at."</p> + +<p>The orientation during these days was not markedly disordered, +when one got down to it. Although she spoke of State prison, it +was always found she knew the name and the location of the +hospital, the names of people around her, even the date approximately, +though she was apt to say it was February 19, 1492, or +October 19, 1492, or when the year was not given as 1492 she +said it was "1900 or 1901, or 1911 or 1912." Frequently, however, +it was hard to hold her attention.</p> + +<p>Finally, it should be mentioned that she very often wet herself +in bed or when standing, even when standing in the examining +room.</p> + +<p>2. The period following and lasting for two months may be +given in the form of abstracts of each note.</p> + +<p><i>November 7:</i> Yesterday quiet, though struggling. Says without +change of expression, "I saw four people killed—my mother, +my brother, a priest, and my dear sister—we were all killed." +Again, "I don't know where I am," "I am an orphan, my people +died" (without affect).</p> + +<p><i>November 20:</i> More quiet recently, says little, but tries to get +out when brought to the examining room, but when not prevented +walks slowly about as before, says she wants to go home. Looks +peculiarly blank.</p> + +<p><i>November 23:</i> Has remained quiet, says she is Dr. M.'s wife. +But when told she is not married, she agrees. Her attitude towards +the doctor is not changed, but when the nurses talk to him, +she has tried to prevent it.</p> + +<p><i>December 6:</i> Has remained quietly in bed, gazing about. +Slow in motion. She has spoken of being Dr. M.'s wife, again +President Wilson's wife, again "Vincent (brother) is the ruler +of the world."</p> + +<p>At interview says little, seems abstracted, answers briefly in +low tone. (Does anything bother you?) "No." (Are you natural?) +"Yes." (Who are you?) "C. H." (correct). (You +said you were the President's wife?) "No." (Are you married?) +"No." (You talked about the kingdom?) "I own the kingdom" +(affectlessly). (Where is Vincent?) "Here." (Have you heard<!-- Page 171 --><span class='pagenum'><a name="Page_171" id="Page_171">[171]</a></span> +him?) "Yes." (What did he say?) "Nothing." (Is he all +right?) "Yes." (Where is your mother?) "Home." (Why +don't you go home?) "I can't." (Why not?) "I can't." (Why +not?) "The family tree is broken, the Cardinal." (What about +him?) "Nothing." (Retrospectively she said later she thought +her brother was a cardinal.)</p> + +<p><i>December 8:</i> When her mother visited her she said "It is +about time you come—I thought you were dead." Has walked +down the hall "looking" for her dead cousin. When asked if she +wanted to see her brother, said, "Ain't he dead?"</p> + +<p><i>December 12:</i> Cries out in an affectless tone like a huckster, +"Father MacN., take me to Heaven," repeating this over and over.</p> + +<p><i>December 15:</i> Quiet as a rule, then for a time at the door, +pulling at it and with whining voice but affectlessly saying "Give +me the key—I want to go to the river—you can't keep me from +Heaven—it is either Heaven or the river, give me the keys, give +me the keys, open the door," "The niggers are taking possession." +To the physician to whom she had claimed to be married, often +repeats "You don't belong to me, I don't belong to you." (What +about the niggers?) "A band of niggers, that is all they are." +(Are the nurses niggers?) "That is all they are." Asked about +her people, she says "They are in Heaven." (Where are you?) +"I am in Heaven" (without change of expression). Again, when +asked where her people are, says "At home." Then she went +willingly back to bed and was quiet. In the afternoon she again +went to the door and tried to get out. When questioned, she +said "I don't want to be an animal," "Everybody is making an +animal of me" (pointing to an animal picture). Then again, +while trying the door, repeats in the same affectless manner that +she wants to go "to the river," "to the bottom of the river," "to +Heaven to see my mother." This last was said in a whining +tone, with some tears. She kept turning the knob, tried to get +the keys, and struggled impulsively when prevented.</p> + +<p><i>December 23:</i> Though quiet on the whole, when a visitor came +yesterday, she ran after this woman saying "I want my generations," +and clung to her, and to-day at intervals keeps talking +about wanting to see her generations but is often quiet. (Retrospectively +she said she wanted to see all her ancestors from the +beginning of time.)</p> + +<p><!-- Page 172 --><span class='pagenum'><a name="Page_172" id="Page_172">[172]</a></span> +<i>December 27:</i> Of late often talks affectlessly about wanting +to die or wanting to go to Heaven, struggling impulsively to get +medicine away from the nurses, asking for poison, trying to drink +her own urine, or even the fluid in the bed pan after she had been +given an enema, all evidently with suicidal intent.</p> + +<p><i>December 28:</i> Still constant, impulsive and apparently affectless +attempts at suicide, tries to get medicine away from nurses, +to get the fire extinguisher bottles, a bottle of ink, etc., struggling +when prevented.</p> + +<p>But when examined quiet, even smiles at a joke. When questioned, +denies feeling either worried or depressed. She said she +wanted to go home. She gave poor attention to the questions. +Later she threw a wet sheet over a patient and laughed (this is +rare). Later she slapped another patient. Again she began to +talk about wishing to go to the grave. Calls Dr. M. "Uncle John."</p> + +<p><i>December 30:</i> Talks either about wanting to die, or wanting +to go to Heaven, or wanting to go to Ireland, all this as usual +in an affectless way. Calls Dr. M. "Uncle John." Keeps shouting +"Take me to Ireland."</p> + +<p><i>January 9, 1914:</i> Often quiet in bed, again goes to door, +talks about wanting to go "to Heaven" or "to Ireland." On the +whole, says little.</p> + +<p>It seems, then, that the transition was not abrupt, that many +traits of the first period remained, but that she was on the whole +much quieter, with the exception of some spells when she insisted +on going out or killing herself. At such times she showed an +affectless, impulsive excitement. Whether there was an element +of perplexity then is not clear from the notes. The topics of +which she spoke also changed. The idea of wealth was rarely +expressed, also the idea of marriage was much in the background, +but prominent ideas were those of death, Heaven, killing herself, +going to Ireland—all of which she produced in an affectless way. +It should be added that she persistently wet and soiled during +this, as well as in the first period.</p> + +<p>3. Then followed three months of greater inactivity. She lay +in bed gazing, moving very little, not even when her meals were +brought. She answered but little and consistently wet and soiled. +This state lasted from about the middle of February until the +beginning of April.</p> + +<p><!-- Page 173 --><span class='pagenum'><a name="Page_173" id="Page_173">[173]</a></span> +4. From this stuporous state she emerged during the next +four weeks, the awakening being associated with persistent efforts +to arouse her. She then was, for six or seven weeks, nearly +normal, so far as her mood went, but had a tendency to cling to +some of her ideas and was overtalkative. Her memory for the +earlier phases of the psychosis was good, as she recalled not only +many external events but most of her false ideas. She said, +however, that her mind had been a blank for the third stage and +she remembered nothing of it. At the end of this time she cleared +up entirely and was discharged as "recovered." She continued +well for some months, during which she was occasionally examined.</p></div> + +<p>This case gives an excellent example of the relationship +of stupor to other manic-depressive reactions. +She begins with an absorbed state, showing +elements of perplexity and mania. With this there +are expansive ideas but, also, statements about +losing everything and being in prison, which suggest +abandonment of life. Next, with increasing +apathy, she begins to speak of death and soon makes +impulsive suicidal attempts. Evidently her mind +was becoming more and more focused on death and +with this there was an appropriate emotional +change. She was either apathetic or the affect exhibited +itself in pure impulsiveness. Then comes +the stupor, when all ideas disappear and mentation +is reduced or absent. When the stupor lifts, the +original ideas appear not only in memory but occasion +a wavering insight. It is appropriate that +she recalled all of her psychosis fairly well with the +exception of the pure stupor, which she remembered +only as a time when her mind was a blank.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_7_8" id="Footnote_7_8"></a><a href="#FNanchor_7_8"><span class="label">[7]</span></a> Hoch, August, and Kirby, George H.: "A Clinical Study of +Psychoses Characterized by Distressed Perplexity." <cite>Archives of +Neurology and Psychiatry</cite>, April, 1919, Vol. I, pp. 415-458.</p></div> + +<div class="footnote"><p><a name="Footnote_8_9" id="Footnote_8_9"></a><a href="#FNanchor_8_9"><span class="label">[8]</span></a> Hoch, August: "A Study of the Benign Psychoses." <cite>Johns +Hopkins Hospital Bulletin</cite>, May, 1915, XXVI, 165.</p> + +<p>A book on "the psychology of manic-depressive insanity" will +shortly appear by the editor.</p></div> +</div> + +<p><!-- Page 174 --><span class='pagenum'><a name="Page_174" id="Page_174">[174]</a></span></p> + +<h2>CHAPTER IX<br /> +<span class="sm">THE PHYSICAL MANIFESTATIONS OF STUPOR</span></h2> + +<p>We must now discuss the most difficult of all the +aspects of the stupor problem. The subject is so +involved and the evidence so inconclusive that observers +will probably interpret the phenomena here +reported according to their individual preconceptions. +What we have to say is therefore published +not so much to convince as to stimulate further +work. The problem is wider than that of the mere +etiology of the stupors we are considering. Their +relationship to manic-depressive insanity is so intimate +that we must tentatively consider this affectless +reaction as belonging to that larger group. A +discussion of the basic pathology of manic-depressive +insanity is outside the sphere of this book. The +author, therefore, thinks it advisable to state somewhat +dogmatically his view, as to the etiology of +these affective reactions, merely as a starting point +for the argument concerning stupors specifically.</p> + +<p>It is our view that the manic-depressive psychoses +may be, and probably are, determined remotely but +fundamentally by an inherent neuropsychic defect, +but this physical and constitutional blemish is non-specific. +The actual psychosis is determined by<!-- Page 175 --><span class='pagenum'><a name="Page_175" id="Page_175">[175]</a></span> +functional, that is, psychological factors. A predisposed +individual exposed to a certain psychic stress +develops a manic-depressive psychosis. Naturally +any physical disease reduces the capacity for normal +response to mental difficulties; hence physical +illness may facilitate the production of a psychosis. +But this intercurrent factor is also non-specific.</p> + +<p>Such is our view of the etiology of manic-depressive +insanity as a whole. When we approach the +study of benign stupors, however, difficult problems +appear. As will be discussed in a later chapter on +the literature, reactions resembling benign stupors +occur as a result of toxins, particularly following +acute rheumatism. Recently the medical profession +has been called on to treat many cases of encephalitis +lethargica where similar symptoms are observed. +If the resemblance amounted to identity, we would +have to admit that a specific toxin may produce a +specific mental reaction which we have concluded on +other grounds to be psychogenic. As a matter of fact, +in two particulars these reactions show relationship +to organic delirium. Knauer reports that in post-rheumatic +stupors illusions are frequent—an ice +bag thought to be a cannon, or a child, etc.—and +there are bizarre misinterpretations of the physical +condition, such as lying on glass splinters, animals +crawling on the body, and so on. Such illusions are, +in our experience, not found in stupor, and, on the +other hand, are cardinal symptoms of delirium. +Further, Knauer reports that even at the height of +post-rheumatic stupor, external stimuli make some<!-- Page 176 --><span class='pagenum'><a name="Page_176" id="Page_176">[176]</a></span> +impression, in that a thoughtful facial expression +appears. In deep stupors, such as occurred in our +series, this response is not seen. The same phenomenon +of "rousing," larval in Knauer's cases, +is often well marked in encephalitis lethargica and +is, of course, a pathognomonic symptom of delirium. +We might therefore think that these conditions are +mixtures of two organic tendencies, namely, delirium +and coma. It is not impossible that resemblances +to benign stupor are due to functional elements +appearing in the reduced physical state as +additions to the organic symptoms. The prominence +of pain might be taken as a likely cause for +an instinctive reaction of withdrawal, which would +account for the emotional palsy of these conditions +on psychogenic grounds. [This argument can be +better understood when the chapter on Psychological +Explanation of Stupor has been read.] We therefore +feel justified in holding that the resemblance +of the symptoms of certain plainly organic reactions +to those of benign stupor do not necessitate a splitting +of these stupors from the manic-depressive +group.</p> + +<p>When we consider certain bodily manifestations +of these typical stupors, however, fresh difficulties +are encountered. Unlike depressions, elations and +anxieties, certain physical symptoms appear with +frequency, even regularity. This would seem to indicate +the presence of physical disease. Inasmuch +as the most constant of them is fever, the natural +conclusion would be that we are dealing with an<!-- Page 177 --><span class='pagenum'><a name="Page_177" id="Page_177">[177]</a></span> +infection which produces a mental state called stupor. +If we were not faced with an obvious relationship +to manic-depressive insanity, where such symptoms +are usually accidental and intercurrent, we +would accept this explanation, but this quandary necessitates +further analysis.</p> + +<p>Let us first consider the fever. In 35 cases, on +whom data of temperature could be found from the +records extant, 28 showed fever usually running +between 99° and 100°, often up to 101° or slightly +over this point. When these cases were analyzed, +however, it was found that 27 were typical and 8 +atypical, showing pictures resembling those described +in the last chapter. Of the latter only one +had a rise of temperature, while of the typical group +only one was afebrile. Therefore, since out of 27 +typical cases 26 had the typical slight fever, we must +conclude it to be a highly specific symptom. Of +these 28 cases the incidence of the fever was as follows: +8 showed it only on admission; in 7 it was +highest on admission but continued at a low rate +throughout the rest of the psychosis; in 5 it extended +without much variation throughout the psychosis; +in 4 it appeared intermittently, while in 2 it was +accentuated during periods when the mental symptoms +were most pronounced. We see, then, that +there is a distinct tendency for the fever to be associated +with the onset of the disease.</p> + +<p>When we look for other data from which we might +discover causes for the fever, we find less than we +would like. The records are of observations made,<!-- Page 178 --><span class='pagenum'><a name="Page_178" id="Page_178">[178]</a></span> +some of them, twenty years ago. Although the +mental examinations were careful, the records of the +physical symptoms either were not made or were +lost in many cases. Consequently our description +must be tentative and is published merely to stimulate +further research as cases come to the attention +of psychiatrists.</p> + +<p>One looks, first, for other evidence of infection. +Some of the cases were thoroughly examined with +modern methods and nothing whatever found. +Blood examinations were made in five cases; three +of these had rather high temperature with the following +blood pictures: Charles O., 103°, leucocytosis +of 23,000, with 91.5% polymorphonuclears; Annie G. +(Case 1), 103°, leucocytosis of 12,000 to 15,000, and +89% polymorphonuclears; Caroline DeS. (Case 2), +104°, 15,000 leucocytes, no differential made, Widal +and diazo reaction negative. These three cases, +then, had marked febrile reactions and leucocytosis. +It is quite possible that they had infections which +were not discovered. Of the other two Rosie K. +(Case 11) had a temperature of 100° and 17,500 +leucocytes associated with a fetid diarrhea, an unquestioned +infection, while Mary C. (Case 7), with +a temperature of only 100°, had no rise in number +of total white cells but 41% of lymphocytes. This +last might be due to an internal secretion or an involuntary +nervous system anomaly. The possibility +of the three high temperatures with leucocytosis +being due to intercurrent infections must be +considered. Charles O. had high fever only for ten<!-- Page 179 --><span class='pagenum'><a name="Page_179" id="Page_179">[179]</a></span> +days during a psychosis of several months. Annie +G.'s high fever was of about the same duration. +Caroline DeS. had short periods of marked pyrexia +in the first and seventh months of her long psychosis. +Except for these episodes, these three patients +had the typical slight elevation of temperature. +Three cases out of thirty-five, in which high fever and +leucocytosis appeared episodically, are hardly +enough to justify the view that stupors are the result +of a specific infection. We must remember, too, that +no focal neurological symptoms are ever observed, +which makes the possibility of a central nervous +system infection highly unlikely.</p> + +<p>An alternative view might be that the slight rise +of fever is somehow the result of stupor, not the +cause of it. The editor consulted Professor Charles +R. Stockard, of Cornell Medical College, as to this +possibility. The following argument is the result +of his suggestions:</p> + +<p>What we call a normal temperature is, of course, +the result of a balance maintained between heat production +and heat loss. Either an increase in the +former or a decrease in the latter must produce +fever. It is possible that heat production may be +increased in many stupors as a result of the muscular +rigidity. Some cases showed higher temperature +when this was more marked, but this was not +sufficiently constant to justify any conclusions being +drawn.</p> + +<p>Heat loss occurs preponderantly as a result of radiation +from the skin and by sweating with conse<!-- Page 180 --><span class='pagenum'><a name="Page_180" id="Page_180">[180]</a></span>quent +evaporation of the secretion. These processes +are functions of the skin and surface circulation. +Are they disturbed in our stupors? We find considerable +evidence that they are. Flushing or dermatographia +occurred in six cases, cold or blue +extremities in four cases, greasy skin in four, +marked sweating in three, the hair fell out in two +cases, while the skin was pathologically dry in one +case, in fact there were few patients who showed +normal skin function. Circulatory anomalies were +also observed. The pulse was very rapid in eleven +cases, weak or irregular in two, and slow in one +case. All these symptoms are expressions of imbalance +in the involuntary nervous system, further +evidence of which is found in the rapid respiration +of six cases and the shallow breathing of one patient. +These pulse and respiration findings are the more +striking in that individuals in stupor are, by the +very nature of their disease, free from emotional +excitement.</p> + +<p>This imbalance could result from a poverty of circulating +adrenalin which is necessary for the activation +of the sympathetic nerves. A cause for low +suprarenal function is to be found in the apathy of +the stupor case. As Cannon and his associates have +so conclusively demonstrated, any emotion which +was open to investigation resulted in an increase of +adrenalin output. As our emotions are constantly +operating during the day—and often enough during +sleep as well in connection with dreams—we must +presume that emotional stimulus is a normal excitant<!-- Page 181 --><span class='pagenum'><a name="Page_181" id="Page_181">[181]</a></span> +for the production of adrenalin. It is therefore inconceivable +that the blood could receive its normal +supply of adrenalin with an apathy of the degree +seen in stupor unless some purely hypothetically +substitutive excitant were found.</p> + +<p>We may therefore tentatively assume that the +fever which marks the onset and frequently the +course of these benign stupors is the result of a +failure of the heat loss function, this being due to +an imbalance in the involuntary nervous system that +is occasioned, in turn, by insufficient circulating adrenalin, +and the final cause for the poor suprarenal +function is to be traced to the most consistent symptom +of the stupor, namely, apathy. This hypothesis +is welcome, not only because it would account adequately +for the fever, but it also tends to accentuate +the relationship with other forms of manic-depressive +insanity, all of which are marked fundamentally +by a pathological emotion. Naturally +enough, one turns to the records again to see if the +blood-pressure of these patients was low, as would +be expected with a poor adrenalin supply. Unfortunately +record was made of the blood-pressure +in only two cases, in both of which the reading was +110 m.m. Two such isolated observations mean, of +course, nothing whatever. It is possible that the +drooling which so many stupor cases show is not +merely the result of the failure of the swallowing +reflex, but represents as well a compensation for +anhydrosis by excessive salivary secretion.</p> + +<p>Another symptom suggestive of involuntary ner<!-- Page 182 --><span class='pagenum'><a name="Page_182" id="Page_182">[182]</a></span>vous +system or endocrine disorder is the highly frequent +suppression of the menstrual function. At +times this may occur as a sequel to mental shock, +as it did in the case of Celia H. (Case 19), who was +menstruating when, frightened by the suicidal attempt +of her brother, the flow ceased abruptly. +That purely psychic factors can produce marked +changes in such functions has been demonstrated by +Forel and other hypnotists time and again; presumably +the effect is produced by way of alteration in +the endocrine or involuntary nervous system influence. +In such cases, however, we can trace the menstrual +suppression directly to an emotional cause. +On the other hand, most women in stupor fail to +menstruate during the bulk of the psychosis at a time +when we believe emotions to be absent or greatly reduced +in their intensity. The recent work of Papanicolaou +and Stockard<a name="FNanchor_9_10" id="FNanchor_9_10"></a><a href="#Footnote_9_10" class="fnanchor">[9]</a> offers a simple explanation +for this phenomenon. They have shown that +in the guinea pig the œstrous cycle can be delayed +by starvation, while in weaker animals a period may +be suppressed completely. When one considers that +even with the greatest care the nutrition of tube-fed +patients is bound to be poor, it would be only +natural to suppose that this malnutrition would +cause such a disturbance in the œstrous cycle and +was evidenced objectively by a failure to menstru<!-- Page 183 --><span class='pagenum'><a name="Page_183" id="Page_183">[183]</a></span>ate. +Even in patients who are not tube-fed, under-nutrition +is to be expected and, as a matter of fact, is +usually observed. The work of Pawlow and Cannon +has shown how essential psychic stimulus is for gastric +digestion. Any condition of apathy would +therefore tend to retard digestion and indirectly affect +nutrition.</p> + +<p>Finally, under the heading of Physical Manifestations +of Stupor, we must consider epileptoid attacks, +of which there was a history in two of our cases, +both of which have already been described in the +first chapter of this book. Anna G. (Case 1), in her +second attack, was treated at another hospital, and +from the account which they sent it appears that +the stupor was immediately preceded by a seizure +in which the whole body jerked. This is, of course, +rather thin evidence of the existence of a definite +convulsion, but in the case of Mary F. (Case 3) we +have a fuller description. During the two days +when the stupor was incubating, she had repeated +seizures of the following nature. She sometimes +said that prior to the attacks it became dark before +her eyes and that her face felt funny or that she had +a pain in the stomach which worked toward her right +shoulder. The attack would begin when sitting in +a chair, with the closing of her eyes, clenching her +fists and pounding the side of the chair. She would +then get stiff and slide on to the floor, where she +would thrash her arms and legs about and move her +head to and fro. The warning of the pain working +from the stomach to the right shoulder is highly<!-- Page 184 --><span class='pagenum'><a name="Page_184" id="Page_184">[184]</a></span> +suggestive of an epileptic aura, although the other +symptoms mentioned so far could have been considered +hysterical or poorly described epileptic phenomena. +The rest of the description indicates an +epileptic seizure more strongly. She frothed at the +mouth and once wet herself during an attack. They +lasted only for a few minutes and she would breathe +heavily after them. At the end of one attack she +wiped the froth from her mouth with her handkerchief +and gave it to her aunt, saying, "Burn that, it +is poison." This is perhaps a little less like epilepsy. +It is plainly impossible for us to say with +any positiveness that either these were or were not +genuine convulsions, but it is nevertheless important +to record them, because such phenomena are observed +fairly frequently in dementia præcox cases +but are practically unknown in manic-depressive insanity. +This, then, would be another example of +the resemblance to dementia præcox in these stupors +which are unquestionably benign.<a name="FNanchor_10_11" id="FNanchor_10_11"></a><a href="#Footnote_10_11" class="fnanchor">[10]</a></p> + +<p><!-- Page 185 --><span class='pagenum'><a name="Page_185" id="Page_185">[185]</a></span> +We see, then, in reviewing all the physical manifestations +of the benign stupors, that none occurred +which cannot be explained as secondary to the mental +changes, and therefore, until such time as physical +symptoms are reported which cannot be so explained, +we see no reason for changing our view +that the benign stupor is to be regarded as one of +the manic-depressive reactions.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_9_10" id="Footnote_9_10"></a><a href="#FNanchor_9_10"><span class="label">[9]</span></a> Papanicolaou, G. N., and Stockard, C. R., "Effect of Under-feeding +on Ovulation and the Œstrous Rhythm in Guinea-pigs." +<cite>Proceedings of the Society of Experimental Biology and Medicine</cite>, +Vol. XVII, No. 7, Apr. 21, 1920.</p></div> + +<div class="footnote"><p><a name="Footnote_10_11" id="Footnote_10_11"></a><a href="#FNanchor_10_11"><span class="label">[10]</span></a> As a matter of fact, if the views of Clark and MacCurdy<a name="FNanchor_B_12" id="FNanchor_B_12"></a><a href="#Footnote_B_12" class="fnanchor">[B]</a> be +accepted, some reason for these epileptic-like attacks may be imagined. +According to them, epilepsy is a disease characterized by a +lack of the natural instinctive interest in the environment which +is expressed chronically in the deterioration, and episodically in +the attacks, the most consistent feature of which is loss of consciousness. +Now, in stupor we have an analogous reaction where, +although consciousness is not disturbed in the sense in which it is +in epilepsy, it is nevertheless considerably affected, inasmuch as +contact with the environment is practically non-existent. The coincident +thinking disorder is quite similar, both in epileptic dementia +and the torpor following seizures and in these benign stupors. MacCurdy +has suggested tentatively that the epileptic convulsion may +be secondary to a very sudden loss of consciousness which removes +a normal inhibition on the muscles, liberating the muscular contractions +which constitute the convulsion. If this view were correct, +it would not be hard to imagine that during the onset of these +stupors the tendency to part company with the environment, which +ordinarily comes on slowly, might occur with epileptic suddenness +and hence liberate convulsive movements. This is, however, a pure +speculation but not fruitless if it serves to draw attention to the +analogies existing between the stupor reaction and some of the mental +symptoms of epilepsy. These analogies are strong; aside from +the obvious clinical differences, the stupor and epileptic reactions +are dynamically unlike in that they are the product of different +temperaments and precipitated by different situations.</p></div> + +<div class="footnote"><p><a name="Footnote_B_12" id="Footnote_B_12"></a><a href="#FNanchor_B_12"><span class="label">[B]</span></a> Clark, L. Pierce. "Is Essential Epilepsy a Life Reaction Disorder?" +<cite>Am. Jour. of the Medical Sciences</cite>, November, 1910, Vol. +CLVIII, No. 5, p. 703. This paper gives a summary of Dr. Clark's +theories.</p> + +<p>MacCurdy, John T., "A Clinical Study of Epileptic Deterioration." +<cite>Psychiatric Bulletin</cite>, April, 1916.</p></div> +</div> + +<p><!-- Page 186 --><span class='pagenum'><a name="Page_186" id="Page_186">[186]</a></span></p> + +<h2>CHAPTER X<br /> + +<span class="sm">PSYCHOLOGICAL EXPLANATION OF THE STUPOR +REACTION</span></h2> + +<p>In the previous chapter mention has been made +of our view that manic-depressive insanity is a +disease fundamentally based on some constitutional +defect, presumably physical, but that its +symptoms are determined by psychological mechanisms. +In accordance with this hypothesis we seek, +when studying the different forms of insanity presented +in this group, to differentiate between the +different types of mental mechanisms observed, and +by this analysis to account for the manifestations of +the disease on purely psychological lines. If benign +stupors belong to this group, then we should +be able to find some specific psychology for this type +of reaction.</p> + +<p>All speech and all conduct, except simple reflex behavior, +are presumably determined by ideas. When +an individual is not aware of the purpose governing +his action, we assume, in psychological study, that an +unconscious motive is present, so that in either case +the first step in psychological understanding of any +normal or abnormal condition is to discover, if +possible, what the ideas are that lead to the actions<!-- Page 187 --><span class='pagenum'><a name="Page_187" id="Page_187">[187]</a></span> +or utterances observed. In the case of stupors the +situation is fairly simple, in that the ideational content +is extremely limited. As has been seen, it is +confined to death and rebirth fancies, other ideas being +correlated with secondary symptoms, such as +belong to mechanisms of other manic-depressive +psychoses. It is not necessary to repeat the catalogue +of the typical stupor ideas, as they have been +given in an earlier chapter. Our task is now to +consider the significance of these death and rebirth +delusions and their meaning for the stupor reaction.</p> + +<p>Thoughts concerned with future and new activities +require energy for their completion in action and +are therefore naturally accompanied by a sense of +effort which gives pleasure to an active mind. When +the sum of energy is reduced, one observes a reverse +tendency called "regression." It is easier to +go back over the way we know than to go forward, +so the weakened individual tends to direct his attention +to earlier actions or situations. To meet a +new experience one must think logically and keep +his attention on things as they are, rather than imagine +things as one would like to have them.</p> + +<p>Progressive thinking is therefore adaptive, while +regressive thinking is fantastic in type, as well as +concerned with the past—a past which in fancy takes +on the luster of the Golden Age. Sanity and insanity +are, roughly speaking, states where progressive +or regressive thinking rule. The essence of a +functional psychosis is a flight from reality to a retreat +of easeful unreality.</p> + +<p><!-- Page 188 --><span class='pagenum'><a name="Page_188" id="Page_188">[188]</a></span></p><p>Carried to the extreme, regression leads one in +type of thinking and in ideas back to childhood and +earliest infancy. The final goal is a state of mental +vacuity such as probably characterizes the infant at +the time of birth and during the first days of extra-uterine +life. In this state what interest there is, +is directed entirely to the physical comfort of the +individual himself, and contact with the environment +is so undeveloped that efforts to obtain from it the +primitive wants of warmth and nutrition are confined +to vague instinctive cries. Evolution to true +contact with the world around implies effort, the +exercise of self-control, and also self-sacrifice, since +the child soon learns that some kind of <i lang="la">quid pro quo</i> +must be given. Viewed from the adult standpoint, +the emptiness of this early mental state must seem +like the Nirvana of death. At least death is the +only simple term we can use to represent such a complete +loss of our habitual mental functions. When +life is difficult, we naturally tend to seek death. +Were it not for the powerful instinct of self-preservation, +suicide would probably be the universal mode +of solving our problems. As it is, we reach a compromise, +such as that of sleep, in which contact with +reality is temporarily abandoned. In so far as sleep +is psychologically determined, it is a regressive phenomenon. +It is interesting that the most frequent +euphemism or metaphor for death is sleep. Sleep +is a normal regression. It does not always give the +unstable individual sufficient relaxation from the demands +of adaptation and so pathological regressions<!-- Page 189 --><span class='pagenum'><a name="Page_189" id="Page_189">[189]</a></span> +take place, one of which we believe stupor to be. +It is important to note that objectively the resemblance +between sleep and stupor is striking. So far +as mental activity in either state can be discovered +by the observer, either the sleeper or the patient in +stupor might be dead. Briefly stated, then, our hypothesis +of the psychological determination of stupor +is that the abnormal individual turns to it as a +release from mental anguish, just as the normal +human being seeks relief in his bed from physical +and mental fatigue. When this desire for refuge +takes the shape of a formulated idea, there are delusions +of death.</p> + +<p>The problem of sleep is, of course, bound up with +the physiology of rest, and as recuperation, in a +physical sense, necessitates temporary cessation of +function, so in the mental sphere we see that relaxation +is necessary if our mental operations are to be +carried on with continued success. This is probably +the teleological meaning of sleep in its psychological +aspects, for in it we abandon diurnal adaptive +thinking and retire to a world of fancy, very often +solving our problems by "sleeping over them." +The innate desire for rest and a fresh start is almost +as fundamental a human craving as is the tendency +to seek release in death. In fact the two are +closely associated both in literature and in daily +speech, for in many phases we correlate death with +new life. If one is to visualize or incorporate the +conception of new life in one term, rebirth is the +only one which will do it, just as death is the only<!-- Page 190 --><span class='pagenum'><a name="Page_190" id="Page_190">[190]</a></span> +word which epitomizes the idea of complete cessation +of effort. Not unnaturally, therefore, we find in +the mythology of our race, in our dreams and in the +speech of our insane patients, a frequent correlation +of these two ideas, whether it comes in the crude +imagery of physical rebirth or projected in fantasies +of destruction and rebuilding of the world. +Many of our psychotic patients achieve in fancy that +for which the Persian poet yearned:</p> + +<div class="poem"><div class="stanza"> +<span class="i0">"Ah Love! could you and I with Him conspire<br /></span> +<span class="i1">To grasp this Sorry Scheme of Things entire,<br /></span> +<span class="i1">Would we not shatter it to bits—and then<br /></span> +<span class="i1">Re-mold it nearer to the Heart's Desire!"<br /></span> +</div></div> + +<p>A vision of a new world is a content occurring not +infrequently in manic states, but before the universe +can be remolded it must be destroyed. Before the +individual can enjoy new life, a new birth, he must +die, and stupor often marks this death phase of a +dominant rebirth fantasy. In this connection it +was not without significance to note that stupors +almost universally recover by way of attenuation +of the stupor symptoms, or in a hypomanic phase +where there seems to be an abnormal supply of energy. +Antæus-like, they rise with fresh vigor from +the Earth. They do not pass into depressions or +anxieties.</p> + +<p>Rebirth fancies unquestionably, then, contain +constructive and progressive elements, but, as has +been stated above, any thinking which implies a +lapse of contact with the environment is, in so far<!-- Page 191 --><span class='pagenum'><a name="Page_191" id="Page_191">[191]</a></span> +as that lapse is concerned, regressive, and in consequence +rebirth fancies, as dramatized by the stupor +patients, are regressive, just as are the delusions +of death itself.</p> + +<p>It is obvious that an acceptance of death implies +rather thorough mental disintegration. Before that +takes place there may be some mental conflict. The +instinct of self-preservation may prevent the individual +from welcoming the notion of dissolution, so +that this latter idea, though insistent, is not accepted +but reacted to with anxiety; hence we often meet +with onsets of stupor characterized by emotional +distress. It has already been suggested that death +may foreshadow another existence. Often in the +psychoses we meet with the idea of eternal union +in death with some loved one whom the vicissitudes +and restrictions of this life prevent from becoming +an earthly partner. This fancy is frequently the +basis of elation. Similarly, new life in a religious +sense as expressed in the delusion of translation to +Heaven, is a common occasion for ecstasy. These +formulations of the death idea may occur as tentative +solutions of the patient's problems leading to +temporary manic episodes while the psychosis is incubating. +It seems that stupor as such appears +only when death and nullity are accepted.</p> + +<p>The above are more or less a priori reasons for +regarding the stupor as a regressive reaction. We +must now consider the clinical evidence to support +this view. In the first place, we always find that +stupor occurs in an individual who is unhappy and<!-- Page 192 --><span class='pagenum'><a name="Page_192" id="Page_192">[192]</a></span> +who has found no other solution than regression +for the predicament in which he is. There is nothing +specific in the cause of this unhappiness. At +times the factors producing it are mainly environmental; +at others, the problem is essentially of the +patient's own making. Of course almost any type +of functional psychosis may emerge from such a +state of dissatisfaction, but it is important to note +that unlike manic states, for instance, stupors invariably +develop from a situation of unhappiness. +Quite frequently the choice of the stupor regression +is determined by some definitely environmental event +which suggests death. This often comes as the actual +death of the patient's father (in the case +of a woman) or employer, events which inflate the +already existing, although perhaps unconscious, desire +for mutual death. Again, the precipitating +factor may be a situation which adds still another +problem and makes the burden of adaptation intolerable, +forcing on him the desire for death. In these +cases the actual psychosis is sometimes ushered in +dramatically with a vision of some dead person +(often a woman's father) who beckons, or there are +dream-like experiences of burial, drowning, and +so on.</p> + +<p>A few cases taken at random from our material +exemplify these features of the unhappiness in +which the psychosis appears as a solution with its +development of the death fancy.</p> + +<p>Alice R., at the age of 25, was much troubled +by worrying over her financial difficulties and the<!-- Page 193 --><span class='pagenum'><a name="Page_193" id="Page_193">[193]</a></span> +shame of an illegitimate child. Retrospectively she +stated, "I was so disgusted I went to bed—I just +gave up hope." Shortly before admission she said +she was lost and damned, and to the nurse in the +Observation Pavilion she pleaded, "Don't let me +murder myself and the baby."</p> + +<p>Caroline DeS. (Case 2) for some time was worried +over the engagement of her favorite brother to a +Protestant (herself a Catholic) and the threatened +change of his religion. At his engagement dinner +she had a sudden excitement, crying out, "I hate her—I +love you—papa, don't kill me." This excitement +lasted for three weeks, during two of which +she was observed, when she spoke frequently of being +killed and going to Heaven. The conflict was +frankly stated in the words, "I love my father but +don't want to die." Then for two weeks she had +some fever, was tube-fed, muttered about being +killed or showed some elation, there being apparently +interrupted stuporous, manic and, possibly, +anxiety episodes. Finally she settled down to a +year of deep stupor.</p> + +<p>Laura A. had for three months poor sleep with +depression over her failure in study. Another +cause for worry was that her father was home and +out of work. She reached a point where she did +not care what happened but continued working. +Ten days before admission she was not feeling well. +The next morning she woke up confused and frightened, +speedily became dazed, stunned, could not +bring anything to her memory. This rather sudden<!-- Page 194 --><span class='pagenum'><a name="Page_194" id="Page_194">[194]</a></span> +stupor onset was not accompanied by any false ideas, +at least none which the family remembered.</p> + +<p>Mary C. (Case 7) was an immigrant who felt +lonely in the new country. Two weeks before admission +her uncle with whom she was living died. +She thought she had brought bad luck, complained +of weakness and dizziness, then suddenly felt mixed +up, her "memory got bad," and she thought she was +going to die. Next she was frightened, heard voices, +thought there was shooting and a fire. For a short +time she was inactive and later began shouting +"Fire!" When taken to the Observation Pavilion, +she was dazed, uneasy, thought she was on a boat or +shut up in a boat which had gone down; all were +drowned. Then came a mild stupor.</p> + +<p>Maggie H. (Case 14), while pregnant, fancied +that her baby would be deformed and that she would +die in childbirth. Three weeks before admission +this event took place. For five days she worried +about not having enough milk, about her husband +losing his job (he did lose it) and thought her head +was getting queer. On the fifth day she cried, said +she was going to die, that there was poison in the +food, that her husband was untrue to her. She became +mute but continued to attend to her baby. She +saw dead bodies lying around, and by the time she +was taken to the Observation Pavilion was in a +marked stupor.</p> + +<p>Turning now to the symptoms of the stupor +proper, we note, first, the effects of the loss of energy +which regression implies. The inactivity and<!-- Page 195 --><span class='pagenum'><a name="Page_195" id="Page_195">[195]</a></span> +apathy which these patients show is too obviously +evidence of this to require further comment. Another +proof of the withdrawal of the libido or interest +is found in the thinking disorder. Directed, +accurate thinking requires effort, as we all know +from the experience of our laborious mistakes when +fatigued. So in stupor there is an inability to perform +simple arithmetical problems, poor orientation +is observed, and so on. Similarly what we remember +seems to be that which we associate with the +impressions received by an active consciousness. +Actual events persist in memory better than those +of fancy, in proof of which one thinks at once of +the vanishing of dreams on waking, with its reëstablishment +of extroverted consciousness. This registration +of impressions requires interest and active +attention. Without interest there is no attention +and no registration. The patient in stupor presents +just the memory defect which we would expect. Indifference +to his environment leads to a poor memory +of external events, while on recovery there may +be such a divorce between consciousness of normal +and abnormal states that the past delusions are +wiped from the record of conscious memory. Withdrawal +of energy then produces not only inactivity +and apathy but grave defects in intellectual capacity.</p> + +<p>The natural flow of interest in regression is to +earlier types of ambition and activity. This is betrayed +not merely by the thought content dealing +with the youth and childhood of the patient, but also +is manifested in behavior. Excluding involution<!-- Page 196 --><span class='pagenum'><a name="Page_196" id="Page_196">[196]</a></span> +melancholia there is probably no psychosis in which +the patients exhibit such infantile reactions as in +stupor. Except for the stature and obvious age of +these patients, one could easily imagine that he was +dealing with a spoiled and fractious infant. One +thinks at once of the negativism which is so like +that of a perverse child and of the unconventional, +personal habits to which these patients cling so stubbornly. +Masturbation, for instance, is quite frequent, +while willful wetting and soiling is still more +common. We sometimes meet with childishness, +both in vocabulary and mode of expression. In one +case there was evidently a delusion of a return to +actual childhood, for she kept insisting that she was +"in papa's house."</p> + +<p>The frequency with which the delusion of mutual +death occurs in stupor is another evidence of its +regressive psychology. The partner in the spiritual +marriage is rarely, if ever, the natural object of +adult affection, but rather a parent or other relative +to whose memory the patient has unconsciously +clung for many years, reawakening in the psychosis +an ambition of childhood for an exclusive possession +that reaches its fulfillment in this delusion. Closely +allied with this is another delusion, that of being +actually dead, which the patients sometimes express +in action, even when not in words. The anesthesia +to pin pricks, the immobility and the refusal to recognize +the existence of the world around, in patients +who give evidence of some intellectual operations +still persisting, are probably all part of a feigned<!-- Page 197 --><span class='pagenum'><a name="Page_197" id="Page_197">[197]</a></span> +death, with the delusion expressing itself in corpse-like +behavior.</p> + +<p>Finally we must consider the meaning of the deep +stupor where no mentation of any kind can be proven +and where none but vegetative functions seem to be +operating. This state is either one of organic coma, +in which case it marks the appearance of a physical +factor not evidenced in the milder stages, or else it +is the acme of this regression by withdrawal of interest. +As has been stated, back of the period of +primitive childish ideas there lies a hypothetical +state of mental nothingness. If we accept the principle +of regression we find historically an analogue +to what is apparently the mental state of deep stupor +in the earliest phases of infancy. This view receives +justification from the study of the phenomenon +of variations in symptoms. Mental faculties at +birth are larval, and if such condition be artificially +produced mental activity must be potentially present +(as it would not be if we were dealing with +coma). In Chapter IV phenomena of interruption +of stupor symptoms were detailed. One case that +was mentioned is now of particular importance as +demonstrating that an appropriate stimulus may +dispel the vacuity of complete stupor by raising +mental functions to a point where delusions are entertained. +This patient retrospectively recalled +only certain periods of her deepest stupor, occasions +when she was visited by her mother. At these times, +as she claimed, she thought she was to be electrocuted +and told her mother so, adding, "Then it<!-- Page 198 --><span class='pagenum'><a name="Page_198" id="Page_198">[198]</a></span> +would drop out of my mind again." Otherwise her +memory for this state was a complete blank. Here +we see a normal stimulus producing not normality +but something on the way towards it, that is, a +condition less profound than the state out of which +the patient was temporarily lifted.</p> + +<p>This case exemplifies the principle of levels in the +stupor reaction which we have found to be of great +value in our study. These levels are correlated +with degrees of regression, as a review of the symptoms +discussed above may show. In the first place, +the dissatisfaction with life, the first phase of regression, +leads to the quietness—the inactivity and +apathy, which are the most fundamental symptoms +of the stupor reaction as a whole. Initiative is lost +and with this comes a tendency for the acceptance +of other people's ideas. That is the probable basis +for the suggestiveness which we concluded was a +prominent factor in catalepsy. Indifference and +stolidity may exist with those milder degrees of regression +which do not conflict with one's critical +sense, and hence may be present without any false +ideas. The next stage in regression is that where +the idea of death appears. Although not accepted +placidly by the subject, its non-acceptance is demonstrated +by the idea being projected—by its appearance +as a belief that the patient will be killed. This +notion of death coming from without has again two +phases, one with anxiety where normality is so far +retained that the patient's instinct of self-preservation +produces fear, and a second phase where this in<!-- Page 199 --><span class='pagenum'><a name="Page_199" id="Page_199">[199]</a></span>stinct +lapses and the patient so far accepts the idea +of being killed as to speak of it with indifference. +The next step in regression is marked by the spoiled-child +conduct, interest being so self-centered as to +lead to autoerotic habits and the perverse reactions +which we call negativism. When death is accepted +but mental function has not ceased, the latter is confined +to a dramatization of death in physical symptoms +or to such speech and movements as indicate +a belief that the patient is dead, under the water, or +in some such unreal situation. Finally, when all +evidence of mentation in any form is lacking, we see +clinically the condition which we know as deep stupor +and which we must regard psychologically as +the profoundest regression known to psychopathology, +a condition almost as close to physiological unconsciousness +as that of the epileptic.</p> + +<p>Naturally we do not see individual cases in which +all these stages appear successively, each sharply +defined from its predecessor. To expect this would +be as reasonable as to look for a man whose behavior +was determined wholly by his most recent experience. +Any psychologist knows that every +human being behaves in accordance with influences +whose history is recent or represents the habit of a +lifetime. At any given minute our behavior is not +simply determined by the immediate situation, but is +the product of many stages in our development. +Quite similarly we should not expect in the psychoses +to find evidences of regression to a given period of +the individual's life appearing exclusively, but<!-- Page 200 --><span class='pagenum'><a name="Page_200" id="Page_200">[200]</a></span> +rather we should look for reactions at any given +time being determined preponderantly by the type +of mentation characteristic for a given stage of his +development. As a matter of fact, we see in psychoses, +particularly in stupor, more sharply defined +regressions to different levels than we ever see in +normal life.</p> + +<p>Our psychological hypothesis would be incomplete +and probably unsound if it could not offer as valid +explanations for the atypical features in our stupor +reactions as for the typical. The unusual features +which one meets in the benign stupors are ideas or +mood reactions occurring apparently as interruptions +to the settled quietude or in more protracted +mild mood reactions, such as vague distress, depression +or incomplete manic symptoms, which have been +described in the chapter on affect. The interruptions +are easily explained by the theory of regression. +If stupor represents a complete return to the +state of nothingness, then the descent to the Nirvana +or the re-ascent from it should be characterized +by the type of thinking with the appropriate mood +which belongs to less primitive stages of development. +A review of our material seems to indicate +that there is a definite relationship between the type +of onset and the character of the succeeding stupor. +For instance, in the cases so far quoted in this book, +the onsets characterized by mere worry and unhappiness +and gradual withdrawal of interest had all +of them typical clinical pictures. On the other +hand, of those who began with reactions of definite<!-- Page 201 --><span class='pagenum'><a name="Page_201" id="Page_201">[201]</a></span> +excitement, anxiety or psychotic depression, there +were interruptions which looked like miniature +manic-depressive psychoses in all but one case. +This would lead one to think that these patients retraced +their steps on recovery or with every lifting +of the stupor process, moved slightly upward on +the same path on which they had traveled in the first +regression. The case of Charlotte W. (Case 12), +which is fully discussed in the chapter on Ideational +Content, offers excellent examples of these principles.</p> + +<p>The next atypical feature is the phenomenon of +reduction or dissociation of affect, the frequency of +which is mentioned in Chapter V. As the law of stupor +is apathy, normal emotions should be reduced +to indifference and no abnormal moods, such as elation, +anxiety or depression, should occur. What +often happens is that these psychotic affects appear +but incompletely, often in dissociated manifestations. +This looks like a combination of two +psychotic tendencies, the stupor reduction process +which inhibits emotional response and the tendency +to develop abnormal affects which characterize +other manic-depressive psychoses. There is no +general psychological law which makes this view unlikely. +One cannot be anxious and happy at the +same instant, although one can alternate in his feelings; +but one can fail to react adequately to a given +stimulus when inhibited by general indifference. In +fact it is because apathy is, properly speaking, not<!-- Page 202 --><span class='pagenum'><a name="Page_202" id="Page_202">[202]</a></span> +a mood but an absence of it, that it can be combined +with a true affect. It is possible, therefore, to have +a combination of stupor and another manic-depressive +reaction, while the others cannot combine but +only alternate.<a name="FNanchor_11_13" id="FNanchor_11_13"></a><a href="#Footnote_11_13" class="fnanchor">[11]</a></p> + +<p>Finally we must discuss the psychological meaning +of cases, such as those described in Chapter +VIII, where we concluded that there were +psychoses resembling stupors superficially. It +seemed likely that these patients were absorbed in +their own thoughts, rather than being in a condition +of mental vacuity. It is not difficult to explain the +objective resemblance. All evidence of emotion +(apart from subjective feeling tone which the subject +may or may not report) is an expression of contact +with the outer world. There must be externalization +of attention to environment before a mood +becomes evident. A moment's reflection will show +this to be true, for no further proof is needed than +the phenomena of dreaming. The attention being +given wholly to fantasies, the subject lies motionless, +mute and placid, although passing through varied +autistic experiences. Only when the dream becomes +too vivid, disturbs sleep and re-directs attention to +the environment—only then is emotion objectively<!-- Page 203 --><span class='pagenum'><a name="Page_203" id="Page_203">[203]</a></span> +betrayed. There is an appearance of apathy and +mental vacuity which the dreamer can soon declare +to be false. He was feeling and thinking intensely. +In any condition, therefore, such as that of perplexity +or of an absorbed manic state, the patient may +be objectively in the same condition as a typical +stupor. The histories of the two psychoses differentiate +the two reactions which may be indistinguishable +at one interview. The keynote of one reaction +is <em>indifference</em>, while that of absorption is +<em>distraction</em>, a perversion of attention to an inner, +unreal world.</p> + +<p>In summary we may recapitulate our hypotheses. +Stupor represents, psychologically speaking, the +simplest and completest regression. Adaptation to +the actual environment being abandoned, attention +reverts to earlier interests, giving symptoms of +other manic-depressive reactions in the onset or +interruptions, and finally dwindles to complete indifference. +The disappearance of affective impulse +leads to objective apathy and inactivity, while the +intellectual functions fail for lack of emotional +power to keep them going. The complicated mental +machine lies idle for lack of steam or electricity. +The typical ideational content and many of the +symptoms of stupor are to be explained as expressions +of death, for a regression to a Nirvana-like +state can be most easily formulated in such a delusion. +Other clinical conditions may temporarily +and superficially resemble stupor on account of the<!-- Page 204 --><span class='pagenum'><a name="Page_204" id="Page_204">[204]</a></span> +attention being misdirected and applied to unproductive +imaginations. To employ our metaphor +again, in these false stupors the current is switched +to another, invisible machine but not cut off as in +true stupor.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_11_13" id="Footnote_11_13"></a><a href="#FNanchor_11_13"><span class="label">[11]</span></a> The reader will note that this view is opposed to that of +Kraepelin, who has written largely on so-called "<em>mixed conditions</em>" +in manic-depressive insanity. We believe that careful clinical studies +confirm our opinion and that his classification is based on less +thorough observation and analysis. This subject will be discussed +at greater length in a forthcoming book on "The Psychology of +Morbid and Normal Emotions," by Dr. MacCurdy.</p></div> +</div> + +<p><!-- Page 205 --><span class='pagenum'><a name="Page_205" id="Page_205">[205]</a></span></p> + +<h2>CHAPTER XI<br /> +<span class="sm">MALIGNANT STUPORS</span></h2> + +<p>As we have seen, the benign stupors are characterized +by apathy, inactivity, mutism, a thinking disorder, +catalepsy and negativism. All these symptoms +are also found in the stupors occurring in dementia +præcox. In fact this symptom complex has usually +been regarded as occurring only in a malignant setting. +There can be no question about the resemblance +of benign to dementia præcox stupors. Even +such symptoms as poverty and dissociation of affect, +usually regarded as pathognomonic of dementia +præcox, have been described in the foregoing chapters. +Either recovery in our cases was accidental +or there is a distinct clinical group with a good prognosis. +If the latter be true, the symptoms must +follow definite laws; if they did not, we would have +to abandon our principles of psychiatric classification. +Naturally, then, we seek to find the differences +between the cases that recover and those that do not. +There is never any difficulty in diagnosis where a +stupor appears as an incident in the course of a recognized +case of catatonic dementia præcox. We +shall therefore consider only such clinical pictures as +resemble those described in this book, in that the<!-- Page 206 --><span class='pagenum'><a name="Page_206" id="Page_206">[206]</a></span> +symptoms on admission to a hospital or shortly +after are those of stupor. It should be our ambition +to make a positive diagnosis before failure to +recover in a reasonable time leads to a conclusion +of chronicity.</p> + +<p>It is probably safe to assume, on the basis of as +large a series as ours, that the symptoms of stupor +<i lang="la">per se</i> imply no bad prognosis. Further, it has been +noted that a relatively pure type of reaction is seen, +the symptoms appearing with tolerable consistency. +In analyzing the histories of dementia præcox patients, +therefore, one looks for inconsistencies +among, or additions to, the stupor symptoms. We +may say at the outset that we have been able to find +no case of malignant stupor that showed what we +regard as a typical benign stupor reaction, and it is +questionable whether partial stupor as we have described +it, ever occurs with a bad prognosis. Usually +the discrepant symptoms in the dementia præcox +cases are sufficiently marked to enable one to +make a positive diagnosis quite soon after the case +comes under observation.</p> + +<p>The law of benign stupor is a limitation of energy, +emotion and ideational content. In dementia præcox +we have a re-direction of attention and interest +to primitive fantastic thoughts and a consequent +perversion of energy and emotion. In many malignant +stupors one can detect evidence of this second +type of reaction in symptoms that are anomalous +for stupor. For instance, one meets with frequent +silly and inexplicable giggling. Then, too, smiling,<!-- Page 207 --><span class='pagenum'><a name="Page_207" id="Page_207">[207]</a></span> +tears or outbursts of rage, the occasions for which +are not manifest, are much more frequent than in +typical stupor. Similarly, delusional ideas (not +concerned with death at all) may appear or the patient +may indulge in speech that is quite scattered, +not merely fragmentary. Two cases may be cited +briefly to illustrate these dementia præcox symptoms +superadded to those of stupor.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 20.</span>—<i>Winifred O'M.</i> Age: 19. Single. Admitted to the +Psychiatric Institute May 6, 1911.</p> + +<p><i>F. H.</i> The occurrence of other nervous or mental disease in +the family was denied.</p> + +<p><i>P. H.</i> The patient seems to have been rather shy and goody-goody +in disposition. According to her mother this seclusiveness +did not begin to be markedly noticeable until the winter before +her psychosis, when there was some trouble about getting work. +She had previously been to a business school. Then she held a +position as stenographer temporarily. When this job was over +she had a number of positions that did not last long and was +once idle for two months. In February (three months before +admission) her father was out of work, which added to her worry.</p> + +<p><i>Onset of Psychosis:</i> Nine days before admission a young man +died in the house where they lived. The next day her mother +insisted on the patient and her sister going to the funeral. On +coming home the patient complained of being afraid and having +a funny feeling. She woke up at 2:30 that night and lit all the +gas, for which she could give no explanation. The day following, +or a week before admission, she was slow, confused, could not get +her clothes together. The next day she was restless and worried, +giving a superficial explanation for the latter. She played the +piano a great deal. The following day she was fidgety and cried. +At 4 p.m. she was put to bed and appeared to fall asleep. At +midnight when a priest called she said to him privately that she +was all over the world, that she went to the 12th floor of the +Metropolitan Building, that she sat down and took the man's +money, $7, and came right away. She recognized the priest.<!-- Page 208 --><span class='pagenum'><a name="Page_208" id="Page_208">[208]</a></span> +Three days before admission she wanted to stay in bed, kept her +eyes closed. When spoken to she would smile but did not open +her eyes. She did not pass her urine all day. Her mother then +gave her some medicine which the doctor had left. The patient +immediately had a peculiar attack in which she heaved her breast, +drew her head back, clenched her fists and worked her feet. Saliva +escaped from the side of her mouth. This attack lasted some +three to five minutes.</p> + +<p>Her mother then called an ambulance and she was taken to the +<i>Observation Pavilion</i>. She thought that the ambulance doctor +was an uncle, a soldier in the Philippines, of whom she was very +fond. There she remained in bed, with all her muscles relaxed, +her mouth constantly open, saying nothing and indeed resisting +efforts which were made to get her to open her eyes.</p> + +<p><i>Under Observation:</i> She sat or lay down with her eyes closed +and usually limp, although occasionally resistive. There was practically +no reaction to pin pricks. Sometimes she opened her +mouth as if to speak but rarely did so except in a very low tone +and after repeated questioning. Her answers were rarely relevant. +To the usual orientation questions she gave no answers +that would indicate that she knew where she was. Sometimes she +said "Jimmy" when asked her name, and replied to another +question, "Jimmy big smile on." Once she said, "I don't know +myself—what I am talking for—what I am doing." In general +her speech seemed to indicate that her thought was directed +entirely inward and that she paid no attention whatever to the +questions. In most benign cases such a condition is accompanied +by perplexity or a dreamy, dazed expression. This the patient +had not. On the other hand, she was sometimes definitely scattered. +For example, when asked, How do you feel? she replied, +"Large all name." Again to the command, Tell me your trouble, +her answer was, "I couldn't tell my mother last night and I can't +tell her this night and I can't tell my <em>proud</em>." She referred in +a fragmentary way to being crazy and to having been dead. She +admitted hearing voices but may not have understood the question.</p> + +<p>A week after admission, when visited by her mother, the latter +asked her to kiss her. The patient opened her mouth widely and +put out her tongue. This is a type of response which we have +never seen in our benign cases.</p> + +<p><!-- Page 209 --><span class='pagenum'><a name="Page_209" id="Page_209">[209]</a></span> +Two days later repeated questioning made it evident that the +patient knew more about her environment than would be expected, +judging from her other symptoms. She gave the month correctly +knew that she was in a hospital and told of having recently been +visited by her father. At the same interview she spoke of masturbation, +of wanting to marry her uncle, and of having been in +bed with her father. The last she referred to as a "fall." Such +frank incest ideas are never found in benign psychosis in our +experience. Other dementia præcox ideas appeared quite soon, +for within three days, when she was talking slightly more freely, +she spoke of having often imagined she was having sexual experiences +as a result of the influence of a man who lived upstairs, +and that even when sitting with her family at the table she felt +sexual sensations.</p> + +<p>Her condition then remained essentially the same for some +time. Then about six weeks after admission she became somewhat +less resistive, was frequently seen sitting up in bed, moving her +lips considerably (without speech) and regarding the surroundings +with a bright interested expression and occasionally smiles. +About this time she began exposing herself and chewing her +finger nails.</p> + +<p>Four months after admission she was noted as being very +resistive and negativistic, allowing saliva to accumulate in her +mouth and making no attempt to keep the flies off her. At the +same time she would keep in her mouth food that had been put +there without chewing it.</p> + +<p>Two months later she seemed to laugh occasionally when other +patients did so, but at the same time she showed a cataleptic +tendency and was quite mute.</p> + +<p>Six months after admission she began to feed herself but rather +sloppily. When one would speak to her, she would occasionally +smile, but if shaken she would weep silently. About this time she +began to do a little work in the ward, pushing a floor polisher.</p> + +<p>For the next couple of months her condition was about the +same. She would stand around the ward, doing a little work if +urged, might even dance if forced to. She was consistently mute. +She was dirty but often decorated herself. Rarely she was +assaultive.</p> + +<p>Then ten months after admission she one day suddenly became<!-- Page 210 --><span class='pagenum'><a name="Page_210" id="Page_210">[210]</a></span> +talkative, distractible and emotional, laughing and crying. There +was with this, however, no open elation. Her talk was obscene, +at times flighty, at times definitely scattered. All her habits were +filthy.</p> + +<p>This pseudomanic episode lasted for a couple of months, and +then she settled down to a fairly consistent deterioration with +indifference, silly laughter, occasional assaultiveness, destructiveness +and untidiness.</p> + +<p>Nearly two years after admission she had another period of +excitement lasting about a couple of months. Shortly after this +she began to fail physically, and in November, 1913, two years +and five months after her admission, she died of pulmonary +tuberculosis.</p></div> + +<p>In summary, then, we see that this patient exhibited +symptoms of dementia præcox from the outset +of her stupor, with scattering, genital sensations +and incest ideas. The stupor symptoms gradually +gave way to the typical indifference, negativism, obscenity, +filthiness and inexplicable conduct of +dementia præcox. At the beginning, however, the +condition was superficially similar to that of a benign +stupor, it being only on careful observation +that other symptoms were noted.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 21.</span>—<i>Rose S.</i> Age: 23. Admitted to the Psychiatric +Institute April 5, 1905.</p> + +<p><i>F. H.</i> The mother was living, the father dead. Otherwise no +pertinent information was secured.</p> + +<p><i>P. H.</i> The patient was said always to have been somewhat +seclusive, mingling little with other people; this tendency was so +strong that she would leave the room when visitors came. She +always slept a great deal. It was stated that she was able to do +heavy housework quite well, but never learned cooking.</p> + +<p>At 16 she hired out as a servant for a year and a half, and then +did laundry work. When 18 she had an illegitimate child by a +co-worker.</p> + +<p><!-- Page 211 --><span class='pagenum'><a name="Page_211" id="Page_211">[211]</a></span> +<i>History of Psychosis:</i> About a year before admission the +patient's sister was burned to death. When the patient heard of +this she said that something had come up in her throat. Henceforth +she often complained of a lump in her throat, and often bit +her nails. Two months before admission she suddenly left the +laundry, again spoke of the lump in her throat, and claimed to +have seen the dead sister. Two weeks later when the family had +an anniversary mass for the sister the patient appeared sad, but +the following day laughed, said she had seen her "sister beckoning +her to come." She also thought she saw her picture "and Heaven +was behind it." She also talked of "dead relatives and friends." +A reaction of levity in connection with a sister's death is highly +suggestive of a malignant psychosis.</p> + +<p>Two weeks before admission her mother found her in a stupor, +immovable, with her eyes closed. In 24 hours she woke up, began +to sing "Rest for the Weary," prayed, then was stuporous again +for six hours. When she came out of this, she said she was +"going to die," God had told her so and talked of her own funeral +arrangements. She again went into a stupor, in which she was +sent to the Observation Pavilion.</p> + +<p>At the <i>Observation Pavilion</i> she was described as happy, laughing, +singing, saying she felt happy, but adding, "I like to be sad +too, I am going to Heaven Easter Sunday." She claimed that +her sister frequently stood in front of her, and that she knew she +wanted her to go with her.</p> + +<p><i>Under Observation:</i> For about three weeks the patient showed +a variable stupor. She would lie with a mask-like face inaccessible, +cataleptic, drooling saliva, often with her mouth open. +When taken up, she was usually perfectly flaccid, but once she +let herself slide on the floor after she had stood immobile at the +window. Sometimes there was marked resistance to passive +motions, especially when attempts were made to open her mouth +or eyes, or on one occasion when the examiner tried to open her +hand in which she held her handkerchief. Yet when one persisted +in urging her to respond there frequently could be elicited more +or less marked reactions. Thus repeatedly she could be made to +obey some commands, as showing the tongue, etc., even when she +would not answer. Once when her eyes were opened, tears rolled +down her cheeks—again, she usually reacted to pin pricks by<!-- Page 212 --><span class='pagenum'><a name="Page_212" id="Page_212">[212]</a></span> +slight flushing, once she said, "Stop! it hurts." Again, she said, +"Leave me alone, I want to sleep."</p> + +<p>So far the description of this reaction is that of a benign +stupor. There were, however, other symptoms. In the first place, +she could sometimes be made to open her eyes and write, although +she would not speak. In spite of the penmanship being careless, +there were no mistakes. This exhibition of an unhabitual and +more difficult intellectual effort when the patient was mute is +suggestive of an inconsistency. So was her habit of sometimes +singing a hymn, "Rest for the Weary," when no other sign of +mental life was given. But, more important than these, she could +not infrequently be induced to answer questions and at such times +she spoke promptly and with natural affective response.</p> + +<p>A number of her replies were of the type to be expected in a +benign stupor. In the first place, she spoke of her condition as +"going off to sleep" and also as "death," "I was dead all day." +"I died three times yesterday," or she merely described it by +saying "I go off into states when I lie with my mouth open and +eyes closed, and cannot speak or open my eyes." When asked +how she got into this condition, she said "My sister died and I +think it was on my mind." Again she said she became sad at +the anniversary mass of the sister and had been sad ever since. +On the other hand, she also stated that when she came home +from the mass she first was silly and danced. Spontaneously she +spoke of having frequently had visions of her dead sister; once +she saw her with wings. In explanation of her singing "Rest for +the Weary," she said it was the hymn sung at her father's +funeral. An anomalous feature had to do with her description +of her feelings. She claimed to have no memory of her stupor +periods and yet said of them: "I feel peaceful-like," or "I feel +awfully happy and sad together," or "I am sad and contented—I +like it that way."</p> + +<p>A striking symptom was that, when a sensory examination was +made during the first few days during one of the periods when +she responded well, she showed glove and stocking anesthesia, +also anesthesia of neck and left breast.</p> + +<p>But in addition to the above statements the patient also began +to make others of a definite dementia præcox type. About ten +days after admission she said, "What any one says goes right<!-- Page 213 --><span class='pagenum'><a name="Page_213" id="Page_213">[213]</a></span> +through my brain," or she talked of being hypnotized. "The +typewriting machine turned my eyes—three or four girls turned +my eyes—they look at me and get their chance, their left eye—turning +me into images. I want to be the way I was born—turn +my body! look how their bodies are turned before they die," or +"Take it if you get it—he got the name out—I was over there to +death—himself to death—of, you know—you played out—she is +played out." ... This while she snickered between the sentences. +As early as four weeks after admission she had begun to giggle +or laugh, often in an empty fashion, and a transition from the +more constrained stuporous state, with interruptions of laughter, +to an indifferent silly, muttering to herself was gradual.</p> + +<p>In 1909 she was described as not talking, standing around, +showing no interest in anything, muttering. The only response +obtained was "I don't know." In December, 1911, she was transferred +to another hospital as a case of deteriorated dementia +præcox.</p></div> + +<p><i>To Recapitulate:</i> We have here a young woman +who for a year had indefinite mental symptoms and +suddenly developed a stupor. This was atypical in +that she sang and wrote when otherwise apparently +deeply stuporous. When persuaded to talk, her utterances, +even as early as ten days after admission, +were of a malignant type and with such statements +she giggled. This last is apparently a highly important +sign. Quite frequently in our cases the first +signal of a dementia præcox reaction has been giggling +in a setting of what was apparently a typical +benign stupor.</p> + +<p>As has frequently been stated, symptoms of benign +stupor are closely interrelated. Consequently +the reaction is, when benign, a consistent one. We +do not find free speech with profound apathy and in<!-- Page 214 --><span class='pagenum'><a name="Page_214" id="Page_214">[214]</a></span>activity, +nor do we expect to meet with unimpaired +intellectual functions when other evidences of deep +stupor are present. The inconsistency of mental +operations which characterize dementia præcox, +however—the "splitting" tendency which Bleuler +has emphasized in his term "schizophrenia"—is +just that added factor which may produce disproportionate +developments of the various stupor +symptoms in the dementia præcox type of that reaction. +Examples of this have been given in the two +cases just quoted. The history of the following patient +shows this tendency more prominently.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 22.</span>—<i>Nellie H.</i> Age: 20. Admitted to the Psychiatric +Institute June 11, 1907.</p> + +<p><i>F. H.</i> The father had repeated depressions; he died of typhus +fever. The mother was living.</p> + +<p><i>P. H.</i> The brother of the patient stated that she was like other +girls, and very good at school. At 16 she became quieter, less +energetic. She came to America at 17. After arriving here she +has seemed low spirited, cranky and faultfinding. She often +complained of indefinite stomach trouble and headaches; when +at home she often had a cloth around her head. The informant +recalled that she said, "I wish I could get sick for a long time +and get either cured or die." However, she worked. For one and +a half years prior to admission her "crankiness" is said to have +become much worse. She complained continually of being tired; +quarreled much with her mother; said she did not have enough +to eat. It is also stated that she was constantly afraid of losing +her job.</p> + +<p><i>History of Psychosis:</i> For six months before admission she +said frequently that her boss was giving her hints that he liked +her. (She did not know him socially at all.) Six days before +admission she came home, saying the boss had told her he had +no more work for her. Nevertheless, she went back next day and +was again sent home. At home she sat gazing. Next day again<!-- Page 215 --><span class='pagenum'><a name="Page_215" id="Page_215">[215]</a></span> +wanted to go and see the boss, but was prevented. At times she +tried to get out of the window; again sat gazing, repeating to +herself "Always be true." She said she was in love with the +boss. When the doctor gave her medicine she thought it was +poison. Finally she began to be talkative and elated. At the +<i>Observation Pavilion</i> she became very quiet.</p> + +<p><i>Under Observation:</i> She lay in bed indifferent, not eating, +unless spoon-fed, when she would swallow. She soiled herself. +She answered no questions as a rule, and only on one occasion, +when urged considerably, said in answer to questions that this +was a hospital, so that she evidently had more grasp on the nature +of her environment than her behavior indicated. To her brother +who called on her during the first ten days she said she could not +find her lover here (an idea inconsistent with the benign stupor +picture).</p> + +<p>Then she became more markedly stuporous, drooling saliva, +very stiff, often lying with head half raised, gazing stolidly, never +answering, soiling. Later, after a month, this was less consistent. +She now and then went to the closet, sometimes she +smiled, ate some fruit brought to her, spoke a little. Repeatedly +when people came she clung to them, wanted to go home, again +was seen to weep silently. On another occasion she suddenly +threw the dishes on the floor with an angry mood, without there +being any obvious provocation. Again she got quite angry when +urged to eat her breakfast, and on that occasion pulled out some +of her own hair. Usually she had to be fed, was stiff, sitting +with closed fists, not reacting as a rule in any other way, wholly +inaccessible and has been that way for years. The stupor merged +into a catatonic state merely by the development of the inconsistency +in her affective reactions.</p></div> + +<p>We see then that inconsistencies among the stupor +symptoms themselves and the intrusion of definitely +dementia præcox symptoms differentiate the malignant +from the benign reactions. As a matter of +fact, we find, as a rule, that careful examination of +the onset reveals further atypical features, sugges<!-- Page 216 --><span class='pagenum'><a name="Page_216" id="Page_216">[216]</a></span>tions +or definite evidences of a dementia præcox reaction +before the stupor itself appears. One common +occurrence is a slow deterioration of character +and energy that proceeds for months or years before +flagrantly psychotic symptoms appear.</p> + +<p>Then when delusions or hallucinations are eventually +spoken of by the patient, an appropriate or +adequate reaction is lacking. In a benign psychosis +false ideas do not appear with an equable mood +unless the stupor reaction has already begun.</p> + +<p>More important than this, although in benign stupors +there may be a reduction or an insufficient affect, +it is never inappropriate. This pathognomonic +symptom of dementia præcox frequently occurs in +the onset to malignant stupors. In fact we often +find in reviewing such cases that a plain dementia +præcox reaction has been in evidence, that a diagnosis +has not been made simply because the stupor +picture blotted out this earlier psychosis before an +opinion was formed. Frequently these early symptoms +are reported in the anamnesis and not actually +observed by the physician.</p> + +<p>Three cases may be cited as examples of dementia +præcox onsets. It will be noted that the ensuing +stupors were, like those already quoted, atypical.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 23.</span>—<i>Catherine H.</i> Age: 21. Admitted to the Psychiatric +Institute October 10, 1904.</p> + +<p><i>F. H.</i> The mother's brother had two attacks of delirium +tremens. The mother died when the patient was eleven years old; +she is said to have been normal. The father was living.</p> + +<p><i>P. H.</i> The patient was always a nervous child, had very bad<!-- Page 217 --><span class='pagenum'><a name="Page_217" id="Page_217">[217]</a></span> +dreams, but she was smart at school up to ten or eleven, and +played with other girls. Then she began to work less well, got +thin, more nervous, complained of headaches. It was about that +time that her mother died. (The reaction to the death was said +not to have been different from that of her sister.) She was +kept at home and was quiet.... "You could see something was +working on her." She began to menstruate at 14, and it was +claimed that she then wakened up a little. It was further stated +that she was always "stuck up" about her clothes.</p> + +<p>At 16 she went to work in a factory, but her sister thought +the work was too much for her, so she was taken home. Thereafter +she lived alone with her father, doing his housework, her +sister having married about that time. At 17 her hair began +to come out excessively, so that she had to cut it, and when it +grew again it was gray. She became very sensitive about this, +even refused to take positions because she thought people would +remark about it.</p> + +<p>For two years before admission she evidently was different. +Although she did her father's housework well enough, she turned +against her sister and refused to speak to her because, she alleged, +the sister had not come to help her in her housework. Another +pronounced manifestation during that time was her frequent talk +about her bowels. She complained of constipation, creepy, +crawling sensations in the stomach which she thought was a +"tapeworm." She got pamphlets and took patent medicines. She +was taken to a physician nine months before admission, who +operated on her for piles. While still in the hospital she asked +her father to take her home to die (although there was no reason +for such a request). Again she said the gauze had been left in +the rectum too long and that the rectum was full of wind. Later +she said the rectum was closing up. After this, the sister stated, +she was extremely nervous if she passed a day without a movement +of the bowels. She was quiet henceforth, went out less and +said little, claiming it was better for her head if she said little. +She often sat, head in hand, in the hall. All through the summer +she frequently remarked, "I am a good girl." Four months before +admission during a period of five weeks she would let her bowels +move when standing up. This was relieved by enemas. The +father states that she was cranky to him, that sometimes when<!-- Page 218 --><span class='pagenum'><a name="Page_218" id="Page_218">[218]</a></span> +he merely asked a question she would say, "You hurt my feelings," +and once, "You break my heart." Occasionally she seemed to +worry about the money spent for her on doctors and medicine.</p> + +<p>About two months before admission she said everybody was +looking at her. Ten days before admission she said, "I have been +sick all this time and thought I was going to die. Now I think +Tom (her brother) is going to die." She became fearful of +being left alone. Finally she went to the priest, who told her to +go home. Then she prayed, leaving the candles burning in the +room. That night she was found kneeling before a church in her +nightgown. Again she threw a lot of articles into the yard, saying +a curse had been put on her by her father, and she did not wish +to give him anything. When she was taken to the Observation +Pavilion she said, "I am a good girl—my mother is dead—it is all +my father's fault."</p> + +<p>At the <i>Observation Pavilion</i> she put her arm under a hot +water faucet "to save the world," prayed and laughed—again +sank back and appeared as if asleep. She said, "I hear angels +telling me how to pray when I lose my thoughts—sisters and nuns +are all around me here, to save and purify the world now and +forever, and at the hour of our death."</p> + +<p><i>Under Observation:</i> On admission the patient kept her eyes +closed, sang hymns in measured tones, or prayed, or showed a +certain ecstasy in her face while her lips quivered and tears ran +down her cheeks. On the whole, she answered few questions. +When asked how she felt, she said she was happy. (Why do +you cry?) "I was crying when I asked God to save souls." (Are +you afraid?) "Not now, I have been afraid of everything on +Earth ever since my mother died." (What do you mean?) "No +one would look at me or talk to me—they said I was a bad girl, +but I was pure." Again she said, "They laughed about me, talked +about me—and they drew up a play about me—Devil's Island." +Or she spoke about having had stomach trouble, bowel trouble, +teeth trouble, eye trouble, compound, complicated trouble. (What +do you mean?) "Father scolding all the time, he sent me to get +bug medicine (true). God gives that medicine to the one that +started all the trouble—Devil's Island."</p> + +<p>She soiled her bed and was asked why she did it. She said +"I have been transformed into a baby, the Lord said I was too<!-- Page 219 --><span class='pagenum'><a name="Page_219" id="Page_219">[219]</a></span> +pure to be a woman—I had to become a baby to save the world." +Or when asked her name she called herself "Baby Chadwick of +the whole world—divine Irish Catholic World—Amen," or again +"I am the Roman Catholic Irish Divine Baby."</p> + +<p>Although she was not essentially disoriented she called the place +"mid-heaven," or "a holy house, sort of a hospital." She also +said, "In two years more there will be a new world and it will +be more happy and holy."</p> + +<p>The day after entrance the patient, though in part as described, +had a spell when she kept her eyes closed and was rigid. +Spells like these returned. (About a month after admission she +became completely stuporous.) She prayed at times, at other +times was constrained, or kept her eyes closed. Her orientation +throughout was good. The content of her psychosis, in addition +to the praying attitude, had a more or less vague religious +coloring. Thus she called the hospital the "House of God." +Again, when on one occasion she had jumped at the window +guard and was asked "why?" she said "holy communion." Again +she said she was "Mary, Virgin Mother." But this religious trend +was intermingled with remarkable elements of another sort. Thus +when in order to study her knowledge of the events after admission, +she was asked what she had done when she was brought +into the ward, she said, "I went into the sanctuary where my +bowels moved and water passed from me." (Why do you call it +sanctuary?) "Because Jesus did the same thing I did."</p> + +<p>Possibly vague sexual allusions are also contained in the following: +She said one day to the doctor, "Everything went wrong +last night, good, pure, true and holy doctor, I led you astray and +you were dying last night, may the Almighty God forgive me, +I ought to have died, but I fought it out, for, if I had died, my +mother's soul would not have been saved in Heaven and from the +flames of Hell." Again, "I will not look at you again, good, +pure, holy doctor of the world." (Why?) "I am afraid I will +lead you astray." And also: "I led James. Peter astray too." +It should be added that she sometimes masturbated rather +shamelessly.</p> + +<p>She said she heard her mother's voice. (What did she say?) +"Something in the sky for me, angels call for me." (What do the +angels say?) "The name of my good mother in Heaven." Again<!-- Page 220 --><span class='pagenum'><a name="Page_220" id="Page_220">[220]</a></span> +she said she had heard her mother the night she came here. +(What did she say?) "It was like a voice—feed the calf—that +means me, I suppose."</p> + +<p>Then after a month the stupor became more continuous. She +lay totally inactive for the most part, had to be fed, soiled +herself, drooled saliva, was at times cataleptic, often rigid. Her +limbs became cyanotic. A few times tears were seen. On other +occasions she whispered "peace," or "peace for hazing," or "pray—peace," +or "I like to be good." Usually no responses could be +obtained.</p> + +<p>After some months she was at times seen laughing. This +gradually passed into a state of total disinterestedness and inaccessibility. +She could finally be made to polish the floor in an +automatic fashion, but never spoke, and five years after admission +she was transferred to another hospital, where she died +(eleven years after admission to the ward of the Institute) without +any change in her mental condition having taken place.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 24.</span>—<i>Adele M.</i> Age: 22. Admitted to the Psychiatric +Institute November 11, 1904.</p> + +<p><i>P. H.</i> The father stated that the patient was always "cranky," +had outbursts of temper, even when a small child and was quarrelsome; +also said that she was "seclusive," had few friends, was +averse to meeting people, never had a beau. She was taken out +of school at 14 because she was not promoted on two successive +occasions from the same class. Then she was put to work, but +she was usually discharged for incompetency.</p> + +<p><i>Onset of Psychosis:</i> Three years before admission it was +noted that she laughed occasionally without cause. She was idle. +This laughing, and also crying, was sometimes more frequent, +again less noticeable.</p> + +<p>Six months before admission she began to say she wanted to +leave home, but made no move to do so. Then she began to speak +of bad odors, made some remarks about the neighbors talking +about her—saying she should kill herself; again she said the +family would be brought to death, or the mother was falling to +pieces, the father looked sick. She also said her head was swelling +and was getting thick. Finally she wanted to hire a furnished +room and kill herself and asked if 75 cents which she had was +enough to do it with.</p> + +<p><!-- Page 221 --><span class='pagenum'><a name="Page_221" id="Page_221">[221]</a></span> +Two weeks before admission she left home, wandered about +all night, was picked up by the Salvation Army, and returned +to her home. She said she wanted to die.</p> + +<p>At the <i>Observation Pavilion</i> she stated that her mother was +falling to pieces and her father sick. She also said she wanted +to die.</p> + +<p><i>Under Observation:</i> The patient was at first petulant, saying +"I don't want to stay here," turning her face away from the +doctor, generally uninterested. Though it could be established +that she was quite oriented, often her answers were "I don't +know," or she did not answer. But she was also seen crying at +times, and she was apt to bite her finger nails. She had to be +tube-fed. Gradually these tendencies increased so that she lay +in her bed with head covered, saying in a peevish tone, when +spoken to, "Oh, let me alone." And for years she was mute, lying +with her head covered, tube-fed. When reëxamined in 1914 (ten +years later), she was found lying in bed with an empty smile. +There was paper stuffed in her ears. When approached, she +turned her head away and would not talk.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 25.</span>—<i>Catherine W.</i> Age: 42. Admitted to the Psychiatric +Institute November 11, 1904.</p> + +<p><i>F. H.</i> The father died at 75, the mother at 44. Two sisters +died of tuberculosis. A brother wanted to marry but was opposed +by the father; he set fire to the house of the girl and then +drowned himself.</p> + +<p><i>P. H.</i> The patient came to this country when 20, and worked +for some years as a servant. Then she married after a short +acquaintance. The husband, according to his own statement, +drank, and there was friction from the first. She left him a few +weeks after marriage, and a few months later he went to Ireland; +she also went some time later but did not go to see him. Then +they lived together again. They had four children, but had had +no intercourse for nine years.</p> + +<p><i>Development of Psychosis:</i> Eight years before admission the +patient became nervous, slept badly, but got better. It was +claimed that for six years she had been quieter and more sullen +than before. Three years before admission the patient had to +take a place as janitress, since she needed the money. From the +first she had trouble with the tenants and accused everybody of<!-- Page 222 --><span class='pagenum'><a name="Page_222" id="Page_222">[222]</a></span> +being in league against her. Some six or eight weeks after she +had taken the position, she developed what was called typhoid +fever, and some time later the daughter came down with the same +disease. After the typhoid she was more antagonistic towards +her husband, accused him of infidelity, repeatedly locked him out +of the house, but continued to do her housework. About six +months after this illness she left her home, but returned in a +week. She had vague ideas thereafter that the priests were saying +things against the family, and she often quarreled with the +tenants. For a year she had done no work but sat about. Ten +days before admission she stopped eating.</p> + +<p><i>Under Observation:</i> The patient was mute, stolid, gazing +straight ahead, sometimes cataleptic. She had to be tube-fed, +was usually very resistive to any passive motions; quite often she +retained her urine, but she did not hold her saliva. Yet there +was some quick responses at least in the beginning. At such +times it was found that she was oriented, but nothing could ever +be obtained about her feelings, etc., except that she once said, +when asked whether she was worried, that she "felt weak," had +"nothing to worry about." Occasionally she was seen to cry +silently; at times she would breathe faster when questioned, or +flush; once she took hold of the doctor's hand when he questioned +her, and cried, but made no reply. On another occasion she was +affectionate to her son, kissed him, although she paid no attention +to her daughter who accompanied the son. Later she said to the +nurses, "He is the best son that ever lived." But more and more +she became disinterested, totally inaccessible, resistive, had to be +tube-fed. In this condition she remained for five and a half +years. At the end of that time she died of tubercular pneumonia.</p></div> + +<p><!-- Page 223 --><span class='pagenum'><a name="Page_223" id="Page_223">[223]</a></span></p> + +<h2>CHAPTER XII<br /> +<span class="sm">DIAGNOSIS OF STUPOR</span></h2> + +<p>In any functional psychosis an offhand diagnosis +is dangerous. When one deals with such a condition +as stupor, however, the problem is exacting, for, +although "stupor" may be seen at a glance, what is +seen is really only a symptom or a few symptoms. +"Stupor," then, is more of a descriptive than a diagnostic +term. The real problem is to determine the +psychiatric group into which the case should be +placed. This is a difficult task, for the differential +diagnosis rests on the observation and utilization +of minute and unobtrusive details. A correct interpretation +can be only reached by obtaining a +complete history of the onset and observing the +behavior and speech of the patient for a long +period, usually of weeks, sometimes of months. +With these precautionary words in mind, it may +be well to summarize briefly the diagnostic problems +in connection with benign stupor.</p> + +<p>In the first place one naturally considers the differentiation +from conditions of organic stupor or +coma. Since psychotic stupors never develop without +some signs of mental abnormality, the history +is usually a sufficient basis for final judgment.<!-- Page 224 --><span class='pagenum'><a name="Page_224" id="Page_224">[224]</a></span> +In case no anamnesis is obtainable the functional +nature of the trouble may be recognized by the absence +of those physical signs which characterize the +organic stupors. One sees no violent changes in respiration, +pulse or blood-pressure, such as are present +in the intoxication comas of diabetes or nephritis. +There is no characteristic odor to the +breath, and the urine is relatively normal. The unconsciousness +of trauma or apoplexy is accompanied +by focal neurological signs. Even in aerial concussion +(so frequently seen in the war) where no one +part of the brain is demonstrably affected more than +another, there are neurological evidences of what +one might call "physiological" unconsciousness. +The eyes roll independently, the pupils fail to react +to light. On the other hand, there are definite symptoms +characteristic of the functional state. Mental +activity is evidenced by a muscular resistiveness or +retention of urine. Even in states of complete relaxation +the eyes move in unison, the pupils react +to light, and almost universally the corneal reflex is +present. The patient appears in a deep sleep rather +than actually unconscious.</p> + +<p>The post-epileptic sleep may resemble a stupor +strongly. But this condition is temporary and the +situation and appearance of the patient betrays the +fact that he has just had a convulsion. Rarely, protracted +stuporous states occur in epilepsy which +closely resemble the conditions described in this +book. In fact it is probable the true stupors may<!-- Page 225 --><span class='pagenum'><a name="Page_225" id="Page_225">[225]</a></span> +occur in epilepsy just as in dementia præcox or +manic-depressive insanity.</p> + +<p>There is usually little difficulty in the discrimination +of hysterical stupor. Occasionally it shows, +superficially, a similarity to the manic-depressive +type. Fundamentally, there is a wide divergence +between the two processes, in that in the hysterical +form a dissociation of consciousness takes place, +the patient living in a reminiscent, imaginary or +artificially suggested environment, while in a true +stupor there is a withdrawal of interest as a whole +and a consequent diffuse reduction of all mental +processes. This difference is sooner or later manifested +by the appearance in the hysteric of conduct +or speech embodying definite and elaborated ideas.</p> + +<p>As has been stated fully in the last chapter (to +which the reader is referred), the stupor of dementia +præcox is to be differentiated from that of manic-depressive +insanity by the inconsistency of the +symptoms in the former and the appearance of dementia +præcox features during the stupor, such as +inappropriate affect, giggling, or scattering. Further, +the nature of the disorder is usually manifest +before the onset of the stupor as such.</p> + +<p>Sometimes very puzzling cases occur in more advanced +years when it is difficult to say whether one +is dealing with involution melancholia or stupor. +Such patients show inactivity, considerable apathy +and wetting and soiling, and with these a whining +hypochondria, negativism, and often a rather mawkish +sentimental death content without the dramatic<!-- Page 226 --><span class='pagenum'><a name="Page_226" id="Page_226">[226]</a></span> +anxiety which usually characterizes the involution +state. In these cases the diagnosis is bound to be +a matter of taste. In our opinion it is probably +better to regard these as clinically impure types. +They may be looked on as, fundamentally, involution +melancholias (the course of the disease is protracted, +if not chronic) in whom the regressive process +characteristic of stupor is present as well as +that of involution.</p> + +<p>Great difficulties are also met with in the manic-depressive +group proper. So often a stupor begins +with the same indefinite kind of upset as does another +psychosis that the development may furnish +no clew. Any condition where there is inactivity, +scanty verbal productivity and poor intellectual performance +resembles stupor. This triad of symptoms +occurs in retarded depressions, in absorbed +manic states and in perplexities. Negativism and +catalepsy are never well developed except in stupor. +So if these symptoms be present the diagnosis is +simplified. But they are often absent from a typical +stupor. Let us consider these three groups separately.</p> + +<p>The most important difference between stupor +and depression lies in the affect. Although inactive +and sometimes appearing dull the depressive individual +is not apathetic but is suffering acutely. He +feels himself wicked, paralyzed by hopelessness, and +finds proof of his damnation in the apparent change +of the world to his eyes and in the slowness of his +mind. But he is acutely aware of these torments.<!-- Page 227 --><span class='pagenum'><a name="Page_227" id="Page_227">[227]</a></span> +The stupor patient, on the other hand, does not care. +He is neither sad nor happy nor anxious. This +contrast is revealed not only by the patients' utterances +but by their expressions. The stuporous face +is empty, that of the other lined with melancholy. +The intellectual defect, too, is different. In retarded +depression the patient is morbidly aware of difficulty +and slowness, but on urging often performs tests +surprisingly well. In the stupor, however, one is +faced with an unquestionable defect, a sheer intellectual +incapacity.</p> + +<p>In Chapter VIII the differential diagnosis between +perplexity and stupor has already been +touched upon. Here again the affect is a point of +contrast. The patient has not too little emotion +but too much. The feeling of intangible, puzzling +ideas and of an insecure environment causes the +subject distress, of which complaint is made and +which can be witnessed in the furrowed brow and +constrained expression. There is also, as we have +seen, a rich ideational content in these cases, if one +can get at it. The mind is not a blank, as in the +stupor, or concerned only with delusions of death.</p> + +<p>Finally, there are the absorbed manic states. +These are the most difficult, inasmuch as the patient +is often so withdrawn and so introverted that at any +given interview there may be no objective evidence +of mood or ideas. Here the development of the +psychosis is often an aid to diagnosis. The patient +passes through phases of hypomania to great exultation, +the flight becomes less intelligible, with this<!-- Page 228 --><span class='pagenum'><a name="Page_228" id="Page_228">[228]</a></span> +the activity diminishes until finally expression in any +form disappears. If this sequence has not been observed, +continued observation tells the tale. The +patient still has his ideas and may be seen smiling +contentedly over them (not vacuously as does the +schizophrenic) or he may break into some prank or +begin to sing. Any protracted familiarity with the +case leads to a conviction that the patient's mind is +not a blank, but that his attention is merely directed +exclusively inward. Then, too, when his ideas are +discovered, it is found that they are not exclusively +occupied with the topic of death.</p> + +<p><!-- Page 229 --><span class='pagenum'><a name="Page_229" id="Page_229">[229]</a></span></p> + +<h2>CHAPTER XIII<br /> + +<span class="sm">TREATMENT OF STUPOR</span></h2> + +<p>In dealing with cases of benign stupor the first +duty of physician and nurse is naturally the physical +hygiene of the patient. More is needed to be done +in the bodily care of these persons than for most of +the inmates of our hospitals for the insane. It is +perhaps no exaggeration to claim that a deeply +stuporous patient needs as much attention as a suckling +babe. In the first place, the patient must be +fed. It is important for mental recovery that the +individual in stupor should be stimulated to effort +as much as possible. Consequently there is an economy +of time in the long run in taking pains to get +the patient to feed himself in so far as that is possible. +He should be led to the table and assisted +in handling his own spoon and cup. If this is not +practicable, he should then be spoon-fed, and if this +in turn is found to be out of the question, tube-feeding +should be resorted to. But this last should +never be looked on as a permanent necessity, but +only as a method of maintaining the patient's health +until such time as he may be capable of independent +taking of nourishment. In exactly the same way it +is of prime importance to get the patient to attend<!-- Page 230 --><span class='pagenum'><a name="Page_230" id="Page_230">[230]</a></span> +to the natural habits of excretion. He should be +led to the toilet or to a chair commode, and efforts +to this end should be persistent, just as are those +of a good child's nurse who has the ambition of +making her charge develop normal habits. Naturally +those who retain urine and feces should be +watched to see that this retention does not last long +enough to menace health. The physical aspects of +treatment are exhausted with consideration for +cleanliness. On account of the stupor patients' inactivity +and frequent tendency to wetting and soiling, +this is a particularly important consideration. +It goes without saying that the perineal region +should be kept scrupulously clean. If any infections +are to be avoided, eyes, nose and mouth should also +be cleansed frequently. A patient who is so indifferent +as to keep the eyelids open for such a long +time that the sclera dry and ulcerate is also apt to +let flies settle and produce serious ophthalmic disease.</p> + +<p>Less obvious and more important are the measures +undertaken for the mental hygiene of the case. +On account of the tendency present in so many patients +for sudden action while in the midst of an apparently +deep and permanent inactivity, it is necessary +that these cases be not isolated but remain +under constant observation. This is particularly +true of those who have demonstrated impulsive suicidal +explosions.</p> + +<p>Not only on the basis of the psychological theory +of the stupor process, but from the observed phe<!-- Page 231 --><span class='pagenum'><a name="Page_231" id="Page_231">[231]</a></span>nomena +of recovery, we gather that mental stimulation +is of first importance if an amelioration of +the condition is to be attempted. If the stupor reaction +be a regression, which is essentially a withdrawal +of interest and energy rather than a fixation +on a false object, then excitement is desirable and interest +must be reawakened. The withdrawal is +temporary (inasmuch as the psychosis is benign), +but just as a normal person wakes more readily on +a clear sunshiny day than when it rains, so the more +cheering the environment the more rapid the recovery.</p> + +<p>Consequently, although trying to those in charge, +persistent attention should be given the patient. +Feeding and hygienic measures probably have considerable +value in this work. As soon as it is at all +possible the patients should be got out of bed and +dressed. When up, efforts should be directed towards +making them do something, even if it be something +as simple as pushing a floor polisher. On account +of their lack of enthusiasm the stupor cases +are often omitted from the list of those given occupation +and amusement. Even if they go through +the motions of work or play with no sign of interest, +such exercise should not be allowed to lapse. Then, +too, the environment should be changed when practicable. +A patient may improve on being moved +to another building.</p> + +<p>Perhaps the most potent stimulus that we have +observed is that of family visits. In most manic-depressive +psychoses visits of relations have a<!-- Page 232 --><span class='pagenum'><a name="Page_232" id="Page_232">[232]</a></span> +bad effect. The patients become excited, treat the +visitors rudely, perhaps even assault them, and all +their symptoms are aggravated. But the stupor +needs excitement, and an habitual emotional interest +is more apt to arouse him than an artificial one. +In another point the situation differs. As a rule +manic-depressive patients have delusional ideas or +attitudes in connection with their nearest of kin, +so that contact with these stirs up the trouble. +The stupor regression going beneath the level of +such attachments leaves family relationships relatively +undisturbed. Hence, while the visit of a husband +is likely to produce nothing but vituperation +or blows from a manic wife, the stuporous woman +may greet him affectionately and regain thereby +some contact with the world.</p> + +<p>So many cases begin recovery in this manner that +it cannot be mere chance. One patient's improvement, +for instance, dated definitely from the day a +nurse persuaded her to write a letter home. It is +striking, too, how quickly a patient, while somewhat +dull and slow, will brighten up when allowed to return +home. A similar improvement under these +circumstances is often seen in partially recovered +cases of involution melancholia, in whom a psychological +regression similar to that of stupor takes +place. Such experiences make one wonder whether +perhaps these alone of all our insane patients would +not recover more quickly at home than in hospitals, +provided nursing care could be given them.</p> + +<p>This is a mere suggestion. Before treatment can<!-- Page 233 --><span class='pagenum'><a name="Page_233" id="Page_233">[233]</a></span> +be rational the nature of any disease process must +be known, and we do not pretend to have done more +as yet than outline the probable mental pathology +of the benign stupors. The next step is to put +theory into practice and experiment widely with +various means to see if by appropriate stimulation +the average duration of these psychoses cannot be +reduced. It is largely with the hope of inducing +other psychiatrists to carry on such work that this +book is written. There is no other manic-depressive +psychosis which, theoretically, offers such hope of +simple psychological measures being of therapeutic +value.</p> + +<p><!-- Page 234 --><span class='pagenum'><a name="Page_234" id="Page_234">[234]</a></span></p> + +<h2>CHAPTER XIV<br /> + +<span class="sm">SUMMARY OF THE STUPOR REACTION</span></h2> + +<p>Having discussed in detail the various symptoms +and theoretic aspects of the benign stupors, it may +be well to have these observations and speculations +summarized.</p> + +<p>It being established that stupors occur as a temporary +form of insanity<a name="FNanchor_12_14" id="FNanchor_12_14"></a><a href="#Footnote_12_14" class="fnanchor">[12]</a> psychiatry is faced at once +with the problem of describing these conditions accurately +in order to ascertain their nosological position. +To this end we first examined typical cases of +deep stupor and found that the clinical picture is +made up of the following symptoms: In the foreground +stands <em>poverty of affect</em>. The patients are +almost unbelievably apathetic, giving no evidence by +speech or action of interest in themselves or their environment, +unmoved even by painful stimuli. Their +faces are wooden masks; their voices as colorless +when words are uttered. In some cases sudden mood +reactions break through at rare intervals. The second +cardinal symptom is <em>inactivity</em>. As a rule there +is a complete cessation of both spontaneous and reactive +movements and speech. So profound may this<!-- Page 235 --><span class='pagenum'><a name="Page_235" id="Page_235">[235]</a></span> +inhibition be that swallowing and blinking of the +eyes are often absent. The trouble is not a paralysis, +however, for reflexes without psychic components +are unaffected. Possibly related to the inactivity +is the preservation of artificial positions +which is called <em>catalepsy</em>, a fairly frequent phenomenon. +A tendency opposite to the inactivity is +seen in <em>negativism</em>. This perversity is present in +all gradations from outbursts of anger with blows +and vituperation to sullen, or even emotionless, muscular +rigidity. This last occurs most often when the +patient is approached but may be seen when observations +are made at a distance. Frequently <em>wetting</em> +and <em>soiling</em> are due to negativism, when the patient +has been led to the toilet but relaxes the sphincters +so soon as he leaves it. A constant feature is a +<em>thinking disorder</em>. On recovery memory is largely +a blank even for striking experiences during the +psychosis and, when accessible during the stupor +to any questioning, a failure of intellectual functions +is apparent. An <em>ideational content</em> may be gathered +while the stupor is incubating, during interruptions, +or from the recollections of recovered patients. +Its peculiarity is a preoccupation with the +theme of death, which is not merely a dominant +topic but, often, an exclusive interest. Probably to +be related to this is a tendency, present in some +cases, to sudden suicidal impulses, that are as apparently +planless and unexpected as the conduct of +many catatonics. Finally the disease is prone to +exhibit certain <em>physical</em> peculiarities. A low fever<!-- Page 236 --><span class='pagenum'><a name="Page_236" id="Page_236">[236]</a></span> +is common and so are skin and circulatory anomalies. +A loss of weight is the rule, and menstruation +is almost always suppressed.</p> + +<p>As to the frequency of stupor no figures are available, +for the simple reason that the diagnosis in large +clinics has not been made with sufficient accuracy +to justify any statistics. Most of these cases are +usually called catatonia, depression, allied to manic-depressive +insanity or allied to dementia præcox. +The majority of the stupors reported in this book +were in women, but this is merely the result of +chance, since it has been easier in the Psychiatric +Institute to study functional psychoses in the female +division, while the male ward has been reserved +largely for organic psychoses. The majority of the +patients seem to be between 15 and 25 years of age, +so that it is, presumably, a reaction of youthful +years. In our experience most cases occur among +the lower classes, which agrees with the opinion of +Wilmanns who found this tendency among prisoners.</p> + +<p>This gives a brief description of the deep stupor. +But even our typical cases did not present this picture +during the entire psychosis. They showed +phases when, superficially viewed, they were not in +stupor but suffered from the above symptoms as +tendencies rather than states. There are also many +psychoses where complete stupor is never developed. +This gives us our justification for speaking +of the <em>stupor reaction</em>, which consists of these symptoms +(or most of them) no matter in how slight a<!-- Page 237 --><span class='pagenum'><a name="Page_237" id="Page_237">[237]</a></span> +degree they may be present. The analogy to mania +and hypomania is compelling. The latter is merely +a dilution of the former. Both are forms of the +manic reaction. We consequently regard stupor and +partial stupor as different degrees of the same psychotic +process which we term the stupor reaction. +To understand it the symptoms should be separately +analyzed and then correlated.</p> + +<p>The most fundamental characteristic of the stupor +symptoms is the change in affect which can be +summed up in one word—apathy. It is fundamental +because it seems as if the symptoms built around +apathy constitute the stupor reaction. The emotional +poverty is evidenced by a lack of feeling, +loss of energy and an absence of the normal urge +of living. This is quite different from the emotional +blocking of the retarded depression, for in the latter +the patient shows either by speech or facial expression +a definite suffering. The tendency to reduction +of affect produces two effects on such emotions as +internal ideas or environmental events may stimulate. +Exhibitions of emotion are either reduced or +dissociated. For instance, anxiety is frequently +diminished to an expression of dazed bewilderment; +or, isolated and partial exhibitions of mood occur, as +when laughter, tears or blushing are seen as quite +isolated symptoms. This latter—the dissociation of +affect—seems to occur only in stupor and dementia +præcox. It should be noted, however, that inappropriateness +of affect is never observed in a true benign +stupor. A final peculiarity is the tendency to<!-- Page 238 --><span class='pagenum'><a name="Page_238" id="Page_238">[238]</a></span> +interruption of the apathetic habit, when the patient +may return to life, as it were, for a few moments +and then relapse.</p> + +<p>Closely related to the apathy, and probably +merely an expression of it, is the inactivity which +is both muscular and mental. It exists in all gradations +from that of flaccidity of voluntary muscles, +with relaxation of the sphincters, and from states +where there is complete absence of any evidence of +mentation to conditions of mere physical and psychic +slowness. After recovery the stupor patient +frequently speaks of having felt dead, paralyzed +or drugged.</p> + +<p>By far the commonest cause of emotional expression +or interruption in the inactivity is negativism. +This is a perversity of behavior which seems to express +antagonism to the environment or to the +wishes of those about the patient. In the partial +stupors it is seen as active opposition and cantankerousness. +In the more profound conditions it is +represented by muscular resistiveness or rigidity, +or refusal to swallow food when placed in the mouth. +Occasionally, too, the patient may even in a deep +stupor retain urine so long that catheterization is +necessary. All the explanations which one may +gather from the patients' own utterances, mainly +retrospective, seem to point to negativism expressing +a desire to be left alone. The appearance of +perverse behavior in aimless striking or mere muscular +rigidity seems to be an example of dissociation +of affect.</p> + +<p><!-- Page 239 --><span class='pagenum'><a name="Page_239" id="Page_239">[239]</a></span></p><p>Catalepsy is an important symptom because, although +it occurred in slightly less than a third of our +cases, it seems to be a peculiarity of the stupor reaction +found but rarely in other benign psychoses. +It seems never to occur without there being some +evidence of mental activity, and, consequently, we +are forced to conclude that it is of mental rather +than of physical origin. Just what it means psychically +it is impossible to state without much more +extended observations. We conjecture tentatively, +however, that the retention of fixed positions is in +part merely a phenomenon of perseveration, and in +part an acceptance of what the patient takes to be +a command from the examiner, and sometimes a +distorted form of muscular resistiveness.</p> + +<p>The intellectual processes suffer more seriously +in stupor than in any other form of manic-depressive +insanity. Not only do the deep stupors betray +no evidence of mentation during the acme of the +psychosis, but retrospectively they usually speak of +their minds being a blank. Incompleteness and +slowness of intellectual operations are highly characteristic +features of the partial stupors and of the +incubation period of the more profound reactions. +The features of this defect are a difficulty in grasping +the nature of the environment, a slowness in +elaborating what impressions are received, with resulting +disorientation, poor performance of any set +tests and incomplete memory for external events +when recovery has taken place. At times the thinking +disorder may develop with great suddenness or<!-- Page 240 --><span class='pagenum'><a name="Page_240" id="Page_240">[240]</a></span> +improve as quickly, and a tendency to isolated evidences +of mental acuity is another example of the +inconsistency which is so highly characteristic of +stupor. We should note, however, that these sporadic +exhibitions of mentality are always associated +with brief emotional awakening.</p> + +<p>When we turn to examine the fragmentary utterances +of stupor patients, we are surprised by the +narrowness and uniformity of the ideational content. +It seems to be confined to thoughts of death +or closely related conceptions. Thirty-five out of +thirty-six consecutive cases at one time or another +referred literally to death. It is commonest during +the onset, as all but five of these patients spoke of +it during the incubation of their psychoses. Hence +we conclude that death ideas and stupor are consecutive +phenomena in the same fundamental process. +As two-thirds of the series interrupted the stupor to +speak of death or to attempt suicide, we assume +that this relationship persists. Only a quarter gave +any retrospective account of these fancies, so we +presume that their psychotic experiences were repressed +with recovery.</p> + +<p>The usual form in which the idea appears is as +a delusion of going to die or, literally, of being dead. +It may appear as being in Heaven or Hell. A theoretically +important group is that which includes the +patients who, in addition, speak of being in situations +such as under the water or underground, +which we have mythological and psychological evidence +to believe are formulations of a rebirth<!-- Page 241 --><span class='pagenum'><a name="Page_241" id="Page_241">[241]</a></span> +fantasy. Not rarely, preoccupation with death is +expressed in sudden impulsive suicidal attempts.</p> + +<p>The affective setting of these different formulations +is important. A delusion of literal death occurs +with complete apathy. The wish to die is apt +to appear without the usual accompaniment of +sadness or distress but still with considerable +energy when impulsive suicidal attempts are made. +A prospect of death, particularly when there is anticipation +of being killed, is apt in manic-depressive +insanity to occur in a setting of anxiety. Similarly +one ordinarily observes fear in the patient who has +delusions of drowning or burial. In the stupor cases, +however, this painful affect seems to be reduced to +a mere dazed bewilderment or feeble exhibitions of +a desire for safety, such as the slow swimming movements +of a patient who thought she was under the +water. When these ideas of danger become allied +to everyday interests—husband or child imperiled, +etc.—a weak affect in the form of depression is apt +to occur.</p> + +<p>Physical symptoms are more common than in any +other benign psychosis. Of these the most nearly +constant is a low fever, the temperature running between +99° and 101°. Twenty-eight out of thirty-five +cases had this slight elevation with a tendency for it +to occur immediately at the beginning of marked +stupor symptoms. Although the evidence does not +positively exclude any possibility of infection, it +speaks distinctly against this view. A possible explanation +is that the low fever is a secondary symp<!-- Page 242 --><span class='pagenum'><a name="Page_242" id="Page_242">[242]</a></span>tom. +The suprarenal glands may function insufficiently +as a consequence of the emotional poverty, +since all emotions which have been experimentally +studied seem to stimulate the production of adrenalin. +Without this normal hormone for the activity +of the sympathetic nervous system, there would be a +disturbance of skin and circulatory reactions that +would interfere with the normal heat loss. Suggestive +evidence to support this view comes from the +frequency with which the extremities are cyanotic +or cold, the skin greasy, sweating profuse or absent, +and so on. Further observations are necessary to +confirm or disprove this hypothesis, but we feel inclined +to accept it tentatively because it is plausible +and consistent with the view that stupor is essentially +a psychogenic type of reaction. Another +physical anomaly, which is presumably of endocrine +origin, is the suppression of the menses. This probably +results from lowered nutrition. In some cases +it ensues directly on a psychic crisis before any +nutritional change can have taken place. Finally, +among the symptoms of possible physical origin, +epileptoid attacks were described in two of our +cases. This is chiefly of interest in that such phenomena +are extremely rare in the benign psychoses.</p> + +<p>We believe that the mental symptoms summarized +above constitute a specific psychotic type of reaction +capable of appearing in any severity from mere +lethargy and indifference to profound stupor. Since +the prognosis is good, we feel obliged to classify this +with the manic-depressive reactions. Further justi<!-- Page 243 --><span class='pagenum'><a name="Page_243" id="Page_243">[243]</a></span>fication +for this grouping is found in the occurrence +of the stupor reaction as a phase in many manic-depressive +psychoses. A patient may swing from +mania to stupor as from mania to depression, and +when the partial stupors are recognized as milder +forms of the same process, it seems to be a frequent +type of reaction.</p> + +<p>If stupor be a reaction type, its laws must be +psychological. According to the view of modern +psychopathology, the essence of insanity is regression +with indolent thinking as opposed to progressive +and energetic mentation. One can look on +stupor as being a profound regression. Effort is +abandoned (apathy and inactivity), while the ideational +content expresses a desire for a retreat from +the world in death. It is possible to think of this +regression as a return to the mental habit of the +suckling period, when spontaneous effort is at its +minimum. This, too, is the time when petulance and +tantrums are frequent expression of a wish to be left +alone, which may account for the negativism as a +consistent symptom of the same regressive progress.</p> + +<p>Just as we regress in sleep, to rise refreshed for a +new day's duties, so the stupor case often shows excessive +energy in a hypomanic phase before complete +normality is reached. This corresponds again +to the age-old association of the ideas of death and +rebirth which we see together so frequently in +stupor. It is the psychology of wiping the slate +clean for a fresh start.</p> + +<p>The development and symptoms of stupor furnish<!-- Page 244 --><span class='pagenum'><a name="Page_244" id="Page_244">[244]</a></span> +evidence in support of the hypothesis of this type of +regression. Dissatisfaction of any kind is the setting +in which the psychosis begins and the commonest +precipitating factor is some reminder of death. That +loss of energy appears with the stupor is evident +from the inactivity and apathy, while the thinking +disorder can be shown to be the result of the same +loss. The different "levels" of the stupor reaction +also conform to a theory of regression. First there +is mere indifference and quietness; then appear +false ideas when normality is so far abandoned as +to mean a loss of the sense of reality; withdrawal of +interest from the environment, with its consequent +centering of self, leads to the next stage—that of the +spoiled child reaction; then follows the exclusion of +the world around in the dramatization of death; +finally, in the deepest stupor, mentation is so far +abandoned that we can gather no evidence of even +this delusion being present.</p> + +<p>Atypical features in stupor have to do mainly with +interruptions, interludes as it were, of elation, +anxiety or perplexity. These are explicable as +awakenings from the nothingness of stupor into +imaginations such as characterize the other manic-depressive +psychoses. When such tendencies are +present, the co-existence of the stupor process may +tone down the emotional response or prevent its +complete repression so that insufficient or dissociated +affects appear. A combination of the stupor +tendency to apathy with the mood of another reac<!-- Page 245 --><span class='pagenum'><a name="Page_245" id="Page_245">[245]</a></span>tion +is probably the only combination of affects to +be met with in psychiatry.</p> + +<p>The stupor reaction, then, is a simple regression, +with a limitation of energy, emotion and ideational +content, the last being confined to notions of death. +All functional psychoses are regressions. How do +the others differ from this? We need only answer +this question in so far as it concerns the clinical +states resembling benign stupors. Stupors occur +frequently in catatonic dementia præcox. In this +disease there is a regression of interest to primitive +fantastic thoughts, and with this a perversion of +energy and emotion. This corrupts the purity of the +stupor picture so that inconsistencies, such as empty +giggling, atypical delusions and scattered speech, +occur. Other impurities are to be found in the +frequent orientation of the dementia præcox stupor +patient which is discovered to be astonishingly good, +or in free speech associated with apathy and inactivity. +Such symptoms usually appear quite early and +should enable one to make a positive diagnosis +within a short time after patient comes under observation. +As a matter of fact, in many if not most +cases there is a slow onset characterized by the +pathognomonic symptoms of dementia præcox before +the actual stupor sets in.</p> + +<p>Other psychoses superficially resembling stupor +are the perplexity and absorbed manic (manic +stupor) states. We have reason to believe that both +these conditions are essentially the result of absorption +in kaleidoscopic ideas. Their appearance<!-- Page 246 --><span class='pagenum'><a name="Page_246" id="Page_246">[246]</a></span> +is that of inactivity and indifference to the outside +world, just as a dreamer seems placid and apathetic. +But these reactions are not without emotion which +may sometimes be obvious, and the richness of the +mental content is sooner or later manifest.</p> + +<p>Finally, from a practical standpoint, an important +peculiarity of benign stupor is the tendency for response +to stimulation in amelioration of the process. +Close attention to these patients is advisable, therefore, +not merely for the sake of their physical health, +but also because any attention tends to keep them +mentally alive or revive their waning energy. Visits +of relations often initiate recovery in a striking way. +From occurrences such as these, psychiatrists +should gain hints for valuable therapeutic experiments.</p> + +<p>So much for the technical, psychiatric aspects of +the stupor problem. We have frequently spoken of +it, however, as a psychobiological reaction. If this +be a sound view, similar tendencies should appear +in everyday life, the psychotic phenomena being +merely the exaggerations of a fundamental type of +human and animal behavior. Shamming of death in +the face of danger and animal catalepsy come to +mind at once, but since we know nothing of the associated +affective states we should be chary of using +them even as analogies. We are on safer ground in +discussing problems of human psychology.</p> + +<p>It is evident that there are psychological parallels +between the stupor reaction and sleep, while future +work may show physiological similarities as well.<!-- Page 247 --><span class='pagenum'><a name="Page_247" id="Page_247">[247]</a></span> +Apathy towards the environment, inactivity and a +thinking disorder are common to both. But sleep +reactions do not occur in bed alone. Weariness produces +indifference, physical sluggishness, inattention +and a mild thinking disorder such as are seen +in partial stupors. The phenomena of the midday +nap are strikingly like those of stupor. The individual +who enjoys this faculty has a facility for retiring +from the world psychologically and as a result +of this psychic release is capable of renewed activity +(analogous to post-stuporous hypomania) that cannot +be the result of physiological repair, since the +whole affair may last for only a few minutes.</p> + +<p>In everyday life there are more protracted states +where the comparison can also be made. When life +fails to yield us what we want, we tend to become +bored—a condition of apathy and inactivity, forming +a nice parallel to stupor inasmuch as external +reminders of reality and demands for activity are +apt to call out irritability. A form of what is really +mental disease, although not called insanity, is permanent +boredom, a deterioration of interest, energy +and even intelligence by which many troubled souls +solve their problems. A sudden withdrawal from +the world we call stupor. When the same thing +happens insidiously, the condition is labeled according +to the financial and social status of the victim. +He is a bum, a loafer, a mendicant or, more politely, +a disillusioned recluse. Frequently this undiagnosed +dement has satisfied himself with a weak, cynical +philosophy that life is not worth while.</p> + +<p><!-- Page 248 --><span class='pagenum'><a name="Page_248" id="Page_248">[248]</a></span></p><p>It is but a step from valueless life to death and +the same tendency which makes the patient fancy he +is dead, leads the tired man to sleep, the poet to +sigh in verse for dissolution, and the myth maker +to fabricate rebirth. The religions of the world are +full of this yearning, which reaches its purest expression +in the belief and philosophy of Nirvana. +The ideational content of stupor has also its analogue +in crime. The desire for perpetuation of relationships +unprosperous in this world is not seen only +in the delusion of mutual death. One can hardly +pick up a newspaper without reading of some unhappy +man or woman who has slain a disillusioned +lover and then committed suicide.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_12_14" id="Footnote_12_14"></a><a href="#FNanchor_12_14"><span class="label">[12]</span></a> Kirby, George H.: "The Catatonic Syndrome and Its Relation +to Manic-Depressive Insanity." <cite>Jour. of Nervous and Mental Disease</cite>, +Vol. XL, No. 11, 1913.</p></div> +</div> + +<p><!-- Page 249 --><span class='pagenum'><a name="Page_249" id="Page_249">[249]</a></span></p> + +<h2><a name="CHAPTER_XV" id="CHAPTER_XV">CHAPTER XV</a><br /> + +<span class="sm">THE LITERATURE OF STUPOR<a name="FNanchor_C_15" id="FNanchor_C_15"></a><a href="#Footnote_C_15" class="fnanchor">[C]</a></span></h2> + +<p>The cases of benign stupor which we report here +are not clinical curiosities. Taking the symptoms as +the products of a reaction type, the latter is really +quite common. One, therefore, asks what other +psychiatrists have done with this material. How +have they described these stupors, how classified +them? This chapter, essentially an appendix, attempts +to give a brief answer to this inquiry. No +attempt is made to catalogue all that has been written +on or around this subject but only to mention +typical reports and viewpoints.</p> + +<p>The French, beginning with Pinel in the 18th +Century, were the first to write extensively of +stupor. An excellent paper by Dagonet<a name="FNanchor_13_16" id="FNanchor_13_16"></a><a href="#Footnote_13_16" class="fnanchor">[13]</a> appeared +in 1872, in which such literature as had appeared up +to that time is discussed. He defines "Stupidity" +as a form of insanity in which "delirious" ideas +may or may not be present, which has for its characteristic +symptoms a state of more or less manifest<!-- Page 250 --><span class='pagenum'><a name="Page_250" id="Page_250">[250]</a></span> +stupor and a greater or less incapacity to coördinate +ideas, to elaborate sensations experienced and accomplish +voluntary acts necessary for adaptation. +This would seem to include our "partial stupor," as +well as the more marked cases.</p> + +<p>He quotes an excellent definition from Louyer +Villermay (Dict. des sc. méd. t. LIII, p. 67). "Stupor +is a term applied to stupefaction of the brain. +It is recognizable by the diminution or enfeeblement +of internal sensation and by a greater difficulty in +exercising memory, judgment and imagination. It +is accompanied by a general numbness and a weakness +of feeling and movement. The patient, then, +has an indefinite and stupid expression, he understands +questions put to him with difficulty, and +answers them with effort or not at all. He seems +overwhelmed with sleep, he forgets to withdraw his +tongue after showing it to the doctor, he complains +of no uncomfortable sensation, of no illness, he +seems to take no interest in what goes on about him.... +The stupor patient is a fool who does not speak, +in this being more tolerable than the one who speaks +[delightful naiveté!]. One who is dumbfounded by +surprise or fright is also to be called stuporous."</p> + +<p>Dagonet says stupor results from various causes, +such as exhaustion, or emotional and intellectual +factors. Clinically it varies in kind and degree according +to the situation in which it develops. When +it develops during normal mental health, it disappears +when its cause does. In insanity it appears +in the course of a psychosis of some duration, of<!-- Page 251 --><span class='pagenum'><a name="Page_251" id="Page_251">[251]</a></span> +which it seems a part, an exaggeration of some +symptom of the general condition. Evidently he +views stupor as a type of reaction: as a more or less +complete suspension of the operation of intellectual +faculties, a more or less sudden subtraction of +nervous forces. This reaction can result from a +fright or the memory of it, a brain lesion or trauma, +the action of narcotics, exhausting fevers, excessive +grief, the terrors of alcoholic hallucinations, epileptic +seizures, profound anemia and nervous exhaustion +consequent on sexual excess. He is careful to +say that both symptoms and treatment vary with +the varied etiologies.</p> + +<p>He credits Pinel with being the first to call attention +to stupor. This author claimed that some +persons with extreme sensibility could be so upset +by any violent emotion as to have their faculties +suspended or obliterated. He noted, too, that +stupors frequently terminated in manic phases of +20 to 30 days' duration. Pinel also emphasized the +apathy of these cases. Esquirol called stupor +"acute dementia," a term which persisted in French +literature for a long time. He described an interesting +circular case where alternations between +mania and typical stupor took place. He mentions +too the dangerous, impulsive tendencies of many +patients. Georget emphasized the fact which Pinel +had also noted, that retrospectively the stupor patient +says his mind was a blank during the attack. +In 1835 Etoc-Demazy published on the subject. He +regarded stupor not as a separate form of insanity<!-- Page 252 --><span class='pagenum'><a name="Page_252" id="Page_252">[252]</a></span> +but a complication ensuing on monomania or mania. +He recognized the partial as well as complete stupor. +He thought the condition was due to cerebral +edema, as did other writers of that period. Dagonet +remarks about this last—a lesson not learned in +fifty years by the profession—that demonstrable +edema does <em>not</em> produce the typical symptoms of +stupor. Baillarger in 1843 (Annales Médico-psychologiques) +was the first whose ambition to simplify +psychiatric types led to denial of a separate kind +of reaction. He claimed that stupor was not a form +of insanity but an extension of a "délire mélancholique." +As Dagonet remarks, every symptom by +which he characterizes stupor is a psychiatric symptom +and insanity can consist just as well in the +diminution as the perversion or exaltation of normal +faculties. Some of Baillarger's cases had false +ideas, some apparently none at all. Dagonet thinks +this justifies two types, one a dream-like state and +another where no ideas are present, although he +admits one may be an exaggeration of the other. +Brierre de Boismont (Annales Médico-psychologique, +1851, p. 442) compares these two kinds of +stupors to deep sleep when intelligence is completely +suspended and to sleep with dreams. (These two +types would correspond to our "absorbed mania" +and true deep stupor.) He urges strongly the +separation of stupor from melancholia as an entirely +different type of reaction, in this connection citing +the views pro and con of various authors. Of these<!-- Page 253 --><span class='pagenum'><a name="Page_253" id="Page_253">[253]</a></span> +Delasiauve is particularly cogent in discriminating +stupor from melancholia on the grounds of the difference +of the emotional reactions and of the intellectual +disorder and the real paucity of thought in +the former psychosis.</p> + +<p>After quoting these and other authors, Dagonet +offers an explanation for the diversity of opinion. +He says that stupor following another psychosis +may retain some of its symptoms, so that a mixture +obtains, as often in medicine. He then gives excellent +descriptions of three types: the deep stupor +with paralysis of the faculties, the cases that are +absorbed in false ideas, and ecstatic cataleptics.</p> + +<p>The remainder of his paper is concerned with +cases and discussions about them. He cites examples +of stupor following fear or other emotional +shocks, following grave injuries such as the loss of +a limb, following head trauma and with typhoid +fever. As to the last he points out that delirious +features are prominent. Many authors have assigned +sexual excesses as a cause of stupor. The +psychosis, Dagonet says, is not pure but more a +mixture of hypochondria and depression. Relationship +with mania is next considered. He says that +stupor may succeed, alternate with or precede +mania. His cases seem mainly to have been what +we call absorbed manics or manic stupors. In fact, +he uses the last term. The commonest introductory +psychosis, he claims, is depression, but from his +brief case reports it would seem that most of his<!-- Page 254 --><span class='pagenum'><a name="Page_254" id="Page_254">[254]</a></span> +patients were not stuporous, in the narrow sense of +the term, but severely retarded depressions. In fact, +in perusing his case material comprising "stupors" +in the course of many types of functional insanity, +or as a complication of epilepsy or general paralysis, +it is evident that in practice he does not follow +the discriminative definitions of the earlier portion +of his paper. For him, apparently, patients who +are markedly inaccessible to examination from +whatever cause are "stuporous." He closes with +excellent remarks on physical and psychic treatment. +As to prognosis he has nothing to say beyond +the opinion that most of the cases recover.</p> + +<p>If Dagonet be accepted as summarizing the early +French work, we can conclude that their generalizations +were on the whole quite sound. These were: +that stupor is an abnormal mental reaction, usually +psychogenic but often the result of exhaustion, that +it consists in a paralysis of emotion, will and intelligence; +that the prognosis is usually good; that +mental stimulation may produce recovery. What +remained to be done after this work was the refinement +in detail of these generalizations, particularly +in respect to the differentiation of prognostically +benign and malignant types. But other Frenchmen +did not take up this work, apparently, for the brilliant +psychopathologists of the next generations +attended to stupor only in so far as it was hysterical.</p> + +<p>An Englishman, however, soon took up the task, +adding more exactness to his formulations. New<!-- Page 255 --><span class='pagenum'><a name="Page_255" id="Page_255">[255]</a></span>ington<a name="FNanchor_14_17" id="FNanchor_14_17"></a><a href="#Footnote_14_17" class="fnanchor">[14]</a> +published his important paper in 1874. A +nascent stage of stupor, he thinks, is a common reaction +to great exhaustion, "such as hard mental +work, prolonged or acute illness, dissipation, etc." +Such conditions, like the grave psychotic forms, he +regarded as due to physical exhaustion of the brain +cells, but, since he thought psychic stress could produce +this exhaustion, this "organic" view did not +bias his general formulations. He makes a division +into two stupors: Anergic Stupor and Delusional +Stupor. The former may be primary, being generally +caused by a sudden intense shock (Esquirol's +"Acute Dementia"), or secondary (a) to convulsions +of any kind, (b) to mania in women, (c) to any +other prolonged nervous exhaustion. The delusional +form results from (a) intense melancholia, (b) from +general paralysis in which it may be intercurrent, +(c) from epileptic seizures. When one examines his +points of difference between these two types, it becomes +clear that Newington really gave an excellent +differentiation of benign and malignant stupor—in +fact, it is the only serious attempt at such discrimination +prior to this present work. What is more +remarkable is the fact that, although he clearly saw +the clinical differences, he failed to see that the two +types differed prognostically. His description is +given in a table sufficiently concise to justify its +quotation <i lang="la">in extenso</i>.</p> + +<p><!-- Page 256 --><span class='pagenum'><a name="Page_256" id="Page_256">[256]</a></span></p> + +<table class="symp" summary="Differences between Anergic and Delusional stupor" width="95%"> + +<tr><th></th><th><i>ANERGIC STUPOR</i></th> <th><i>DELUSIONAL STUPOR</i></th></tr> + +<tr><th class="rhead"><i>Etiology</i>—</th> +<td>Hereditary and + individual liability to + sudden loss of <i lang="la">vis nervosa</i>.</td> + +<td>Hereditary.</td></tr> + +<tr><th class="rhead"><i>Onset</i>—</th> + +<td>Rapid.</td> + +<td>Usually insidious, may be almost +instantaneous.</td></tr> + +<tr><th class="rhead"><i>Symptoms</i>—</th> +<td>Intellect greatly + impaired.</td> +<td>Conduct shows reasoning power.</td> +</tr> + +<tr><th class="rhead"><i>Memory</i>—</th> +<td>Seems to be swept + away as far as possible.</td> + +<td>Found after recovery to have +been preserved to a great +extent.</td></tr> + +<tr><th class="rhead"><i>Emotional Capacity</i>—</th> +<td>Nil or + almost so. Tears frequent + but due to relaxation of + sphincter muscles. Features + relaxed, eyes vacant and not + constantly fixed.</td> + +<td>Evidence of grief, fear, etc., in +facial expressions and wringing +and clasping of hands. +Tears rare. Great contraction +of features [grimacing?]. +Eyes fixed on one +point, usually upwards or +downwards, or else obstinately +closed.</td> +</tr> + +<tr><th class="rhead"><i>Volition</i>—</th> +<td>Almost absent.</td> + +<td>Frequently great stubbornness, +refusal to do what is +wanted. On the other hand, +intense determination in +following out own plan.</td></tr> + +<tr><th class="rhead"><i>Motor System</i>—</th> +<td>Weak and uncertain. + Patient has to be + led about and if placed on a + seat or in some position does + not move. ("Cataleptoid" + condition.)</td> + +<td>But little interfered with, +independently of sheer asthenia, +produced by patient's + conduct. May stand behind +door or kneel on floor in +constrained position even for +days.</td></tr> + +<tr> +<th class="rhead"><!-- Page 257 --><span class='pagenum'><a name="Page_257" id="Page_257">[257]</a></span> +<i>Sensory System</i><br /> +<i>Reflex System</i>—</th> + +<td><span class="xlg">}</span> Both dull.</td> + +<td>Ditto. There seems to be a +much greater ability to bear +severe pain.</td></tr> + +<tr><th class="rhead"><i>Pupils</i>—</th> +<td>Dilated.</td> +<td>Tendency to contraction.</td></tr> + +<tr><th class="rhead"><i>Sleep</i>—</th> +<td>Generally good.</td> +<td>Intense sleeplessness.</td></tr> + +<tr><th class="rhead"><i>General bodily condition</i>—</th> +<td> Emaciation, sometimes extreme, + usually rapid, with + rapid recovery of flesh. + Often not much loss of + weight, though whole tone is + lowered.</td> + +<td>Affected <i lang="la">pari passu</i> with +mental state and seems + governed by it.</td></tr> + +<tr><th class="rhead"><i>Vascular System</i>—</th> +<td>Pulse slow, + sometimes almost imperceptible. + Cyanotic appearance, edema + and iciness of extremities. + Great decrease of vitality + in peripheral structures, + as shown by asthenic + eruptions and production of + vermin.</td> + +<td>Pulse weak and often quick +and thready. Complexion +anemic and sallow. The +other appearances may be +present but come on later +and are less marked.</td></tr> + +<tr><th class="rhead"><i>Digestive System</i>—</th> +<td>Tongue + clean or if furred it is moist. + Appetite <em>apathetic</em>, bowels + not irregular, but habits + very dirty.</td> + +<td>Tongue dry, small and furred. +Refusal of food. Great +constipation. Dirtiness of +habits rare.</td></tr> + +</table> + +<p>If one compares these data with those given in +the chapter on Malignant Stupors, it is seen that in +the main Newington has made the same discrimination +as we have. He is certainly wrong in denying +"negativism" to his anergic type. Probably, too, +he attempts too fine a distinction between the<!-- Page 258 --><span class='pagenum'><a name="Page_258" id="Page_258">[258]</a></span> +physical symptoms of the two groups. His conclusions +are interesting: that in the anergic cases there +is an <em>absence</em> of cerebration, while amongst the delusional +there is an abnormal <em>presence</em> of intense but +perverted cerebration. This is not unlike our own +view. He thinks the difference in memory is the +most important differential point. Sex is important +in determining the nature of the stupor, for he found +the anergic type following mania in females only. +He observed such an end to manic attacks in 6 out +of 36 cases. All his cases were under 30 and he regards +the prognosis as good on the whole. As to +treatment he emphasizes the necessity for "moral +pressure" as a stimulus and cites a case of rapid +improvement after a change of scene.</p> + +<p>Since 1874 very little advance has been made by +British psychiatrists, as seen by a perusal of Clouston's<a name="FNanchor_15_18" id="FNanchor_15_18"></a><a href="#Footnote_15_18" class="fnanchor">[15]</a> +summary in 1904. He regards sex exhaustion +as a highly frequent cause, although Dagonet had +shown 32 years before that sex abuse does not produce +a true stupor. He thinks stupor usually follows +depression or mania and says that "the 'Confusional +Insanity' of German and American authors is just +a lesser degree of stupor." Omitting his stupors in +general paralysis and epilepsy he makes three clinical +divisions: <em>melancholic or conscious stupor</em>, which +is not a product of delusions, although delusions of +death or great wickedness may be present, impulsiveness +and fits may be observed; <em>anergic or<!-- Page 259 --><span class='pagenum'><a name="Page_259" id="Page_259">[259]</a></span> +unconscious stupor</em>, which corresponds roughly to +our deep, benign stupor; and <em>secondary stupor</em> after +acute mental disease, which resembles our partial +stupor. He warns against a rash diagnosis of dementia +in this last group. His views on the importance +of mental causation and the relation to manic-depressive +insanity may be gathered from these +sentences: "The condition of the mental portion of +the convolutions in stupor is probably analogous to +the stupidity of a nervous child when terrified or +bullied." "Stupor is frequently one of the stages +of alternating insanity following the exalted condition. +It is more apt to occur in those where the +exalted period is acutely maniacal. The stupor is +usually melancholic in form." Since he claims that +the anergic is a "very curable form of mental disease," +while only 50% of the melancholic cases recover, +it seems clear that this division is not +prognostically final. The "melancholic" is evidently +Newington's "delusional" without his more accurate +discrimination of symptoms.</p> + +<p>From the standpoint of accurate description the +opinion may be ventured that there is a gap in the +literature from the early French writers and Newington +up to the paper by Kirby, which has been discussed +in the first chapter. This gap is filled by +literature of the German schools and their adherents +in other countries. German psychiatry has been +concerned mainly with classification or the elaborate +examination of certain symptoms. Inevitably such +a program militates against detached objective clini<!-- Page 260 --><span class='pagenum'><a name="Page_260" id="Page_260">[260]</a></span>cal +description. It is hard to record symptoms that +interfere with classification. German psychiatry has +tended to make the insane patient a type rather +than an individual. Hence the gap in the descriptive +literature of stupor.</p> + +<p>The necessity of establishing the possibility of +some stupors having a good prognosis has arisen +from Kraepelin's work. He can rightly be viewed +as the father of modern psychiatry because he introduced +a classification based on syndromes and +taught us to recognize these disease groups in their +early stages. Inevitably with such an ambitious +scheme as the pigeon-holing of all psychotic phenomena +some mistakes were made. Most of these +appear in the border zone between dementia præcox +and manic-depressive insanity. The latter group +being narrowly defined, the former had to be a waste +basket containing whatever did not seem to be a +purely emotional reaction. Clinical experience soon +proved that many cases which, according to Kraepelin's +formulæ, were in the dementia præcox group, +recovered. Adolf Meyer was one of the first to protest +and offered categories of "Allied to Manic-Depressive +Insanity" or "Allied to Dementia Præcox," +as tentative diagnostic classifications to include +the doubtful cases.</p> + +<p>Difficulties with stupor furnish an excellent example +of the confusion which results from the adoption +of rigid terminology. The earlier psychiatrists +were free to regard a patient in stupor as capable +of recovery as well as deterioration. When Kahl<!-- Page 261 --><span class='pagenum'><a name="Page_261" id="Page_261">[261]</a></span>baum +included stupor with "Catatonia," the situation +was not changed, for he did not claim a hopeless +prognosis for this group. But when Kraepelin made +catatonia a subdivision of dementia præcox, all +stupors (except obvious phases of manic-depressive +insanity) had to be hysterical or malignant. Faced +with this dilemma psychiatrists have either called +recoveries "remissions" or, like E. Meyer, claimed +that one-fifth or one-fourth of catatonics really get +well.</p> + +<p>As a matter of fact it seems clear that stupor is a +psychobiological reaction that can occur in settings +of quite varied clinical conditions. It is not necessary +to detail publications describing stupors in +hysteria, epilepsy, dementia præcox or in the organic +psychoses. It may be of interest, however, to cite +some examples of acute, benign stupors and the discussion +of them which appear in the literature of +recent years.</p> + +<p>An important group is that of stupors occurring +as prison psychoses. Stern<a name="FNanchor_16_19" id="FNanchor_16_19"></a><a href="#Footnote_16_19" class="fnanchor">[16]</a> mentions that acute +stupors are found in this group. Wilmanns<a name="FNanchor_17_20" id="FNanchor_17_20"></a><a href="#Footnote_17_20" class="fnanchor">[17]</a> examined +the records for five years in a prison and +discovered that there were two forms of psychotic +reaction, a paranoid and a stupor type. It is interesting +psychologically that the former appeared +largely among prisoners in solitary confinement,<!-- Page 262 --><span class='pagenum'><a name="Page_262" id="Page_262">[262]</a></span> +while the stupors developed preponderantly among +those who were not isolated. The stupors recovered +more quickly. He describes the psychosis thus: +The prisoner becomes rather suddenly excited, destructive +and assaultive; then soon passes into an +inactive state, where he lies in bed, mute, with open +expressionless eyes. He is clean, however; eats +spontaneously and attends to his own hygienic +needs. Some cases are roused by transport from +the jail to the hospital but sink into lethargy again +when they reach their beds. Physically, they show +disturbances of sensation which vary from analgesia +to hypesthesia. There are a rapid pulse, positive +Romberg sign, exaggerated reflexes, fibrillary +twitching of the tongue and tremor of the hands. +Recovery takes place gradually. They begin to +react to physical stimuli and to answer questions, +although still inhibited, until consciousness is quite +clear. When speech begins, it is found that they are +usually disoriented for place and time as the result +of an amnesia which sets in sharply with the excitement. +This memory defect gradually improves <i lang="la">pari +passu</i> with the other symptoms.</p> + +<p>Two attacks in the same prisoner of what seem to +have been typical stupor are reported by Kutner<a name="FNanchor_18_21" id="FNanchor_18_21"></a><a href="#Footnote_18_21" class="fnanchor">[18]</a> +and Chotzen.<a name="FNanchor_19_22" id="FNanchor_19_22"></a><a href="#Footnote_19_22" class="fnanchor">[19]</a> The patient was a recidivist of unstable +mental make-up. At the age of 34 he was sent<!-- Page 263 --><span class='pagenum'><a name="Page_263" id="Page_263">[263]</a></span> +to prison for three years. Shortly after confinement +began, he became stuporous, being mute and negativistic, +soiling, refusing food and showing stereotypy. +On being shifted to another institution he appeared +suddenly much better, although he remained +apathetic and dull for some months. A striking +feature was a complete amnesia, not merely for the +stupor but also for his trial and entrance to the +prison. At the age of 42, he was again incarcerated. +A practically identical picture again developed, with +recovery when his environment was changed, and +with a similar amnesia. Recovery seemed to be +complete and there were no hysterical stigmata. +The interesting features of this case are that a +typical stupor seems to have been precipitated by +imprisonment, while the retroactive amnesia covering +a painful period of the patient's life reminds one +of hysteria.</p> + +<p>A case which is more difficult to interpret is reported +briefly by Seelig.<a name="FNanchor_20_23" id="FNanchor_20_23"></a><a href="#Footnote_20_23" class="fnanchor">[20]</a> A man of 20 with bad +inheritance tried to steal 100 marks. When sent to +jail he became ill shortly before his trial was due +and was sent to a hospital. There he seemed anxious, +was shy, and gave slow answers, with initial +lip motions and had to be urged to take hold of +objects. All this sounds more like a pure depression +than a stupor. But he also had paralogia. This +might make one think of a Ganser reaction on the +background of depression. S., however, calls it an<!-- Page 264 --><span class='pagenum'><a name="Page_264" id="Page_264">[264]</a></span> +hysterical stupor, although he agreed with Moeli +that it was hard to differentiate from a catatonic +state.</p> + +<p>Löwenstein<a name="FNanchor_21_24" id="FNanchor_21_24"></a><a href="#Footnote_21_24" class="fnanchor">[21]</a> reports an interesting case of a +dégénéré who had had hysterical attacks. He suddenly +developed stupor symptoms, which lasted with +interruptions for nearly two years. After recovery +and during the interruptions the patient explained +his mutism, refusal to swallow, his filthiness and +general negativism as all occasioned by delusions. +He was commanded by God to act thus, the attendants +were devils, and so on. He spoke, too, of being +under hypnotic influence. In addition there were +other delusions such as that he had killed his +brother. The attack came on with the belief that he +was going to die, otherwise none of the ideas were +typical of the stupors we have studied. Another +incongruous symptom was that he did not seem to +be really apathetic, he reacted constantly to the environment. +The author comments on the absence of +senseless motor phenomena, such as would be expected +in a "catatonic." His complete memory of +the psychosis also speaks against the usual form of +stupor. It seems possible that this psychosis was +neither hysterical nor a benign stupor in our sense, +but, rather, an acute schizophrenic reaction such as +one occasionally sees. From the account which Löwenstein +gives, one gathers that the patient was absorbed +in a wealth of imaginations.</p> + +<p><!-- Page 265 --><span class='pagenum'><a name="Page_265" id="Page_265">[265]</a></span></p><p>Gregor<a name="FNanchor_22_25" id="FNanchor_22_25"></a><a href="#Footnote_22_25" class="fnanchor">[22]</a> tells of a stupor which is unusual in that +it consisted only of symptoms connected with inactivity, +which did not affect the intellectual processes. +The patient was a rubber worker who suddenly developed +a depression with self-accusation and +convulsions. She was soon admitted to a clinic and +then showed mutism and catalepsy. Later she became +totally immobile with no apparent psychic +reactions, and soiled. Gregor studied pulse, respiration +and respiratory volume in their reflex manifestations +and found nothing unusual. Next he +tried to discover if there were voluntary alterations +in respiration. He discovered that the respiratory +curve could be changed by calling out words to her, +by odors associated with suggestions, menaces, etc. +[This is suggestive of the dissociation of affect, +which we have discussed.] After two months she +recovered, <em>with complete recollection of the stupor +period</em>. It was then proven that the absence of +reactions was not the same as the lack of perception +of stimuli.</p> + +<p>Froederström<a name="FNanchor_23_26" id="FNanchor_23_26"></a><a href="#Footnote_23_26" class="fnanchor">[23]</a> reports a case that suggests hysteria, +where the stupor lasted for 32 years. A girl +at the age of 14 fell on the ice, had a headache, went +to bed and stayed there for 32 years. She lay there<!-- Page 266 --><span class='pagenum'><a name="Page_266" id="Page_266">[266]</a></span> +immobile, occasionally spoke briefly and took nourishment, +when it was put at a definite place at the +edge of the bed. At first (according to a late statement +of her brothers) this consisted only of water +but was soon changed to two glasses of milk a day. +After being in this state for ten years she was placed +in a hospital for two weeks, where she was mute, +did not react to pin pricks and had to be fed. It +seems that at home she secretly looked after herself, +for she kept her hair and nails in condition. Sometimes +she sat up and stared at the ceiling.</p> + +<p>After attending to the patient for 30 years, her +mother died. The patient cried for several days +when told of it, and after this she took nourishment +of her own accord. Two years later a brother died. +Again she cried on hearing the news. Her father, +who looked after her when the mother was dead, also +died. Then a governess came into the home, who +noticed that furniture was moved about when she +was alone.</p> + +<p>At the age of 46 she suddenly woke up and asked +at once for her mother. She claimed total amnesia +for the period of her stupor, including the stay at +the hospital. She could summon memories of her +childhood, however. Her brothers she did not recognize +and said, "They must be small." She recalled +the fall on the ice and coming home with +headache, toothache and pain in the back. Her general +knowledge was limited but she could read and +write. Her expression and appearance was that of +a young person, only her atrophic breasts and the<!-- Page 267 --><span class='pagenum'><a name="Page_267" id="Page_267">[267]</a></span> +fat on her buttocks betraying her age. She had been +well for four years at the time the report was made.</p> + +<p>He thinks that a certain tendency to exaggeration +and simulation speak for hysteria. We would be +more inclined to view the fact that she looked after +herself in spite of complete amnesia as evidence of +hysteria.</p> + +<p>Another protracted case suggestive of hysteria is +that reported by Gadelius.<a name="FNanchor_24_27" id="FNanchor_24_27"></a><a href="#Footnote_24_27" class="fnanchor">[24]</a> The patient was a +tailor, 32 years old, who had always been rather +taciturn and slow. A year before admission he began +to have ideas of persecution and to shun people. Then +he developed a stereotyped response, "It is nice +weather," whenever he was addressed. A month +before admission inactivity set in. He would sit +immobile in his chair with closed eyes and relaxed +face; he resisted when an attempt was made to put +him to bed. His color was pale.</p> + +<p>He was taken to hospital on November 1, 1882, +where he was observed to be immobile and to have +little reaction to pin pricks. When a limb was raised, +it fell limply. However, he would leave bed to go to +the toilet. Tube-feeding became necessary, but when +the tube was inserted in his nose, he woke up. He +then showed an amnesia not merely for his illness +but for his whole life: he did not know his father, +that he was married or that he had a mother. To<!-- Page 268 --><span class='pagenum'><a name="Page_268" id="Page_268">[268]</a></span>wards +the end of November, he became limp again +and answered, "I don't know" to most questions. +In December, however, he improved again and for +a few months these variations occurred. From +April, 1883, to May, 1886, he was in deep stupor, +almost absolutely immobile and close to being completely +anesthetic even with strong Faradic currents. +Towards the end of this period he walked +about <em>whenever he thought he was not watched</em>. He +was very cautious about this and became motionless +any time he became aware of observation. (Gadelius +thinks this was not simulation but the expression of +an automatism on the basis of a vague fixed idea.)</p> + +<p>This condition persisted apparently for five years +more, by the end of which time the anesthesia had +turned into a hyperesthesia. A year later he began +to eat. It was now found that he had an amnesia +for his illness and former life, so that he did not +even recognize a needle or pair of scissors. He knew +that he was born in the month of February and retained +some facility in calculation, in speech, walking +and usual motions. Then he regained all his +memories and resumed his trade as tailor. He was +discharged in June, 1893, nearly eleven years after +admission.</p> + +<p>It seems safe to say that elements at least of hysteria +appear in this history, such as the profound +retroactive amnesia and appearance of simulation +in the conduct of the patient. Accurate and rapid +grasp of the environment is necessary for such a +watch as he kept on the eye of his attendants. Men<!-- Page 269 --><span class='pagenum'><a name="Page_269" id="Page_269">[269]</a></span>tal +acuity of this grade combined with amnesia looks +more like an hysterical than a manic-depressive +process.</p> + +<p>Leroy<a name="FNanchor_25_28" id="FNanchor_25_28"></a><a href="#Footnote_25_28" class="fnanchor">[25]</a> describes a case much like ours which is +interesting from a therapeutic standpoint. The patient +was a woman who passed from a severe depression +with hallucinations and anxiety into a long +stupor, from which she recovered completely. There +was no negativism and no affect, although the latter +appeared so soon as contact began to be established. +When well she had a complete amnesia for the onset +of the psychosis. Leroy attributed the recovery, in +part at least, to the thorough attention given the +patient. Kraepelinian rigidity is seen, however, in +the author's refusal to regard the case as "circular" +because of the lack of all cyclic symptoms. He takes +refuge in the meaningless label "Mental Confusion."</p> + +<p>An important group of cases is that of the stupors +occurring during warfare. Considering stupor as +a withdrawal reaction, it is surprising there were so +few of them, although partial stupor reactions as +functional perpetuation of concussion were very +common. The editor saw several typical cases in +young children in London who passed into long +"sleeps" apparently as a result of the air raids.<!-- Page 270 --><span class='pagenum'><a name="Page_270" id="Page_270">[270]</a></span> +Myers<a name="FNanchor_26_29" id="FNanchor_26_29"></a><a href="#Footnote_26_29" class="fnanchor">[26]</a> has given us the best account of stupors in +actual warfare. A typical case was that of a man +who was found in a dazed condition and difficult to +arouse. He could give little information about himself, +could neither read nor write and never spoke +voluntarily. A week later his speech was still limited +and labored and no account of recent events +could be obtained from him. Under hypnosis he was +induced to talk of the accident which had precipitated +this disorder. He became excited in telling +his story, evidently visualizing many of the events. +In several successive séances, more data were obtained +and a cure effected. Myers points out that +in all his cases there was a mental condition which +varied from slight depression to actual stupor, all +had amnesias of variable extent and all had headaches. +The mental content seemed to be confined to +thoughts of bombardment, with a tendency for the +mind always to wander to this topic. The author +thinks that pain is a guardian protecting the patient +from too distressing thoughts. An effort to speak +would cause pain in the throat of a case of mutism +and, sometimes, when a distressing memory was +sought after under hypnosis, physical pain would +wake the sleeper. His view is that pains tend to +preserve the mutism and amnesia, so that there are +"inhibitory processes" causing the stupor, which +prevent the patient from further suffering. He does<!-- Page 271 --><span class='pagenum'><a name="Page_271" id="Page_271">[271]</a></span> +not find either in theory or experience reason to +believe that these conditions are the result of either +suggestion or "fixed ideas." He thinks it natural +that the last symptom of the stupor to disappear +should be mutism, as speech and vision are the +prime factors in communicating with environment. +[As has been noted frequently in this book, mutism +is a common residual symptom of the benign +stupor.] Myers believes that in nearly every instance +mutism follows stupor and is merely an attenuation +of the latter process. When deafness is +associated with mutism, he thinks it is often due +merely to the inattention of the stuporous state.</p> + +<p>In this connection we should mention that Gucci<a name="FNanchor_27_30" id="FNanchor_27_30"></a><a href="#Footnote_27_30" class="fnanchor">[27]</a> +points out that stupor patients with mutism of long +duration may, when requested, read fluently and +then relapse again into complete unreactiveness +towards auditory impressions. This, we would say, +is probably an example of a more or less automatic +intellectual operation occurring when the patient is +sufficiently stimulated, although he cannot be raised +to the point of spontaneous verbal productivity.</p> + +<p>As these scattered reports about benign stupors +are so unsatisfactory, one naturally turns to text-books. +Little more appears in them. Kraepelin +treats stupors occurring in manic-depressive insanity +as falling into two groups, the depressive and<!-- Page 272 --><span class='pagenum'><a name="Page_272" id="Page_272">[272]</a></span> +manic. The former seems to be nearer to our cases, +judging by the statements in his rather sketchy account. +He regards stupor as being the most extreme +degree of depressive retardation. [This possibility +has been discussed in the chapter on Affect.] His +description seems perhaps to include cases which we +would regard as perplexity states or absorbed +manias. Activity is reduced, they lie in bed mute, +do not answer, may retract shyly at any approach, +but on the other hand may not ward off pin pricks. +Sometimes there is catalepsy and lack of will, again +there may be aimless resistance to external interference. +They hold anything put into their hands, +turning it slowly as if ignorant of how to get rid of +it. They may sit helpless before food or may allow +spoon-feeding. Not rarely they are unclean. As to +the mental content, he says they sometimes utter a +few words, which give an insight into confused delusions +that they are out of the world, that their brains +are split, that they are talked about, or that something +is going on in the lower part of the body. The +affect is indefinite except for a certain bewilderment +about their thoughts and an anxious uncertainty towards +external interference. Intellectual processes +suffer. They are disoriented and do not seem to +understand the questions put to them. An answer +"That is too complicated" may be made to some +simple command. Kraepelin thinks that the disorder +is sometimes more in the realm of the will than of +thinking, for one patient could do a complicated calculation +in the same time as a simple addition. After<!-- Page 273 --><span class='pagenum'><a name="Page_273" id="Page_273">[273]</a></span> +recovery the memory for the period of the psychosis +is poor and quite gone for parts of it. Occasionally +there may be bursts of excitement, when they leave +the bed; they may scold in a confused way or sing a +popular song.</p> + +<p>His manic stupor is a "mixed condition," a combination +of retardation with elated mood. The condition +is different from the depressive stupor in that +activity is more frequent, either in constant fumbling +with the bed clothes or in spasmodic scolding, +joking, playing of pranks, assaultiveness, erotic +behavior or decoration. The affect is usually apparent +in surly expression or happy, or erotic, demeanor. +They are usually fairly clear and oriented +and often with good memory for the attack but with +evasive explanations for their symptoms. One cannot +make any classification of the ideas he quotes, +but it is apparent from all his description that the +minds of these "manic stupors" are not a blank but +rather that there is a fairly full mental content.</p> + +<p>Wernicke, unhampered by classifications of catatonia +and manic-depressive insanity with inelastic +boundaries, calls all stupor reactions akinetic psychoses +with varying prognosis. He does not make +Kraepelin's mistake of confusing the apathy of +stupor with the retardation of depression, stating +distinctly that the processes are different.</p> + +<p>Bleuler also has grasped this discrimination. He +points out that the thinking disorder in what he +terms "Benommenheit" (dullness) differentiates +such conditions from affectful depression with re<!-- Page 274 --><span class='pagenum'><a name="Page_274" id="Page_274">[274]</a></span>tardation. +He writes, of course, mainly of dementia +præcox,<a name="FNanchor_28_31" id="FNanchor_28_31"></a><a href="#Footnote_28_31" class="fnanchor">[28]</a> but makes some remarks germane to our +problem. In the first place he denies the existence +of stupor as a clinical entity, except perhaps as the +quintessence of "Benommenheit", it is the result of +total blocking of mental processes. Consequently, +he says, one can observe the external features of +stupor in all akinetic catatonics, in marked depressive +retardation, when there is a lack of interest, +affect or will, in autism, with twilight states, as a +result of negativism or, finally, when numerous +hallucinations distract the patient's attention into a +world of fancy. He notes that in all stupors (with +the exception, perhaps, of "Benommenheit") the +symptoms may disappear with appropriate psychic +stimulation or that some reaction, no matter how +larval, may be observed. He speaks, for instance, +of the visits of relatives waking the patient up.</p> + +<p>His only real group is "Benommenheit," which +he separates out as a true clinical entity. This seems +to correspond roughly with our "Partial Stupors." +It is essentially an affectless, thinking disorder, +usually acute, sometimes chronic, occurring among +schizophrenics. He believes that it is the result of +some organic process (intracranial pressure or +toxin). Activity is much reduced or absent; they +have poor understanding, answer slowly or confusedly; +their actions are sometimes as ridiculous as +those of people in panic (e.g., throwing a watch out<!-- Page 275 --><span class='pagenum'><a name="Page_275" id="Page_275">[275]</a></span> +of the window when the house is on fire); the defect +is best seen in writing, for large elisions are found +in sentences. He was able to analyze only one case +and she retained her affect; it was even labile and +marked. One suspects that such a case might, perhaps, +not really find a place in the "Benommenheit" +group even as Bleuler himself describes it.</p> + +<p>With the exception of Kirby, whose work has already +been discussed in the introduction, we have +been able to find only one author who has attempted +any symptomatic discrimination of the recoverable +and malignant catatonic states. Raecke<a name="FNanchor_29_32" id="FNanchor_29_32"></a><a href="#Footnote_29_32" class="fnanchor">[29]</a> made a +statistical study and found that 15.8% recovered, +10.8% improved, 54.4% remained in institutions, +while 30% died. With the etiology mainly exogenous +20% recovered and 14.3% improved. A good +outcome was seen in 30.2% of hereditary cases, +while only 22.7% did well in the non-hereditary +group. His most important contribution is in his +formulation of good and bad symptoms. He thinks +that dull, apathetic behavior with uncleanliness and +loss of shame are not so unfavorable as has been +thought. Malignant symptoms are grimacing with +prolonged negativism but without essential affect +anomaly, decided echopraxia and echolalia and +protracted catalepsy. We would agree with this, +although command automatisms have not been +prominent either in our benign or malignant +stupors.</p> + +<p><!-- Page 276 --><span class='pagenum'><a name="Page_276" id="Page_276">[276]</a></span></p><p>Two writers have made special observations that +should be confirmed and amplified before their significance +can be established. Whitwell<a name="FNanchor_30_33" id="FNanchor_30_33"></a><a href="#Footnote_30_33" class="fnanchor">[30]</a> thinks that +in addition to a diminished activity of the heart +there exists a pathological tension. Ziehen says that +he also has frequently seen angiospastic pulse-curves +in exhaustion stupor or acute dementia, but +that other pulse pictures may be seen as well. Any +such studies should be correlated rigorously with the +clinical states before they can have any meaning. +Wetzel<a name="FNanchor_31_34" id="FNanchor_31_34"></a><a href="#Footnote_31_34" class="fnanchor">[31]</a> tested the psychogalvanic reflex in stupors +and in normal persons who simulated stupors. He +found them different.</p> + +<p>Only one publication has come to our attention in +which an attempt is made at psychological interpretation +of various symptoms in stupor. Vogt<a name="FNanchor_32_35" id="FNanchor_32_35"></a><a href="#Footnote_32_35" class="fnanchor">[32]</a> derives +much from a restriction of the field of consciousness. +Only one idea is present at a time, hence +there is no inhibition and impulsiveness occurs. +Similarly, if the idea appear from without, it, too, +is not inhibited, which produces the suggestibility +that in turn accounts for catalepsy. Stereotypy and +perseveration are other evidences of this narrowness +of thought content. Negativism is a state, he +says, of perseverated muscular tension. [This +would apply only to muscular rigidity.] So far as it<!-- Page 277 --><span class='pagenum'><a name="Page_277" id="Page_277">[277]</a></span> +goes, this view seems sound. Of course it leaves +the problem at that interesting point, Why the restriction +of consciousness?</p> + +<p>If stupor be a psychobiological reaction, it should +occur, occasionally, in organic conditions just as the +deliria of typhoid fever may contain many psychogenic +elements. Gnauck<a name="FNanchor_33_36" id="FNanchor_33_36"></a><a href="#Footnote_33_36" class="fnanchor">[33]</a> reports such a case. The +patient, a woman, was poisoned by carbon dioxide. +At first there was unconsciousness. Then, as she +became clearer, it was apparent that she was clouded +and confused. She soiled. Neurological symptoms +were indefinite; enlargement of the left pupil, difficult +gait and exaggerated tendon reflexes. Months +later she was still apathetic, although her inactivity +was sometimes interrupted by such silly acts as +cutting up her shoes. After five months she recovered +with only scattered memories of the early part +of her psychosis. What seems like a typical stupor +content was recalled, however. She thought she was +standing in water and heard bells ringing.</p> + +<p>Stupor-like reactions are not infrequent in connection +with or following fevers. Bonhoeffer<a name="FNanchor_34_37" id="FNanchor_34_37"></a><a href="#Footnote_34_37" class="fnanchor">[34]</a> describes +a type that follows a febrile Daemmerzustand +of a few hours or a day at most. The affect +suddenly goes, disorientation sets in. Although +outbreaks of anxiety may be intercurrent, the dominant +picture is of stupor. Reactions are slowed,<!-- Page 278 --><span class='pagenum'><a name="Page_278" id="Page_278">[278]</a></span> +often there is catalepsy. Sometimes there is a retention +defect and confabulation to account for the +recent past. Again the retention may be good. In +the foreground stands a strong tendency to perseveration. +This may affect speech to the point of +an apparent aphasia or produce paragraphia. +Plainly organic aphasia and focal neurological +symptoms are sometimes seen.</p> + +<p>As Knauer<a name="FNanchor_35_38" id="FNanchor_35_38"></a><a href="#Footnote_35_38" class="fnanchor">[35]</a> has gone thoroughly into the question +of the febrile stupors, the reader is referred to +his paper for a digest of the literature on this topic. +Mention has already been made in Chapter IX to +this publication, where the close resemblance of +these rheumatic, to our benign functional, stupors +has been noted. Discrimination seems to be possible +only on the basis of delirium-like features being +added in the organic group.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_C_15" id="Footnote_C_15"></a><a href="#FNanchor_C_15"><span class="label">[C]</span></a> This chapter has been written mainly from material in Dr. +Hoch's notes which was manifestly incomplete. No claim is made +for its exhaustiveness.</p> +<p class="ralign"><i>The Editor.</i></p> + +</div> + +<div class="footnote"><p><a name="Footnote_13_16" id="Footnote_13_16"></a><a href="#FNanchor_13_16"><span class="label">[13]</span></a> Dagonet, M. H.: "De la Stupeur dans les Maladies Mentales et +de l'Affection mentale désignée sous le Nom de Stupidité." <cite>Annales +Medico-Psychologiques</cite>, T. VII, 5e Serie, 1872.</p></div> + +<div class="footnote"><p><a name="Footnote_14_17" id="Footnote_14_17"></a><a href="#FNanchor_14_17"><span class="label">[14]</span></a> Newington, H. Hayes: "Some Observations on Different Forms +of Stupor, and on Its Occurrence after Acute Mania in Females." +<cite>Journal of Mental Science</cite>, Vol. XX, 1874, p. 372.</p></div> + +<div class="footnote"><p><a name="Footnote_15_18" id="Footnote_15_18"></a><a href="#FNanchor_15_18"><span class="label">[15]</span></a> Clouston: "Mental Diseases." J. & A. Churchill, 1904.</p></div> + +<div class="footnote"><p><a name="Footnote_16_19" id="Footnote_16_19"></a><a href="#FNanchor_16_19"><span class="label">[16]</span></a> Stern: "Ueber die akuten Situations-psychosen der Kriminellen." +Abstracted, <cite>Zeitschr. f. d. ges. Neurol. u. Psychiatrie</cite>, Referate Bd. +V, S. 554.</p></div> + +<div class="footnote"><p><a name="Footnote_17_20" id="Footnote_17_20"></a><a href="#FNanchor_17_20"><span class="label">[17]</span></a> Wilmanns, K.: "Statische Untersuchungen über Gefängnisspsychosen." +<cite>Allgemeine Zeitschr. f. Psychiatrie</cite>, Bd. LXVII, S. 847.</p></div> + +<div class="footnote"><p><a name="Footnote_18_21" id="Footnote_18_21"></a><a href="#FNanchor_18_21"><span class="label">[18]</span></a> Kutner: "Ueber katatonischer Zustandsbilder bei Degenerierten." +<cite>Allgemeine Zeitschr. f. Psychiatrie</cite>, Bd. LXVII, S. 375.</p></div> + +<div class="footnote"><p><a name="Footnote_19_22" id="Footnote_19_22"></a><a href="#FNanchor_19_22"><span class="label">[19]</span></a> Chotzen: "Fall von degenerativem Stupor." Abstracted, +<cite>Zeitschr. f. d. ges. Neur. u. Psychiatrie</cite>, Referate, Bd. VI, S. 1077.</p></div> + +<div class="footnote"><p><a name="Footnote_20_23" id="Footnote_20_23"></a><a href="#FNanchor_20_23"><span class="label">[20]</span></a> Seelig: "Psychiatrischer Verein in Berlin, 1904." <cite>Neurol. +Centralbl.</cite>, 1904, S. 421.</p></div> + +<div class="footnote"><p><a name="Footnote_21_24" id="Footnote_21_24"></a><a href="#FNanchor_21_24"><span class="label">[21]</span></a> Löwenstein: "Beitrag zur Differentialdiagnose des katatonische +u. hysterische Stupors." <cite>Allg. Zeitschr. f. Psychiatrie</cite>, Bd. LXV.</p></div> + +<div class="footnote"><p><a name="Footnote_22_25" id="Footnote_22_25"></a><a href="#FNanchor_22_25"><span class="label">[22]</span></a> Gregor: "Über die Diagnose psychischer Prozesse im Stupor." +Leipzig Meeting, 1907. Reported in <cite>Neurol. Centralbl.</cite>, 1907. S. +1083.</p></div> + +<div class="footnote"><p><a name="Footnote_23_26" id="Footnote_23_26"></a><a href="#FNanchor_23_26"><span class="label">[23]</span></a> Froederström: "La Dormeuse d'Okno. 32 ans de Stupeur, +Guérison complète. Nouvelles Iconographies de la Salpétrière," +1912, No. 3. Reviewed by E. Bloch, <cite>Neur. Centralbl.</cite>, 1913, S. 852, +and by Forster, <cite>Zeitschr. f. d. ges. Neur. u. Psychiatrie</cite>, Referate, +Bd. VI, S. 510.</p></div> + +<div class="footnote"><p><a name="Footnote_24_27" id="Footnote_24_27"></a><a href="#FNanchor_24_27"><span class="label">[24]</span></a> Gadelius: "Ett ovanligt fall af stupor med nära 9-arig oafbruten +tvangsmatning; uppvaknande; total amnesi; helsa" (<cite>Hygiea</cite>, 1894, +LVI., Part 2, No. 10, p. 355). Abstracted by Walker Berger, <cite>Neurol. +Centralbl.</cite>, 1895, S. 186.</p></div> + +<div class="footnote"><p><a name="Footnote_25_28" id="Footnote_25_28"></a><a href="#FNanchor_25_28"><span class="label">[25]</span></a> Leroy: "Un cas de stupeur, guéri au bout de deux ans et +demi." <cite>Bull. de la Soc. Clin. de Méd. Ment.</cite>, III, 276, 1910. Abstracted +in <cite>Zeitschr. f. d. ges. Neurol. u. Psychiatrie</cite>, Referate, Bd. +II, S. 495.</p></div> + +<div class="footnote"><p><a name="Footnote_26_29" id="Footnote_26_29"></a><a href="#FNanchor_26_29"><span class="label">[26]</span></a> Myers, Charles S.: "Contributions to the Study of Shell Shock." +<cite>Lancet</cite>, January 8, 1916, pp. 65-69. <cite>Lancet</cite>, September 6, 1916, pp. +461-467.</p></div> + +<div class="footnote"><p><a name="Footnote_27_30" id="Footnote_27_30"></a><a href="#FNanchor_27_30"><span class="label">[27]</span></a> Gucci, R.: "Sopra una particolarità del mutismo per stupore +communicazione preventive." <cite>Archivio italiano per le malattie +nervose</cite>, 1889, XXVI, 69-108. Reviewed in <cite>Neurol. Centralbl.</cite>, 1889, +S. 659.</p></div> + +<div class="footnote"><p><a name="Footnote_28_31" id="Footnote_28_31"></a><a href="#FNanchor_28_31"><span class="label">[28]</span></a> "Dementia Præcox oder Gruppe der Schizophrenie" Aschaffenburg's +"Handbuch der Psychiatrie."</p></div> + +<div class="footnote"><p><a name="Footnote_29_32" id="Footnote_29_32"></a><a href="#FNanchor_29_32"><span class="label">[29]</span></a> Raecke: "Zur Prognose der Katatonie." <cite>Arch. f. Psychiatrie</cite>, +Bd. XLVII, 1, 1910.</p></div> + +<div class="footnote"><p><a name="Footnote_30_33" id="Footnote_30_33"></a><a href="#FNanchor_30_33"><span class="label">[30]</span></a> Whitwell: "A Study of the Pulse in Stupor." <cite>Lancet</cite>, Oct. +17, 1891. Reviewed by Ziehen, <cite>Neurol. Centralbl.</cite>, 1892, S. 290.</p></div> + +<div class="footnote"><p><a name="Footnote_31_34" id="Footnote_31_34"></a><a href="#FNanchor_31_34"><span class="label">[31]</span></a> Wetzel: "Die Diagnose von Stuporen." Baden-Baden Meeting +of May, 1911. Reported in <cite>Neurol. Centralbl.</cite>, 1911, S. 886.</p></div> + +<div class="footnote"><p><a name="Footnote_32_35" id="Footnote_32_35"></a><a href="#FNanchor_32_35"><span class="label">[32]</span></a> Vogt, Ragner: "Zur Psychologie der Katatonischen Symptome." +<cite>Centralbl. für Nervenheilkunde</cite>, 1902, S. 433.</p></div> + +<div class="footnote"><p><a name="Footnote_33_36" id="Footnote_33_36"></a><a href="#FNanchor_33_36"><span class="label">[33]</span></a> Gnauck, R.: "Stupor nach Kohlenoxydvergiftung" (<cite>Charité-Annalen</cite>, +1883, p. 409). Reviewed by Moeli, <cite>Neurol. Centralbl.</cite>, 1883, +S. 237.</p></div> + +<div class="footnote"><p><a name="Footnote_34_37" id="Footnote_34_37"></a><a href="#FNanchor_34_37"><span class="label">[34]</span></a> Bonhoeffer: "Die Symptomatischen Psychosen," 1910.</p></div> + +<div class="footnote"><p><a name="Footnote_35_38" id="Footnote_35_38"></a><a href="#FNanchor_35_38"><span class="label">[35]</span></a> Knauer, A.: "Die im Gefolge des akuten Gelenkrheumatismus +auftretenden psychischen Storungen." <cite>Zeitschr. f. d. ges. Neurol. +u. Psychiatrie</cite>, Bd. XXI, S. 491-559.</p></div> +</div> + +<p><!-- Page 279 --><span class='pagenum'><a name="Page_279" id="Page_279">[279]</a></span></p> + +<h2>INDEX</h2> + +<ul> +<li>absorption, <a href="#Page_163">163</a></li> + +<li>activity, reduction of, <a href="#Page_36">36</a>, <a href="#Page_100">100</a>, <a href="#Page_120">120</a></li> + +<li>acute dementia, <a href="#Page_251">251</a></li> + +<li>adaptation, <a href="#Page_107">107</a>, <a href="#Page_192">192</a></li> + +<li>adrenalin, <a href="#Page_180">180</a></li> + +<li>affect, <a href="#Page_9">9</a>, <a href="#Page_22">22</a>, +<a href="#Page_32">32</a>, <a href="#Page_44">44</a>, <a href="#Page_113">113</a>, +<a href="#Page_116">116</a>, <a href="#Page_117">117</a>, <a href="#Page_123"><i>123</i></a>, <a href="#Page_170">170</a></li> + +<li>affect, dissociation of, <a href="#Page_128">128</a>, <a href="#Page_201">201</a>, <a href="#Page_205">205</a>, <a href="#Page_237">237</a></li> + +<li>affect, inappropriate, <a href="#Page_216">216</a>, <a href="#Page_237">237</a></li> + +<li>affect, poverty of, <a href="#Page_234">234</a></li> + +<li>affect, shallow, <a href="#Page_127">127</a></li> + +<li>affectlessness, <a href="#Page_171">171</a>, <a href="#Page_172">172</a></li> + +<li>affects, combination of, <a href="#Page_245">245</a></li> + +<li>agitation, <a href="#Page_156">156</a></li> + +<li>akinesis, <a href="#Page_121">121</a></li> + +<li>akinetic psychoses, <a href="#Page_4">4</a>, <a href="#Page_274">274</a></li> + +<li>albuminuria, <a href="#Page_40">40</a></li> + +<li>allied to dementia præcox, <a href="#Page_236">236</a>, <a href="#Page_260">260</a></li> + +<li>allied to manic-depressive, <a href="#Page_236">236</a>, <a href="#Page_260">260</a></li> + +<li>allopsychic, <a href="#Page_135">135</a></li> + +<li>ambivalence, <a href="#Page_147">147</a></li> + +<li>amnesia, <a href="#Page_9">9</a>, <a href="#Page_24">24</a>, <a href="#Page_68">68</a>, +<a href="#Page_70">70</a>, <a href="#Page_267">267</a>, <a href="#Page_269">269</a></li> + +<li>anergic or unconscious stupor, <a href="#Page_258">258</a></li> + +<li>anergic stupor, <a href="#Page_255">255</a>, <a href="#Page_256">256</a></li> + +<li>anesthesia, <a href="#Page_196">196</a>, <a href="#Page_212">212</a>, <a href="#Page_268">268</a></li> + +<li>anger, <a href="#Page_118">118</a>, <a href="#Page_139">139</a></li> + +<li>angiospastic, <a href="#Page_276">276</a></li> + +<li>animal, turning into, <a href="#Page_171">171</a></li> + +<li>Antæus, <a href="#Page_190">190</a></li> + +<li>apathy, <a href="#Page_36">36</a>, <a href="#Page_48">48</a>, +<a href="#Page_112">112</a>, <a href="#Page_122">122</a>, <a href="#Page_123">123</a>, +<a href="#Page_151">151</a>, <a href="#Page_152">152</a>, <a href="#Page_163">163</a>, +<a href="#Page_181">181</a>, <a href="#Page_195">195</a>, <a href="#Page_225">225</a>, <a href="#Page_237">237</a></li> + +<li>apathy, resemblance to absorption, <a href="#Page_202">202</a></li> + +<li>anxiety, <a href="#Page_122">122</a>, <a href="#Page_123">123</a>, <a href="#Page_126">126</a>, +<a href="#Page_137">137</a>, <a href="#Page_153">153</a>, <a href="#Page_162">162</a>, +<a href="#Page_166">166</a>, <a href="#Page_198">198</a>, <a href="#Page_226">226</a></li> + +<li>apoplexy, <a href="#Page_224">224</a></li> + +<li>arteriosclerotic dementia, <a href="#Page_80">80</a></li> + +<li>attention, <a href="#Page_195">195</a></li> + +<li>atypical features, explanation of, <a href="#Page_200">200</a></li> + +<li>autoerotism, <a href="#Page_199">199</a></li> + +<li>automatism, <a href="#Page_268">268</a></li> +</ul> + +<ul> +<li> +Baillarger, <a href="#Page_252">252</a></li> + +<li>behavior, <a href="#Page_195">195</a></li> + +<li>"Benommenheit," <a href="#Page_67">67</a>, <a href="#Page_273">273</a>, <a href="#Page_274">274</a></li> + +<li>bewilderment, <a href="#Page_79">79</a>, <a href="#Page_112">112</a>, +<a href="#Page_120">120</a>, <a href="#Page_126">126</a></li> + +<li>Bleuler, <a href="#Page_67">67</a>, <a href="#Page_273">273</a></li> + +<li>blocking, <a href="#Page_163">163</a></li> + +<li>blood-pressure, <a href="#Page_181">181</a></li> + +<li>blushing, <a href="#Page_9">9</a></li> + +<li>Bonhoeffer, <a href="#Page_277">277</a></li> + +<li>boredom, <a href="#Page_247">247</a></li> + +<li>bowels, interest in, <a href="#Page_217">217</a></li> + +<li>brain tumor, <a href="#Page_5">5</a></li> + +<li>breath, holding, <a href="#Page_62">62</a></li> + +<li>Brierre de Boismont, <a href="#Page_252">252</a></li> + +<li>burial, <a href="#Page_111">111</a>, <a href="#Page_192">192</a></li> +</ul> + +<ul><li>Calculation, <a href="#Page_23">23</a>, <a href="#Page_24">24</a></li> + +<li>Calvary, <a href="#Page_111">111</a></li> + +<li>Cannon, <a href="#Page_180">180</a></li> + +<li>Cases +<ul> +<li> Adele M. (Case 24), <a href="#Page_220">220</a></li> +<li> Alice R., <a href="#Page_135">135</a>, <a href="#Page_140">140</a>, <a href="#Page_192"><i>192</i></a></li> +<li> Anna G. (Case 1), <a href="#Page_6"><i>6</i></a>, <a href="#Page_47">47</a>, <a href="#Page_48">48</a>, +<a href="#Page_68">68</a>, <a href="#Page_74">74</a>, <a href="#Page_77">77</a>, <a href="#Page_109">109</a>, +<a href="#Page_127">127</a>, <a href="#Page_136">136</a>, <a href="#Page_140">140</a>, <a href="#Page_145">145</a>, +<a href="#Page_147">147</a>, <a href="#Page_183">183</a></li> +<li> Anna L. (Case 16), <a href="#Page_135">135</a>, <a href="#Page_149"><i>149</i></a>, <a href="#Page_158">158</a></li> +<li> Anna M., <a href="#Page_135">135</a></li> +<li> Annie K. (Case 5), <a href="#Page_24"><i>24</i></a>, <a href="#Page_69">69</a>, <a href="#Page_72">72</a>, +<a href="#Page_105">105</a>, <a href="#Page_110">110</a>, <a href="#Page_111">111</a>, <a href="#Page_136">136</a>, +<a href="#Page_139">139</a>, <a href="#Page_141">141</a></li> +<li><!-- Page 280 --><span class='pagenum'><a name="Page_280" id="Page_280">[280]</a></span> + Bridget B., <a href="#Page_135">135</a></li> +<li> Caroline de S. (Case 2), <a href="#Page_11"><i>11</i></a>, <a href="#Page_68">68</a>, <a href="#Page_109">109</a>, +<a href="#Page_141">141</a>, <a href="#Page_178">178</a>, <a href="#Page_193">193</a></li> +<li> Catherine H. (Case 23), <a href="#Page_216"><i>216</i></a></li> +<li> Catherine M. (Case 18), <a href="#Page_158"><i>158</i></a></li> +<li> Catherine W. (Case 25), <a href="#Page_221"><i>221</i></a></li> +<li> Celia C. (Case 17), <a href="#Page_155"><i>155</i></a></li> +<li> Celia H. (Case 19), <a href="#Page_167"><i>167</i></a></li> +<li> Charles O., <a href="#Page_143">143</a>, <a href="#Page_144">144</a>, <a href="#Page_178">178</a></li> +<li> Charlotte W. (Case 12), <a href="#Page_83"><i>83</i></a>, <a href="#Page_106">106</a>, <a href="#Page_112">112</a>, <a href="#Page_113">113</a>, +<a href="#Page_116">116</a>, <a href="#Page_127">127</a>, <a href="#Page_136">136</a>, <a href="#Page_141">141</a>, <a href="#Page_144">144</a>, +<a href="#Page_166">166</a>, <a href="#Page_201">201</a></li> +<li> Emma K., <a href="#Page_71">71</a>, <a href="#Page_140">140</a></li> +<li> Harriett C., <a href="#Page_138">138</a></li> +<li> Helen M., <a href="#Page_130">130</a></li> +<li> Henrietta B., <a href="#Page_138">138</a>, <a href="#Page_140">140</a></li> +<li> Henrietta H. (Case 8), <a href="#Page_42"><i>42</i></a>, <a href="#Page_74">74</a>, +<a href="#Page_77">77</a>, <a href="#Page_105">105</a>, <a href="#Page_106">106</a>, <a href="#Page_110">110</a>, +<a href="#Page_111">111</a>, <a href="#Page_115">115</a>, <a href="#Page_136">136</a></li> +<li> Isabella M., <a href="#Page_136">136</a>, <a href="#Page_144">144</a>, <a href="#Page_147">147</a></li> +<li> Johanna B., <a href="#Page_135">135</a>, <a href="#Page_138">138</a></li> +<li> Johanna S. (Case 13), <a href="#Page_91"><i>91</i></a>, <a href="#Page_120">120</a>, <a href="#Page_127">127</a>, <a href="#Page_136">136</a></li> +<li> Josephine G., <a href="#Page_138">138</a></li> +<li> Laura A., <a href="#Page_71">71</a>, <a href="#Page_77">77</a>, <a href="#Page_135">135</a>, +<a href="#Page_138">138</a>, <a href="#Page_140">140</a>, <a href="#Page_142">142</a>, <a href="#Page_193">193</a></li> +<li> Maggie H. (Case 14), <a href="#Page_71">71</a>, <a href="#Page_96">96</a>, <a href="#Page_109">109</a>, <a href="#Page_140">140</a>, <a href="#Page_194">194</a></li> +<li> Margaret C. (Case 10), <a href="#Page_55"><i>55</i></a>, <a href="#Page_75">75</a>, <a href="#Page_78">78</a></li> +<li> Mary C. (Case 7), <a href="#Page_39"><i>39</i></a>, <a href="#Page_42">42</a>, <a href="#Page_71">71</a>, <a href="#Page_74">74</a>, <a href="#Page_77">77</a>, +<a href="#Page_121">121</a>, <a href="#Page_136">136</a>, <a href="#Page_138">138</a>, <a href="#Page_178">178</a>, <a href="#Page_194">194</a></li> +<li> Mary D. (Case 4), <a href="#Page_20"><i>20</i></a>, <a href="#Page_47">47</a>, <a href="#Page_69">69</a>, <a href="#Page_70">70</a>, +<a href="#Page_71">71</a>, <a href="#Page_74">74</a>, <a href="#Page_76">76</a>, <a href="#Page_109">109</a>, <a href="#Page_136">136</a>, <a href="#Page_145">145</a></li> +<li> Mary F. (Case 3), <a href="#Page_14"><i>14</i></a>, <a href="#Page_68">68</a>, <a href="#Page_105">105</a>, <a href="#Page_110">110</a>, <a href="#Page_111">111</a>, +<a href="#Page_115">115</a>, <a href="#Page_140">140</a>, <a href="#Page_142">142</a>, <a href="#Page_164">164</a>, <a href="#Page_183">183</a></li> +<li> Mary G., <a href="#Page_140">140</a>, <a href="#Page_141">141</a></li> +<li> Meta S. (Case 15), <a href="#Page_99"><i>99</i></a>, <a href="#Page_109">109</a>, <a href="#Page_127">127</a>, <a href="#Page_135">135</a></li> +<li> Nellie H. (Case 22), <a href="#Page_214"><i>214</i></a></li> +<li> Pearl F. (Case 9), <a href="#Page_51"><i>51</i></a>, <a href="#Page_75">75</a>, <a href="#Page_142">142</a></li> +<li> Rose S. (Case 21), <a href="#Page_210"><i>210</i></a></li> +<li> Rose Sch. (Case 6), <a href="#Page_35"><i>35</i></a>, <a href="#Page_74">74</a>, <a href="#Page_75">75</a>, <a href="#Page_145">145</a></li> +<li> Rosie K. (Case 11), <a href="#Page_62"><i>62</i></a>, <a href="#Page_75">75</a>, <a href="#Page_105">105</a>, <a href="#Page_112">112</a>, <a href="#Page_178">178</a></li> +<li> Winifred O'M. (Case 20), <a href="#Page_207"><i>207</i></a></li> +</ul> +</li> + +<li>catalepsy, <a href="#Page_13">13</a>, <a href="#Page_21">21</a>, <a href="#Page_31">31</a>, <a href="#Page_32">32</a>, <a href="#Page_36">36</a>, <a href="#Page_86">86</a>, <a href="#Page_94">94</a>, <a href="#Page_95">95</a>, <a href="#Page_102">102</a>, <a href="#Page_115">115</a>, <a href="#Page_128">128</a>, <a href="#Page_143"><i>143</i></a>, <a href="#Page_144">144</a>, +<a href="#Page_145">145</a>, <a href="#Page_147">147</a>, <a href="#Page_209">209</a>, <a href="#Page_211">211</a>, <a href="#Page_235">235</a>, <a href="#Page_239">239</a></li> + +<li>catatonia, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_50">50</a>, <a href="#Page_128">128</a>, <a href="#Page_205">205</a>, <a href="#Page_236">236</a>, <a href="#Page_261">261</a></li> + +<li>catheterization, <a href="#Page_85">85</a>, <a href="#Page_86">86</a>, <a href="#Page_102">102</a></li> + +<li>cemetery, <a href="#Page_105">105</a>, <a href="#Page_112">112</a></li> + +<li>childbirth, <a href="#Page_159">159</a></li> + +<li>childhood, <a href="#Page_188">188</a>, <a href="#Page_195">195</a></li> + +<li>Chotzen, <a href="#Page_262">262</a></li> + +<li>Christ, <a href="#Page_86">86</a>, <a href="#Page_115">115</a></li> + +<li>Christian Science, <a href="#Page_150">150</a></li> + +<li>circular psychosis, <a href="#Page_5">5</a>, <a href="#Page_126">126</a></li> + +<li>circulation, <a href="#Page_180">180</a></li> + +<li>Clark, <a href="#Page_184">184</a></li> + +<li>clouding, <a href="#Page_67">67</a></li> + +<li>Clouston, <a href="#Page_258">258</a></li> + +<li>cocoon, <a href="#Page_109">109</a></li> + +<li>coffin, <a href="#Page_88">88</a>, <a href="#Page_106">106</a>, <a href="#Page_114">114</a></li> + +<li>coma, <a href="#Page_176">176</a>, <a href="#Page_223">223</a></li> + +<li>concussion, aerial, <a href="#Page_224">224</a></li> + +<li>confusion, <a href="#Page_163">163</a></li> + +<li>constipation, <a href="#Page_92">92</a></li> + +<li>convent, <a href="#Page_117">117</a></li> + +<li>convulsive attacks, <a href="#Page_15">15</a></li> + +<li>crime, <a href="#Page_248">248</a></li> + +<li>crucifix, <a href="#Page_88">88</a></li> + +<li>crucifixion, <a href="#Page_86">86</a>, <a href="#Page_106">106</a>, <a href="#Page_114">114</a>, <a href="#Page_161">161</a></li> + +<li>crustaceans, <a href="#Page_148">148</a></li> + +<li>cut-up idea, <a href="#Page_94">94</a></li> + +<li>cyanosis, <a href="#Page_32">32</a>, <a href="#Page_63">63</a>, <a href="#Page_180">180</a></li> +</ul> + +<ul> +<li>Dagonet, <a href="#Page_3">3</a>, <a href="#Page_249">249</a>, <a href="#Page_250">250</a>, <a href="#Page_253">253</a>, <a href="#Page_254">254</a>, <a href="#Page_258">258</a></li> + +<li>death, feigned, <a href="#Page_5">5</a>, <a href="#Page_83">83</a>, <a href="#Page_137">137</a>, <a href="#Page_196">196</a>, <a href="#Page_246">246</a></li> + +<li>death, mutual, <a href="#Page_192">192</a></li> + +<li>death, projected, <a href="#Page_198">198</a></li> + +<li>death, relation with affect, <a href="#Page_110">110</a></li> + +<li>death ideas, <a href="#Page_3">3</a>, <a href="#Page_46">46</a>, <a href="#Page_47">47</a>, <a href="#Page_50">50</a>, <a href="#Page_52">52</a>, <a href="#Page_58">58</a>, <a href="#Page_65">65</a>, <a href="#Page_83">83</a>, <a href="#Page_97">97</a>, <a href="#Page_104"><i>104</i></a>, <a href="#Page_107">107</a>, <a href="#Page_109">109</a>, <a href="#Page_110">110</a>, +<a href="#Page_111">111</a>, <a href="#Page_114">114</a>, <a href="#Page_115">115</a>, <a href="#Page_119">119</a>, <a href="#Page_122">122</a>, <a href="#Page_136">136</a>, <a href="#Page_137">137</a>, <a href="#Page_138">138</a>, <a href="#Page_152">152</a>, <a href="#Page_153">153</a>, <a href="#Page_156">156</a>, +<a href="#Page_159">159</a>, <a href="#Page_163">163</a>, <a href="#Page_166">166</a>, <a href="#Page_187">187</a>, <a href="#Page_190">190</a>, <a href="#Page_191">191</a>, <a href="#Page_192">192</a>, <a href="#Page_199">199</a>, <a href="#Page_212">212</a>, <a href="#Page_225">225</a>, <a href="#Page_235">235</a>, <a href="#Page_240">240</a></li> + +<li>death of others, <a href="#Page_192">192</a></li> + +<li>deep stupor, <a href="#Page_1"><i>1</i></a>, <a href="#Page_6">6</a>, <a href="#Page_41">41</a>, <a href="#Page_199">199</a></li> + +<li>deep stupor, explanation of, <a href="#Page_197">197</a></li> + +<li>Delasiauve, <a href="#Page_253">253</a></li> +<li><!-- Page 281 --><span class='pagenum'><a name="Page_281" id="Page_281">[281]</a></span> +delirium, <a href="#Page_176">176</a></li> + +<li>delusional stupor, <a href="#Page_255">255</a>, <a href="#Page_256">256</a></li> + +<li>delusions, <a href="#Page_165">165</a></li> + +<li>délire mélancholique, <a href="#Page_252">252</a></li> + +<li>dementia præcox, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_62">62</a>, <a href="#Page_123">123</a>, <a href="#Page_127">127</a>, <a href="#Page_128">128</a>, <a href="#Page_205">205</a>, <a href="#Page_225">225</a></li> + +<li>depression, <a href="#Page_5">5</a>, <a href="#Page_117">117</a>, <a href="#Page_123">123</a>, <a href="#Page_137">137</a>, <a href="#Page_156">156</a>, <a href="#Page_236">236</a>, <a href="#Page_253">253</a></li> + +<li>depression, differentiation of, <a href="#Page_48">48</a>, <a href="#Page_124">124</a>, <a href="#Page_226">226</a></li> + +<li>dermatographia, <a href="#Page_102">102</a>, <a href="#Page_180">180</a></li> + +<li>deterioration, <a href="#Page_210">210</a></li> + +<li>diabetes, <a href="#Page_224">224</a></li> + +<li>diarrhea, <a href="#Page_45">45</a>, <a href="#Page_64">64</a>, <a href="#Page_178">178</a></li> + +<li>dissociation, <a href="#Page_225">225</a></li> + +<li>distress, <a href="#Page_119">119</a>, <a href="#Page_122">122</a>, <a href="#Page_154">154</a>, <a href="#Page_156">156</a>, <a href="#Page_162">162</a></li> + +<li>dreams, <a href="#Page_161">161</a>, <a href="#Page_190">190</a></li> + +<li>drooling, <a href="#Page_132">132</a>, <a href="#Page_181">181</a></li> + +<li>drowning, <a href="#Page_87">87</a>, <a href="#Page_192">192</a></li> +</ul> + +<ul> +<li>Earth, <a href="#Page_107">107</a>, <a href="#Page_111">111</a>, <a href="#Page_190">190</a></li> + +<li>echolalia, <a href="#Page_275">275</a></li> + +<li>echopraxia, <a href="#Page_275">275</a></li> + +<li>ecstasy, <a href="#Page_91">91</a>, <a href="#Page_162">162</a>, <a href="#Page_191">191</a></li> + +<li><i>élan vital</i>, <a href="#Page_123">123</a></li> + +<li>elation, <a href="#Page_44">44</a>, <a href="#Page_91">91</a>, <a href="#Page_123">123</a>, <a href="#Page_127">127</a>, <a href="#Page_151">151</a>, <a href="#Page_157">157</a></li> + +<li>electric chair, <a href="#Page_85">85</a>, <a href="#Page_110">110</a>, <a href="#Page_119">119</a></li> + +<li>electricity, <a href="#Page_150">150</a></li> + +<li><a name="emaciation" id="emaciation">emaciation</a>, <a href="#Page_8">8</a>, <a href="#Page_32">32</a>, <a href="#Page_58">58</a></li> + +<li>emotion, <a href="#Page_62">62</a></li> + +<li>emotion, inconsistency of, <a href="#Page_126">126</a></li> + +<li>emotions and contact with reality, <a href="#Page_164">164</a></li> + +<li>energy, <a href="#Page_187">187</a>, <a href="#Page_194">194</a></li> + +<li>epilepsy, <a href="#Page_5">5</a>, <a href="#Page_183">183</a>, <a href="#Page_199">199</a>, <a href="#Page_224">224</a>, <a href="#Page_242">242</a>, <a href="#Page_254">254</a></li> + +<li>epileptic aura, <a href="#Page_184">184</a></li> + +<li>epileptic confusion, <a href="#Page_80">80</a></li> + +<li>epileptic deterioration, <a href="#Page_80">80</a></li> + +<li>erotic, <a href="#Page_161">161</a></li> + +<li>erotic ideas, <a href="#Page_90">90</a></li> + +<li>Esquirol, <a href="#Page_251">251</a></li> + +<li>Etoc-Demazy, <a href="#Page_251">251</a></li> + +<li>Euripides, <a href="#Page_2">2</a></li> + +<li>excretion, habits of, <a href="#Page_230">230</a></li> + +<li>extroversion, <a href="#Page_195">195</a></li> +</ul> + +<ul> +<li>family visits, <a href="#Page_232">232</a></li> + +<li>father, <a href="#Page_104">104</a>, <a href="#Page_109">109</a>, <a href="#Page_110">110</a></li> + +<li>fear, <a href="#Page_111">111</a></li> + +<li>fever, <a href="#Page_8">8</a>, <a href="#Page_13">13</a>, <a href="#Page_26">26</a>, <a href="#Page_32">32</a>, <a href="#Page_38">38</a>, <a href="#Page_40">40</a>, <a href="#Page_45">45</a>, <a href="#Page_64">64</a>, <a href="#Page_102">102</a>, <a href="#Page_160">160</a>, <a href="#Page_176"><i>176</i></a>, <a href="#Page_235">235</a>, <a href="#Page_241">241</a></li> + +<li>filthiness, <a href="#Page_210">210</a></li> + +<li>fire, <a href="#Page_151">151</a>, <a href="#Page_157">157</a></li> + +<li>flippancy, <a href="#Page_129">129</a></li> + +<li>flushing, <a href="#Page_27">27</a>, <a href="#Page_127">127</a>, <a href="#Page_128">128</a>, <a href="#Page_180">180</a></li> + +<li>food, refusal of, <a href="#Page_99">99</a>, <a href="#Page_104">104</a></li> + +<li>Forel, <a href="#Page_182">182</a></li> + +<li>Froederström, <a href="#Page_265">265</a></li> + +</ul> + +<ul> +<li>Gadelius, <a href="#Page_267">267</a>, <a href="#Page_268">268</a></li> + +<li>Ganser reaction, <a href="#Page_263">263</a></li> + +<li>Georget, <a href="#Page_251">251</a></li> + +<li>German psychiatry, <a href="#Page_259">259</a></li> + +<li>Gnauck, <a href="#Page_277">277</a></li> + +<li>giggling, <a href="#Page_206">206</a></li> + +<li>God, <a href="#Page_115">115</a>, <a href="#Page_160">160</a>, <a href="#Page_162">162</a></li> + +<li>Golden Age, <a href="#Page_187">187</a></li> + +<li>Gregor, <a href="#Page_265">265</a></li> + +<li>Gucci, <a href="#Page_271">271</a></li> + +<li>guilt, <a href="#Page_157">157</a></li> +</ul> + +<ul> +<li>hair, loss of, <a href="#Page_32">32</a>, <a href="#Page_58">58</a>, <a href="#Page_180">180</a></li> + +<li>heat production and loss, <a href="#Page_179">179</a>, <a href="#Page_181">181</a>, <a href="#Page_242">242</a></li> + +<li>Heaven, <a href="#Page_87">87</a>, <a href="#Page_88">88</a>, <a href="#Page_104">104</a>, <a href="#Page_106">106</a>, <a href="#Page_108">108</a>, <a href="#Page_109">109</a>, <a href="#Page_111">111</a>, <a href="#Page_114">114</a>, <a href="#Page_115">115</a>, <a href="#Page_117">117</a>, <a href="#Page_118">118</a>, <a href="#Page_160">160</a>, <a href="#Page_162">162</a>, <a href="#Page_166">166</a>, <a href="#Page_171">171</a>, <a href="#Page_191">191</a>, <a href="#Page_240">240</a></li> + +<li>Hell, <a href="#Page_240">240</a></li> + +<li>Hoch, <a href="#Page_164">164</a></li> + +<li>hyperæmia, <a href="#Page_8">8</a></li> + +<li>hyperesthesia, <a href="#Page_268">268</a></li> + +<li>hypochondria, <a href="#Page_225">225</a>, <a href="#Page_253">253</a></li> + +<li>hypomania, <a href="#Page_243">243</a></li> + +<li>hypnotism (see <a href="#mesmerism">mesmerism</a>), <a href="#Page_145">145</a>, <a href="#Page_213">213</a></li> + +<li>hysteria, <a href="#Page_3">3</a>, <a href="#Page_135">135</a>, <a href="#Page_184">184</a>, <a href="#Page_225">225</a>, <a href="#Page_264">264</a>, <a href="#Page_267">267</a>, <a href="#Page_269">269</a></li> +</ul> + +<ul> +<li>ideational content, <a href="#Page_82">82</a>, <a href="#Page_235">235</a></li> + +<li>immobility, <a href="#Page_85">85</a>, <a href="#Page_94">94</a>, <a href="#Page_196">196</a></li> + +<li>immorality, <a href="#Page_150">150</a></li> + +<li>impulsiveness, <a href="#Page_50">50</a>, <a href="#Page_113">113</a>, <a href="#Page_128">128</a>, <a href="#Page_172">172</a></li> + +<li>impurities in stupor reaction, <a href="#Page_66">66</a></li> + +<li>inaccessibility, <a href="#Page_141">141</a></li> + +<li>inactivity, <a href="#Page_17">17</a>, <a href="#Page_30">30</a>, <a href="#Page_40">40</a>, <a href="#Page_48">48</a>, <a href="#Page_56">56</a>, <a href="#Page_62">62</a>, <a href="#Page_88">88</a>, <a href="#Page_97">97</a>, <a href="#Page_102">102</a>, <a href="#Page_123">123</a>, <a href="#Page_132"><i>132</i></a>, <a href="#Page_152">152</a>, <a href="#Page_163">163</a>, <a href="#Page_194">194</a>, <a href="#Page_225">225</a>, <a href="#Page_234">234</a>, <a href="#Page_238">238</a></li> + +<li>inactivity, patients' explanation of, <a href="#Page_134">134</a></li> + +<li>incest ideas, <a href="#Page_209">209</a></li> + +<li><!-- Page 282 --><span class='pagenum'><a name="Page_282" id="Page_282">[282]</a></span> +inconsistency of reaction, <a href="#Page_134">134</a>, <a href="#Page_214">214</a>, <a href="#Page_215">215</a>, <a href="#Page_245">245</a></li> + +<li>incontinence (see <a href="#wetting"><i>wetting</i></a> and <a href="#soiling"><i>soiling</i></a>), <a href="#Page_52">52</a>, <a href="#Page_57">57</a></li> + +<li>indifference, <a href="#Page_123">123</a>, <a href="#Page_124">124</a>, <a href="#Page_142">142</a></li> + +<li>infantile reactions, <a href="#Page_196">196</a></li> + +<li>infections, <a href="#Page_5">5</a>, <a href="#Page_178"><i>178</i></a>, <a href="#Page_241">241</a></li> + +<li>insight, <a href="#Page_157">157</a></li> + +<li>insomnia, <a href="#Page_39">39</a></li> + +<li>instinct of self-preservation, <a href="#Page_188">188</a>, <a href="#Page_191">191</a>, <a href="#Page_198">198</a></li> + +<li>interest, <a href="#Page_99">99</a>, <a href="#Page_195">195</a></li> + +<li>internal secretions, <a href="#Page_178">178</a></li> + +<li>internal thoughts, <a href="#Page_163">163</a></li> + +<li>interruptions of stupor, <a href="#Page_130">130</a>, <a href="#Page_197">197</a>, <a href="#Page_238">238</a>, <a href="#Page_244">244</a></li> + +<li>introversion, <a href="#Page_164">164</a>, <a href="#Page_227">227</a></li> + +<li>involuntary nervous system, <a href="#Page_178">178</a>, <a href="#Page_180">180</a></li> + +<li>involution melancholia, <a href="#Page_129">129</a>, <a href="#Page_195">195</a>, <a href="#Page_225">225</a>, <a href="#Page_226">226</a></li> +</ul> + +<ul> +<li>jaundice, <a href="#Page_21">21</a></li> + +<li>Jung, <a href="#Page_107">107</a></li> +</ul> + +<ul> +<li>Kahlbaum, <a href="#Page_4">4</a>, <a href="#Page_260">260</a></li> + +<li>Kirby, <a href="#Page_4">4</a>, <a href="#Page_6">6</a>, <a href="#Page_164">164</a>, <a href="#Page_234">234</a></li> + +<li>Knauer, <a href="#Page_175">175</a>, <a href="#Page_278">278</a></li> + +<li>Kraepelin, <a href="#Page_4">4</a>, <a href="#Page_260">260</a>, <a href="#Page_269">269</a>, <a href="#Page_271">271</a>, <a href="#Page_272">272</a>, <a href="#Page_273">273</a></li> + +<li>Kutner, <a href="#Page_262">262</a></li> +</ul> + +<ul> +<li>laughter, <a href="#Page_56">56</a>, <a href="#Page_141">141</a></li> + +<li>Leroy, <a href="#Page_269">269</a></li> + +<li>leucocytosis, <a href="#Page_8">8</a>, <a href="#Page_13">13</a>, <a href="#Page_40">40</a>, <a href="#Page_64">64</a>, <a href="#Page_178">178</a></li> + +<li>levels, principle of, <a href="#Page_198">198</a>, <a href="#Page_244">244</a></li> + +<li>Löwenstein, <a href="#Page_264">264</a></li> +</ul> + +<ul> +<li>MacCurdy, <a href="#Page_2">2</a>, <a href="#Page_184">184</a></li> + +<li>make-up, mental, <a href="#Page_5">5</a></li> + +<li>malignant stupors, <a href="#Page_205"><i>205</i></a></li> + +<li>mania (or manic), <a href="#Page_5">5</a>, <a href="#Page_126">126</a>, <a href="#Page_137">137</a></li> + +<li>mania, absorbed, <a href="#Page_125">125</a>, <a href="#Page_226">226</a>, <a href="#Page_245">245</a></li> + +<li>manic content, <a href="#Page_166">166</a></li> + +<li>manic-depressive insanity, <a href="#Page_149">149</a>, <a href="#Page_167">167</a></li> + +<li>manic-depressive insanity, mixed conditions in, <a href="#Page_202">202</a></li> + +<li>manic-depressive insanity, pathology of, <a href="#Page_174">174</a></li> + +<li>manic episodes, <a href="#Page_191">191</a></li> + +<li>manic stupor, <a href="#Page_125">125</a>, <a href="#Page_245">245</a>, <a href="#Page_253">253</a></li> + +<li>marriage, <a href="#Page_160">160</a>, <a href="#Page_169">169</a></li> + +<li>masturbation, <a href="#Page_196">196</a>, <a href="#Page_209">209</a>, <a href="#Page_219">219</a></li> + +<li>melancholic or conscious stupor, <a href="#Page_258">258</a></li> + +<li>memory (see <a href="#thinking_disorder">thinking disorder</a>), <a href="#Page_40">40</a>, <a href="#Page_67">67</a>, <a href="#Page_168">168</a>, <a href="#Page_195">195</a></li> + +<li>menstruation, <a href="#Page_8">8</a>, <a href="#Page_56">56</a>, <a href="#Page_61">61</a>, <a href="#Page_100">100</a>, <a href="#Page_168">168</a>, <a href="#Page_182"><i>182</i></a>, <a href="#Page_236">236</a>, <a href="#Page_242">242</a></li> + +<li><a name="mesmerism" id="mesmerism">mesmerism</a>, <a href="#Page_86">86</a>, <a href="#Page_114">114</a>, <a href="#Page_117">117</a>, <a href="#Page_141">141</a>, <a href="#Page_144">144</a></li> + +<li>Meyer, Adolf, <a href="#Page_260">260</a></li> + +<li>Meyer, E., <a href="#Page_261">261</a></li> + +<li>midday nap, <a href="#Page_247">247</a></li> + +<li>mixed conditions, <a href="#Page_202">202</a>, <a href="#Page_273">273</a></li> + +<li>Moeli, <a href="#Page_264">264</a></li> + +<li>Moses, <a href="#Page_108">108</a></li> + +<li>mother's body, <a href="#Page_108">108</a></li> + +<li>movement, spontaneous, <a href="#Page_133">133</a></li> + +<li>muscular resistiveness, <a href="#Page_224">224</a></li> + +<li>mutism, <a href="#Page_10">10</a>, <a href="#Page_22">22</a>, <a href="#Page_31">31</a>, <a href="#Page_57">57</a>, <a href="#Page_62">62</a>, <a href="#Page_88">88</a>, <a href="#Page_104">104</a>, <a href="#Page_124">124</a>, <a href="#Page_134">134</a>, <a href="#Page_209">209</a>, <a href="#Page_271">271</a></li> + +<li>mutual death, <a href="#Page_165">165</a>, <a href="#Page_192">192</a>, <a href="#Page_196">196</a>, <a href="#Page_248">248</a></li> + +<li>Myers, <a href="#Page_270">270</a>, <a href="#Page_271">271</a></li> + +<li>mystics, <a href="#Page_3">3</a></li> + +<li>mythology, <a href="#Page_107">107</a>, <a href="#Page_108">108</a>, <a href="#Page_190">190</a>, <a href="#Page_240">240</a></li> +</ul> + +<ul> +<li>negativism, <a href="#Page_5">5</a>, <a href="#Page_31">31</a>, <a href="#Page_52">52</a>, <a href="#Page_56">56</a>, <a href="#Page_65">65</a>, <a href="#Page_128">128</a>, <a href="#Page_138"><i>138</i></a>, <a href="#Page_139">139</a>, <a href="#Page_199">199</a>, <a href="#Page_209">209</a>, <a href="#Page_225">225</a>, <a href="#Page_235">235</a>, <a href="#Page_238">238</a>, <a href="#Page_243">243</a>, <a href="#Page_276">276</a></li> + +<li>negativism, explanation of, <a href="#Page_196">196</a></li> + +<li>nephritis, <a href="#Page_224">224</a></li> + +<li>neuropsychic defect, <a href="#Page_174">174</a></li> + +<li>neurotic, <a href="#Page_150">150</a></li> + +<li>nervous, <a href="#Page_159">159</a></li> + +<li>Newington, <a href="#Page_3">3</a>, <a href="#Page_254">254</a>, <a href="#Page_255">255</a>, <a href="#Page_257">257</a></li> + +<li>Nirvana, <a href="#Page_166">166</a>, <a href="#Page_188">188</a>, <a href="#Page_200">200</a>, <a href="#Page_248">248</a></li> + +<li>nourishment, <a href="#Page_229">229</a>, <a href="#Page_242">242</a></li> +</ul> + +<ul> +<li>Œdipus, <a href="#Page_165">165</a></li> + +<li>œstrous cycle, <a href="#Page_182">182</a></li> + +<li>onset, <a href="#Page_96">96</a></li> + +<li>onset, depressive, <a href="#Page_99">99</a></li> + +<li>ophthalmic disease, <a href="#Page_230">230</a></li> + +<li>Orestes, <a href="#Page_2">2</a></li> + +<li>organic delirium, <a href="#Page_175">175</a></li> + +<li>organic dementia, <a href="#Page_67">67</a></li> + +<li>organic stupor, <a href="#Page_223">223</a></li> +<li><!-- Page 283 --><span class='pagenum'><a name="Page_283" id="Page_283">[283]</a></span> +orientation (see <a href="#thinking_disorder">thinking disorder</a>), <a href="#Page_9">9</a>, <a href="#Page_53">53</a>, <a href="#Page_154">154</a>, <a href="#Page_156">156</a>, <a href="#Page_159">159</a>, <a href="#Page_170">170</a>, <a href="#Page_245">245</a></li> + +<li>Osiris, <a href="#Page_108">108</a></li> +</ul> + +<ul> +<li>pain, <a href="#Page_133">133</a></li> + +<li>Papanicolaou, <a href="#Page_182">182</a></li> + +<li>paragraphia, <a href="#Page_80">80</a></li> + +<li>paralysis, feeling of, <a href="#Page_105">105</a></li> + +<li>paralysis, general, <a href="#Page_5">5</a>, <a href="#Page_254">254</a></li> + +<li>partial stupor, <a href="#Page_34"><i>34</i></a>, <a href="#Page_206">206</a></li> + +<li>perplexity, <a href="#Page_125">125</a>, <a href="#Page_152">152</a>, <a href="#Page_153">153</a>, <a href="#Page_154">154</a>, <a href="#Page_155">155</a>, <a href="#Page_156">156</a>, <a href="#Page_160">160</a>, <a href="#Page_162">162</a>, <a href="#Page_164">164</a>, <a href="#Page_165">165</a>, <a href="#Page_169">169</a>, <a href="#Page_172">172</a>, <a href="#Page_208">208</a>, <a href="#Page_226">226</a>, <a href="#Page_245">245</a></li> + +<li>perplexity, differentiation of, <a href="#Page_227">227</a></li> + +<li>perseveration, <a href="#Page_145">145</a>, <a href="#Page_148">148</a>, <a href="#Page_276">276</a></li> + +<li>personality, <a href="#Page_1">1</a></li> + +<li>perversity, <a href="#Page_138">138</a></li> + +<li>physical disease, <a href="#Page_175">175</a></li> + +<li>physical symptoms, <a href="#Page_174"><i>174</i></a>, <a href="#Page_176">176</a></li> + +<li>Pinel, <a href="#Page_249">249</a>, <a href="#Page_251">251</a></li> + +<li>poison, <a href="#Page_97">97</a>, <a href="#Page_172">172</a></li> + +<li>primitive ideas, <a href="#Page_108">108</a></li> + +<li>prison, <a href="#Page_105">105</a>, <a href="#Page_169">169</a></li> + +<li>prognosis, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_206"><i>206</i></a></li> + +<li>prostitution, <a href="#Page_157">157</a>, <a href="#Page_161">161</a></li> + +<li>psychoanalysis, <a href="#Page_161">161</a></li> + +<li>psychobiological reaction, <a href="#Page_246">246</a></li> + +<li>psychogalvanic reflex, <a href="#Page_276">276</a></li> + +<li>psychological explanation, <a href="#Page_186">186</a></li> + +<li>psychological factors, <a href="#Page_175">175</a></li> + +<li>pulse, <a href="#Page_63">63</a>, <a href="#Page_92">92</a>, <a href="#Page_128">128</a>, <a href="#Page_180">180</a></li> +</ul> + +<ul> +<li>Rank, <a href="#Page_107">107</a></li> + +<li>reality, <a href="#Page_107">107</a>, <a href="#Page_187">187</a></li> + +<li>recuperation, <a href="#Page_189">189</a></li> + +<li>rebirth, <a href="#Page_107"><i>107</i></a>, <a href="#Page_110">110</a>, <a href="#Page_114">114</a>, <a href="#Page_115">115</a>, <a href="#Page_119">119</a>, <a href="#Page_120">120</a>, <a href="#Page_121">121</a>, <a href="#Page_122">122</a>, <a href="#Page_187">187</a>, <a href="#Page_189">189</a>, <a href="#Page_190">190</a>, <a href="#Page_191">191</a>, <a href="#Page_240">240</a></li> + +<li>regression, <a href="#Page_187">187</a>, <a href="#Page_188">188</a>, <a href="#Page_191">191</a>, <a href="#Page_192">192</a>, <a href="#Page_194">194</a>, <a href="#Page_198">198</a>, <a href="#Page_199">199</a>, <a href="#Page_243">243</a></li> + +<li>religious visions or ideas, <a href="#Page_2">2</a>, <a href="#Page_162">162</a></li> + +<li>resentment, <a href="#Page_98">98</a></li> + +<li>resistiveness, <a href="#Page_54">54</a>, <a href="#Page_97">97</a>, <a href="#Page_102">102</a>, <a href="#Page_112">112</a>, <a href="#Page_127">127</a>, <a href="#Page_129">129</a>, <a href="#Page_133">133</a>, <a href="#Page_141">141</a>, <a href="#Page_147">147</a>, <a href="#Page_156">156</a>, <a href="#Page_211">211</a>, <a href="#Page_225">225</a></li> + +<li>respiration, <a href="#Page_180">180</a></li> + +<li>resurrection, <a href="#Page_159">159</a></li> + +<li>restlessness, <a href="#Page_53">53</a>, <a href="#Page_120">120</a>, <a href="#Page_169">169</a></li> + +<li>retention of urine, <a href="#Page_224">224</a>, <a href="#Page_230">230</a></li> + +<li>rheumatism, <a href="#Page_175">175</a></li> + +<li>rigidity, muscular, <a href="#Page_142">142</a>, <a href="#Page_179">179</a></li> + +<li>Romberg sign, <a href="#Page_262">262</a></li> + +<li>rousing, <a href="#Page_176">176</a></li> +</ul> + +<ul> +<li>sadness, <a href="#Page_111">111</a>, <a href="#Page_113">113</a>, <a href="#Page_121">121</a>, <a href="#Page_122">122</a>, <a href="#Page_124">124</a></li> + +<li>St. Catherine of Siena, <a href="#Page_2">2</a></li> + +<li>St. Paul, <a href="#Page_2">2</a></li> + +<li>saliva, <a href="#Page_30">30</a>, <a href="#Page_63">63</a>, <a href="#Page_181">181</a></li> + +<li>scattered speech, <a href="#Page_207">207</a>, <a href="#Page_208">208</a></li> + +<li>schizophrenia, <a href="#Page_67">67</a>, <a href="#Page_214">214</a></li> + +<li>seclusiveness, <a href="#Page_207">207</a></li> + +<li>secondary stupor, <a href="#Page_259">259</a></li> + +<li>Seelig, <a href="#Page_263">263</a></li> + +<li>self-injury, <a href="#Page_50"><i>50</i></a>, <a href="#Page_57">57</a></li> + +<li>sexual excess, <a href="#Page_251">251</a>, <a href="#Page_253">253</a>, <a href="#Page_258">258</a></li> + +<li>sexual ideas, <a href="#Page_209">209</a>, <a href="#Page_219">219</a></li> + +<li>sexual sensations, <a href="#Page_209">209</a></li> + +<li>ship, <a href="#Page_87">87</a>, <a href="#Page_106">106</a>, <a href="#Page_118">118</a></li> + +<li>sick, <a href="#Page_136">136</a></li> + +<li>skin, dry, <a href="#Page_180">180</a></li> + +<li>skin, greasy, <a href="#Page_43">43</a>, <a href="#Page_180">180</a></li> + +<li>sleep, <a href="#Page_188">188</a>, <a href="#Page_189">189</a>, <a href="#Page_247">247</a></li> + +<li>slowing of thought, <a href="#Page_125">125</a></li> + +<li>slowness, <a href="#Page_85">85</a>, <a href="#Page_119">119</a>, <a href="#Page_160">160</a></li> + +<li>smearing of feces, <a href="#Page_142">142</a></li> + +<li>smiling, <a href="#Page_127">127</a></li> + +<li>social status, <a href="#Page_236">236</a></li> + +<li><a name="soiling" id="soiling">soiling</a>, <a href="#Page_30">30</a>, <a href="#Page_132">132</a>, <a href="#Page_172">172</a>, <a href="#Page_196">196</a>, <a href="#Page_225">225</a>, <a href="#Page_230">230</a>, <a href="#Page_235">235</a></li> + +<li>somatopsychic, <a href="#Page_135">135</a></li> + +<li>sphincters, control of, <a href="#Page_133">133</a></li> + +<li>spirits, <a href="#Page_89">89</a></li> + +<li>spoiled child reaction, <a href="#Page_129">129</a>, <a href="#Page_139">139</a></li> + +<li>starvation, <a href="#Page_182">182</a></li> + +<li>stereotypy, <a href="#Page_276">276</a></li> + +<li>Stern, <a href="#Page_261">261</a></li> + +<li>stimulation, mental, <a href="#Page_231">231</a>, <a href="#Page_246">246</a></li> + +<li>Stockard, <a href="#Page_179">179</a>, <a href="#Page_182">182</a></li> + +<li>stubbornness, <a href="#Page_142">142</a></li> + +<li>stupidity, <a href="#Page_93">93</a></li> + +<li>stupor, diagnosis of, <a href="#Page_223"><i>223</i></a> +<ul> +<li> hysterical, <a href="#Page_225">225</a></li> +<li> malignant, <a href="#Page_205"><i>205</i></a>, <a href="#Page_206">206</a></li> +<li> organic, <a href="#Page_223">223</a></li> +<li> reaction, <a href="#Page_35"><i>35</i></a>, <a href="#Page_236">236</a></li> +<li> relation to manic-depressive insanity, <a href="#Page_173">173</a></li> +</ul></li> + +<li>sudden mental loss, <a href="#Page_71">71</a></li> + +<li>suggestibility, <a href="#Page_145">145</a>, <a href="#Page_198">198</a>, <a href="#Page_276">276</a></li> + +<li><!-- Page 284 --><span class='pagenum'><a name="Page_284" id="Page_284">[284]</a></span> +suicidal impulses, <a href="#Page_50"><i>50</i></a>, <a href="#Page_84">84</a>, <a href="#Page_104">104</a>, <a href="#Page_116">116</a>, <a href="#Page_118">118</a>, <a href="#Page_128">128</a>, <a href="#Page_172">172</a>, <a href="#Page_230">230</a>, <a href="#Page_235">235</a>, <a href="#Page_240">240</a></li> + +<li>suicide, <a href="#Page_188">188</a></li> + +<li>sulkiness, <a href="#Page_129">129</a></li> + +<li>sullenness, <a href="#Page_142">142</a></li> + +<li>suprarenals, <a href="#Page_242">242</a></li> + +<li>swallowing, <a href="#Page_133">133</a></li> + +<li>sweating, <a href="#Page_63">63</a>, <a href="#Page_102">102</a>, <a href="#Page_179">179</a>, <a href="#Page_180">180</a></li> + +<li>swimming movements, <a href="#Page_94">94</a></li> + +<li>syncopal attacks, <a href="#Page_64">64</a></li> +</ul> + +<ul> +<li>tears, <a href="#Page_95">95</a>, <a href="#Page_98">98</a>, <a href="#Page_117">117</a>, <a href="#Page_128">128</a>, <a href="#Page_153">153</a></li> + +<li>tense of ideas, <a href="#Page_116">116</a></li> + +<li><a name="thinking_disorder" id="thinking_disorder">thinking disorder</a>, <a href="#Page_22">22</a>, <a href="#Page_31">31</a>, <a href="#Page_37">37</a>, <a href="#Page_39">39</a>, <a href="#Page_41">41</a>, <a href="#Page_45">45</a>, <a href="#Page_48">48</a>, <a href="#Page_59">59</a>, <a href="#Page_67"><i>67</i></a>, <a href="#Page_75">75</a>, <a href="#Page_124">124</a>, <a href="#Page_125">125</a>, <a href="#Page_148">148</a>, <a href="#Page_152">152</a>, <a href="#Page_157">157</a>, <a href="#Page_235">235</a>, <a href="#Page_239">239</a>, <a href="#Page_247">247</a></li> + +<li>thinking disorder, explanation of, <a href="#Page_195">195</a></li> + +<li>tongue, coated, <a href="#Page_13">13</a></li> + +<li>toxins, <a href="#Page_175">175</a></li> + +<li>trauma, <a href="#Page_5">5</a>, <a href="#Page_224">224</a></li> + +<li>treatment, <a href="#Page_229"><i>229</i></a></li> +</ul> + +<ul> +<li>ulceration of eyes, <a href="#Page_133">133</a></li> + +<li>unconscious ideas, <a href="#Page_163">163</a> +<ul> +<li> motives, <a href="#Page_186">186</a></li> +</ul></li> + +<li>unconsciousness, physiological, <a href="#Page_199">199</a>, <a href="#Page_224">224</a>, <a href="#Page_277">277</a></li> + +<li>underground, <a href="#Page_240">240</a></li> + +<li>understanding, <a href="#Page_67">67</a></li> + +<li>uneasiness, <a href="#Page_93">93</a>, <a href="#Page_94">94</a>, <a href="#Page_95">95</a>, <a href="#Page_121">121</a></li> + +<li>unfaithfulness, <a href="#Page_97">97</a></li> + +<li>unhappiness, <a href="#Page_192">192</a></li> + +<li>urine, retention of, <a href="#Page_31">31</a></li> +</ul> + +<ul> +<li>Villermay, <a href="#Page_250">250</a></li> + +<li>Vogt, <a href="#Page_276">276</a></li> + +<li>vomiting, <a href="#Page_45">45</a></li> +</ul> + +<ul> +<li>water, <a href="#Page_94">94</a>, <a href="#Page_95">95</a>, <a href="#Page_106">106</a>, <a href="#Page_107">107</a>, <a href="#Page_114">114</a>, <a href="#Page_120">120</a></li> + +<li>weakness, <a href="#Page_137">137</a>, <a href="#Page_160">160</a></li> + +<li>wealth, <a href="#Page_169">169</a></li> + +<li>wedding ring, <a href="#Page_117">117</a></li> + +<li>weight (see <a href="#emaciation">emaciation</a>), <a href="#Page_38">38</a>, <a href="#Page_52">52</a>, <a href="#Page_61">61</a></li> + +<li>Wernicke, <a href="#Page_3">3</a>, <a href="#Page_273">273</a></li> + +<li><a name="wetting" id="wetting">wetting</a>, <a href="#Page_30">30</a>, <a href="#Page_40">40</a>, <a href="#Page_132">132</a>, <a href="#Page_151">151</a>, <a href="#Page_170">170</a>, <a href="#Page_172">172</a>, <a href="#Page_196">196</a>, <a href="#Page_225">225</a>, <a href="#Page_230">230</a>, <a href="#Page_235">235</a></li> + +<li>Wetzel, <a href="#Page_276">276</a></li> + +<li>whining, <a href="#Page_171">171</a>, <a href="#Page_225">225</a></li> + +<li>Whitwell, <a href="#Page_276">276</a></li> + +<li>Wilmanns, <a href="#Page_261">261</a></li> + +<li>womb, <a href="#Page_108">108</a></li> + +<li>worry, <a href="#Page_110">110</a></li> + +<li>writing, <a href="#Page_27">27</a></li> +</ul> + +<ul> +<li>Ziehen, <a href="#Page_276">276</a></li> +</ul> + +<div class="tn"> +<h4>Transcriber's Note:</h4> + +<p>The following corrections have been made:</p> + +<ul> +<li><a href="#Page_1">p. 1</a>: antequated to antiquated (antiquated methods)</li> +<li>pp. <a href="#Page_11">11</a>, <a href="#Page_97">97</a>, <a href="#Page_100">100</a>: period to colon (Under Observation:)</li> +<li><a href="#Page_53">p. 53</a>: extra 'when' removed (from 'In June, 1914, when she was seen +smiling at times.' to 'In June, 1914, she was seen smiling at times.')</li> +<li><a href="#Page_64">p. 64</a>: period to colon (Physical condition during the stupor:)</li> +<li><a href="#Page_84">p. 84</a>: 24 italicized to match other dates (October 24)</li> +<li><a href="#Page_91">p. 91</a>: missing blank line added between Case 12 and 13</li> +<li><a href="#Page_93">p. 93</a>: aswer to answer (in answer to questions)</li> +<li><a href="#Page_145">p. 145</a>: diaeresis added to coöperation to match other instances</li> +<li><a href="#Page_150">p. 150</a>: fatiguable to fatigable (nervous and fatigable)</li> +<li><a href="#Page_153">p. 153</a>: phenomenom to phenomenon (unusual phenomenon for a stupor +patient)</li> +<li><a href="#Page_159">p. 159</a>: comma added (correcting his grammar, and cried easily.)</li> +<li><a href="#Page_161">p. 161</a>: missing "in" added (appeared in the statement that her father)</li> +<li><a href="#Page_171">p. 171</a>: missing open quote added (she wants to go "to the river,")</li> +<li><a href="#Page_198">p. 198</a>: funadmental to fundamental (most fundamental symptoms)</li> +<li><a href="#Page_211">p. 211</a>: salivia to saliva (drooling saliva)</li> +<li><a href="#Page_220">p. 220</a>: inaccesibility to inaccessibility (disinterestedness and +inaccessibility)</li> +<li><a href="#Page_252">p. 252</a>: dimunition to diminution (just as well in the diminution)</li> +<li><a href="#Page_256">p. 256</a>: or to of (relaxation of sphincter muscles)</li> +<li>p. 262, <a href="#Footnote_19_22">Footnote 19</a>: v. to u. (Zeitschr. f. d. ges. Neur. u. +Psychiatrie)</li> +<li>p. 265, <a href="#Footnote_23_26">Footnote 23</a>: Zeitsch. to Zeitschr. to match other instances (Zeitschr. f. d. +ges. Neur. u. Psychiatrie)</li> +<li>p. 271, <a href="#Footnote_27_30">Footnote 27</a>: Archivo to Archivio (Archivio italiano per le +malattie nervose)</li> +<li><a href="#Page_280">p. 280</a>, Index: catherization to catheterization</li> +<li><a href="#Page_282">p. 282</a>, Index: ophtalmic to ophthalmic (ophthalmic disease)</li> +</ul> + +<p>Irregularities in capitalization (e.g. Dementia vs. dementia) and +hyphenation (e.g. off-hand vs. offhand) have not been corrected. A +repetitive sentence on p. 46 (Then she became stupid, although neither +sad nor happy. Then, she claimed, she got stupid, but neither sad nor +happy.), and two spaced em-dashes on p. 87 have also been retained. +Minor punctuation errors (e.g. missing period, missing close or open +quote where intended placement is clear) have been corrected without +note. The abbreviations "p.m.", "e.g." and "i.e." have been +standardized, with no space.</p> + +</div> + +<div>*** END OF THE PROJECT GUTENBERG EBOOK 30065 ***</div> +</body> +</html> diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..9a8902e --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #30065 (https://www.gutenberg.org/ebooks/30065) diff --git a/old/30065-0.txt b/old/30065-0.txt new file mode 100644 index 0000000..54ab85e --- /dev/null +++ b/old/30065-0.txt @@ -0,0 +1,10399 @@ +The Project Gutenberg EBook of Benign Stupors, by August Hoch + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Benign Stupors + A Study of a New Manic-Depressive Reaction Type + +Author: August Hoch + +Release Date: September 22, 2009 [EBook #30065] + +Language: English + +Character set encoding: UTF-8 + +*** START OF THIS PROJECT GUTENBERG EBOOK BENIGN STUPORS *** + + + + +Produced by Bryan Ness, S.D., and the Online Distributed +Proofreading Team at http://www.pgdp.net (This book was +produced from scanned images of public domain material +from the Google Print project.) + + + + + + + + + + BENIGN STUPORS + + + THE MACMILLAN COMPANY + + NEW YORK · BOSTON · CHICAGO · DALLAS + ATLANTA · SAN FRANCISCO + + MACMILLAN & CO., Limited + + LONDON · BOMBAY · CALCUTTA + MELBOURNE + + THE MACMILLAN CO. OF CANADA, Ltd. + + TORONTO + + + + + BENIGN STUPORS + + _A STUDY OF + A NEW MANIC-DEPRESSIVE REACTION TYPE_ + + BY + + AUGUST HOCH, M.D. + + LATE DIRECTOR OF THE PSYCHIATRIC INSTITUTE OF THE + NEW YORK STATE HOSPITALS, WARD’S ISLAND, NEW + YORK. LATE PROFESSOR OF PSYCHIATRY, CORNELL + UNIVERSITY MEDICAL COLLEGE, NEW YORK + + New York + THE MACMILLAN COMPANY + 1921 + + _All rights reserved_ + + + PRINTED IN THE UNITED STATES OF AMERICA + + + Copyright, 1921, + By THE MACMILLAN COMPANY + Set up and printed. Published July, 1921. + + + Press of + J. J. Little & Ives Company + New York, U. S. A. + + + TO + MY FORMER COLLEAGUES + IN THE + NEW YORK STATE HOSPITAL SERVICE + + + + +EDITOR’S PREFACE + + +A word should be said as to the origin and history of this book. When +the late Dr. Hoch became Director of the Psychiatric Institute of the +New York State Hospitals in 1910, he found there an interest in just the +kind of psychiatric research which it was his ambition to further. His +predecessor, Adolf Meyer, had developed the conception that the +psychoses should be looked on as psychobiological reactions rather than +rigid nosological entities and had inculcated the habit of scrupulously +thorough examination and record of what the patient said and did. Meyer +had broken away from the sterile habit of making diagnoses in accordance +with the set terms used to label symptoms; and his work and that of his +assistants thus led to a collection of valuable material which could +serve as a useful starting point for the keen clinical investigation of +Hoch. Specifically, attention had already been fixed on the study of the +so-called functional psychoses, comprising what are generally termed +Dementia Præcox and Manic-Depressive Insanity. An urgent problem in this +field was to separate different reaction types in order to discover +which were recoverable and which chronic or progressive. In order to +understand psychological reactions, interrelation rather than mere +coincidence of symptoms must be studied and, to aid in this, free use +was made of the fundamental principles of unconscious mentation as +exposed in the theories of Freud and his followers. + +Almost at the outset it had been discovered that many patients presented +clinical pictures that would not fit into existing diagnostic pigeon +holes. Dr. George H. Kirby, whose skill and industry had made the most +valuable contributions to the archives of the Institute, published in +1913 a brief paper in which he pointed out, not only that many cases +with “catatonic” symptoms recovered, but also that clinically the +behavior of stupor showed it to be related to manic-depressive insanity +as well as dementia præcox. Dr. Hoch took up the problem at this point. +Using Dr. Kirby’s material and adding to it his earlier observations as +well as current cases, he endeavored to work out the essentials of the +stupor reaction. It was his ambition to describe stupor not only in its +psychiatric bearing but also as a life reaction. + +The significance of this task is to be realized only when one considers +the general import of the functional psychoses. They are, biologically, +failures of adaptation. The chronic and deteriorating cases give up the +struggle permanently, while the temporary insanities lay bare the soul +of man as he catches a glimpse of unreality but turns back to face the +world as it is. When one realizes that emotional disturbances are +characteristic of the benign psychoses, it is easy to imagine how much +such studies may ultimately illuminate the problems of normal life. + +The technical value of this work to psychiatry is more immediate. +Kraepelin laid the foundations for systematic classification with his +dementia præcox and manic-depressive groups. But the rigidity of the +latter, allegedly descriptive, term has confused the problem of +classifying many benign psychoses. It was Hoch’s ambition to prove that, +although elation and depression were the commonest mood anomalies in +this group, they had no more theoretic importance than anxiety, +distressed perplexity or apathy. These other moods, although less +frequent, are just as characteristic of the psychoses in this group. In +other words, the name “Anxiety-Apathy Insanity” would be as appropriate, +theoretically, as Kraepelin’s term. In 1919 Hoch and Kirby published a +report on the perplexity cases. This present book was designed to show +that the symptom complex centering around apathy is as distinct as that +which is recognized by all psychiatrists as mania with its predominant +characteristic of elation. + +In 1917 ill health forced Dr. Hoch to resign from his official duties. +He retired to California with the purpose of adding to psychiatric +literature the fruits of his long experience and unrivaled judgment. His +first task was this book. In the midst of this work came a sudden +collapse. As I had been in close touch with his researches, coöperating +in psychological speculations, and was free to devote some time to it, +he asked shortly before his death that I complete the book. This +obligation is incommensurate with the debt I owe for years of +inspiration, tuition and criticism. + +The task has been mainly literary. I found the first five chapters +practically completed, while it has not been difficult, as a rule, to +discover from his copious notes what his intentions were as to the +details of the following chapters. I have been greatly aided by the +assistance of Dr. Adolf Meyer and of Dr. Kirby. The latter has been good +enough to read the entire manuscript, making invaluable suggestions and +criticisms. + + John T. MacCurdy. + +New York. + + + + +TABLE OF CONTENTS + + + CHAPTER PAGE + + EDITOR’S PREFACE vii + + I. INTRODUCTION AND TYPICAL CASES OF DEEP + STUPOR 1 + + II. THE PARTIAL STUPOR REACTIONS 34 + + III. SUICIDAL CASES 50 + + IV. THE INTERFERENCES WITH THE INTELLECTUAL + PROCESSES 67 + + V. THE IDEATIONAL CONTENT OF THE STUPOR 82 + + VI. AFFECT 123 + + VII. INACTIVITY, NEGATIVISM AND CATALEPSY 132 + + VIII. SPECIAL CASES: RELATIONSHIP OF STUPOR TO + OTHER REACTIONS 149 + + IX. THE PHYSICAL MANIFESTATIONS OF STUPOR 174 + + X. PSYCHOLOGICAL EXPLANATION OF THE STUPOR + REACTION 186 + + XI. MALIGNANT STUPORS 205 + + XII. DIAGNOSIS OF STUPOR 223 + + XIII. TREATMENT OF STUPOR 229 + + XIV. SUMMARY OF THE STUPOR REACTION 234 + + XV. THE LITERATURE OF STUPOR 249 + + INDEX 279 + + + + +BENIGN STUPORS + +CHAPTER I + +INTRODUCTION AND TYPICAL CASES OF DEEP STUPOR + + +The fact that psychiatry lags in development and recognition behind +other branches of medicine is due in part to the crudity of its clinical +methods. The evolution of interest in science is from simple, obvious +and tangible problems to more intricate and impalpable researches. +Refined laboratory work has been done in psychiatric clinics, +particularly along histopathological lines, but clinical studies follow +antiquated methods. The internist does not say, “The patient has sugar +in his urine, therefore he has diabetes and therefore he will die.” He +finds a glycosuria and looks for its cause. If this symptom is found to +be related to others in such a way as to justify the diagnosis of +diabetes, a therapeutic problem arises, that of adjusting the chemistry +of the body. The prognosis depends not on the disease but the +interreaction of the organism and the morbid process. Both in diagnosis +and treatment an individual factor, the patient’s metabolism, is of +prime importance. Now in psychiatry, although the personality is +diseased, this personal factor has been almost entirely neglected. +Text-books furnish us with composite pictures which are called diseases, +not with descriptions of reactions brought about by the interplay of +personal and environmental factors. Educated people are not satisfied +with novels that fail to depict real characters. Clinical psychiatry, +however, has been content with the dime-novel type of character +delineation. This is all the more disappointing, inasmuch as the study +of insanity should contribute largely to our knowledge of everyday life. +This defect can only be remedied by looking on every case as a problem +in which the origin of each symptom is to be studied and its relation +traced to all other symptoms and to the personality as a whole. This is +an ambitious task and we do not pretend to any great achievement, merely +to a beginning. + +No better psychoses could be chosen for a preliminary effort than benign +stupors. Every psychiatrist has seen them, although they are wrongly +diagnosed as a rule, and they play no small rôle in the world’s history. +Euripides represents Orestes as having a stupor which is pictured as +accurately as any modern psychiatrist could describe an actual case.[1] +St. Paul is chronicled as falling to the ground, being thereafter blind +and going without food or drink for three days. While apparently +unconscious he had a religious vision. St. Catherine of Siena had +several unquestionable stupors, which are fairly well described. In +fact the mystics in general seem to have had communion with God and the +saints most often when they seemed unconscious to bystanders.[2] The +obsession with death, which seems so intimate a part of the stupor +reaction, is a fundamental theme in poetry, religion and philosophy. The +psychology of this interest is, speaking broadly, the psychology of +stupor. So, from a general standpoint, our problem is related to the +study of one of the most potent ideas which move the soul of man. + +Psychiatrically, stupors have long remained an unsolved riddle. In the +century prior to 1872 (See the digest of Dagonet’s publication in +Chapter XV) French psychiatrists wrote some good descriptions of stupor +and offered brilliant, though sketchy generalizations about the +condition. Two years later an English psychiatrist (Newington, See +Chapter XV) improved on the French work. Little light has been thrown on +the subject since then. The researches of the later French School showed +that stupor often occurs in the course of major hysteria, but this left +many of these episodes obviously not hysterical. When serious attempts +were made at classification, this ubiquitous symptom complex was hard to +handle. Wernicke wisely refrained from attempting more than a loose +descriptive grouping. He called all conditions with marked inactivity +and apathy “akinetic psychoses” and said that some recovered, some did +not. Taxonomic zeal began to blind vision when Kahlbaum formulated his +“Catatonia” and included stupor in the symptom complex. The condition +which we call stupor occurs in the course of many different types of +mental disease. It is true that it is frequent in catatonia but is not +exclusively there. Mongols have black hair and straight hair, but one +cannot therefore say that any black and straight haired man is a Mongol. +Fortunately Kahlbaum prevented serious error by leaving the prognosis of +his catatonia open. When Kraepelin included it in his large group of +Dementia præcox, however, it implied that stupor could not be an acute, +recoverable condition.[3] He unquestionably advanced psychiatry greatly +but his scheme was too ambitious to be accurate. Many observers saw +patients, classified as dements according to Kraepelin’s formulæ, +return, apparently normal, to normal life. Finally Kirby[4] published a +series of cases which showed decisively that this classification was too +rigid. + +Since his paper is the foundation for this present study, it should be +reviewed carefully. He first points out that Kraepelin’s “Dementia +præcox” includes much more than it should with its inevitably bad +prognosis. He shows how others have found patients with catatonic +symptom complexes proceed to recovery and speaks of these symptoms +occurring in epilepsy and even in frankly organic conditions, such as +brain tumor, general paralysis, trauma and infections. Kirby’s first +claim is that there are probably fundamentally different catatonic +processes, deteriorating and non-deteriorating. Lack of knowledge has +prevented us from understanding the meaning of the symptoms and hence +making the discrimination. He points out that stupor seems to represent +an attitude of defense, similar to feigned death in animals, and that in +a number of his cases it was clear that the stupor symbolized the death +of the patient. Apparent negativism, he found to be often a consciously +assumed attitude of aversion towards an unpleasant emotional situation. +In cases where there had been no prodromal symptoms pointing definitely +to dementia præcox the outcome was almost always good. To discriminate +the cases with good outlook from those with bad, he discerned no +difference in the stupors themselves, but observed that the mental +make-up and initial symptoms differed sufficiently for diagnosis to be +made. His most important point is, perhaps, that these benign stupors +showed a definite relationship to manic-depressive insanity in that some +patients passed directly from stupor to typical manic excitement, while +in others a “catatonic” attack replaced a depression in a circular +psychosis. + +Kirby introduces, then, the idea of stupor being a type of reaction +which can occur either in dementia præcox or in manic-depressive +insanity. The matter cannot be left there, in fact it raises new +problems: what constitutes the reaction? how are the various symptoms +interrelated? are they different in deteriorating and acute cases? what +is the teleological significance of the reaction? if it be an integral +part of the manic-depressive group, how does it affect our conceptions +of what manic-depressive insanity is? More than five years have been +spent in endeavors to answer these questions and the results of the +study are now presented. + +Naturally the first point to be settled is: what constitutes the stupor +reaction itself. We can say at the outset that it is seen in the purest +form in benign cases, hence they make up the material of this book. To +discover the symptoms of the disorder one cannot do better than to study +them in their most glaring form in deep stupors, where consistently +recurring phenomena may be assumed to be essential to the reaction. + + + CASE 1.--_Anna G._ Age: 15. Admitted to the Psychiatric + Institute July 25, 1907. + + _F. H._ The mother and two brothers were living and said to + be normal. The father died of apoplexy when the patient was + seven. + + _P. H._ The patient was sickly up to the age of seven, but + stronger after that. It is stated that she got on well at + school, though she was somewhat slow in her work. She was + inclined to be rather quiet, even when a child, a bit shy, + but she had friends and was well liked by others. After + recovery she made a frank, natural impression. She was + always rather sensitive about her red hair. She began to + work a year before admission and had two positions. The + last one she did not like very well, because, she alleged, + the girls were “too tough.” + + Three weeks before admission she came home from work and + said a girl in the shop had made remarks about her red + hair. She wanted to change her position, but she kept on + working until six days before admission. At that time her + mother kept her at home as she seemed so quiet, and when + the mother took her out for a walk she wanted to return, + because “everybody was looking” at her. For the next two + days she cried at times, and repeatedly said, “Oh, I wish I + were dead--nobody likes me--I wish I were dead and with my + father” (dead). She also called to various members of the + family, saying she wanted to tell them something, but when + they came she would only stare blankly. For a day she + followed her mother around, clung to her, said once she + wanted to say something to her, but only stared and said + nothing. + + Four days before admission she became quite immobile, lay + in bed, did not speak, eat or drink. She also had some + fever. + + The patient herself, when well, described the onset of her + psychosis as follows: She knew of no cause except that her + brother, some time before the onset (not clear how long), + was run over by an automobile and had his foot hurt. She + claimed that while still working she lost her ambition, + lost her appetite, did not feel like talking to any one; + that when she went out with her mother it merely seemed to + her that people stared at her. The day before she went to + the Observation Pavilion her cousin came to see her, and + she thought she saw, standing beside this cousin, the + latter’s dead mother. She also thought there was a fire, + and that her sister was sweeping little babies out of the + room. Then, she claimed, she felt afraid (this still on the + day before going to the Observation Pavilion) because she + had repeated visions of an old woman, a witch. This woman + said, “I am your mother, and I gave you to this woman + (i.e., patient’s real mother) when you were a baby.” She + also was afraid her mother was “going away.” + + At the _Observation Pavilion_ she was described as + constrained, staring fixedly into space, mute, requiring to + be dressed and fed. + + _Under Observation:_ 1. For five months the patient + presented a marked stupor. She was for the most part very + inactive, totally mute, staring vacantly, often not even + blinking, so that for a time the conjunctivæ were dry. She + did not swallow, but held her saliva; did not react to pin + pricks or feinting motions before her eyes. Sometimes she + retained her urine, again wet and soiled the bed. Often + there was marked catalepsy, and the retention of very + awkward positions. As a rule she was quite stiff, offering + passive resistance towards any interference. She had to be + tube-fed at first. Later she was spoon-fed, and then would + swallow, in spite of the fact that during the interval + between her feeding she would let saliva collect in her + mouth. For a time she had a tendency to hold one leg out of + bed, and when it was put back would stick the other out. + Sometimes she walked of her own accord to the toilet chair, + but on one occasion wet the floor before she got there. + + During the first month after admission, this stupor was + interrupted for two short periods by a little freer action: + she walked to a chair, sat down, smiled a little, fanned + herself very naturally when a fan was given to her, though + even then did not speak. + + There was, as a rule, no emotional reaction, but after some + months she several times wept when her mother came, though + without speaking. Once when taken to the tub she yelled. + + Her _physical condition_ during this stupor was as follows: + She menstruated freely on admission, then not again until + she was well. Several times she had rises of temperature to + 102° or 103° with a high pulse and respiration; again a + respiration of 40, with but slight rise of temperature, + though the pulse had a tendency to go to 130 and over. She + was apt to show marked skin hyperæmia wherever touched. + With the fever there was found a leucocytosis of from + 11,900 to 15,000, with marked increase of polynuclear + leucocytes (89%). She got very emaciated, so that four + months after admission she weighed 68 lbs. (height 5′ 2″). + + 2. About five months after admission she was often seen + smiling, and again weeping, and she began to talk a little + to the nurses, though not to the doctors. She also began to + eat excessively of her own accord, and rapidly gained + weight, so that by January she weighed 98½ lbs., a gain + of 30 lbs. in two months. Yet she continued to be sluggish. + + 3. For two more months she was apathetic and appeared + disinterested, often would not reply, again, at the same + interview, she would do so promptly and with natural voice. + This condition may be illustrated by the summary of a note + made on January 29, 1908, which is representative of that + period. It is stated that she sat about apathetically all + day, appeared sluggish, but was fairly neat about her + appearance and cleanly in her habits. There was at no time + any evidence of affect, except when asked by the examiner + to put out her tongue so that he could stick a pin in it + she blushed and hid her face. When asked whether she + worried about anything, she denied this. When questions + were asked, she sometimes answered promptly and in normal + voice, again simply remained silent in spite of repeated + urging. On the whole, it seemed that simple impersonal + questions were answered promptly; whereas difficult + impersonal questions or questions which referred to her + condition were not answered at all. She proved to be + oriented. Thus she gave the day of the week, month, year, + the name of the hospital, names of the doctors and nurses + promptly. She also counted quickly and did a few simple + multiplications quickly. But she was silent when asked + where the hospital was located, how long she had been here, + whether she was here one or six months, how she felt. + Questions in regard to the condition she had passed + through, or involving difficult calculations, she did not + answer. However, some questions regarding her condition + asked in such a way that they could be answered by “yes” or + “no” were again answered quite promptly. Thus when asked + whether her head felt all right she said, “Yes, sir.” (Is + your memory good?) “Yes.” (Have you been sick?) “No, sir.” + (Are you worried?) “No.” + + 4. This apathy cleared up too, so that by the middle of + March she was bright, active and smiled freely. With the + nurses she was rather talkative and pleased, though this + was not marked. Towards the physician only was she natural + and free. She then gave the _retrospective account_ of the + onset detailed above. When questioned about her condition + she claimed not to remember the Observation Pavilion, + although recalling vaguely going there in a carriage. She + was almost completely amnesic for a considerable part of + her stay in the Institute. She claimed it was only in + November or December that she began to know where she was + (five months after admission). In harmony with this is the + fact that she did not recall the tube- and spoon-feeding + which had to be resorted to for about four months of this + period. No ideas or visions were remembered. As to her + mutism she said, “I don’t think I could speak,” “I made no + effort,” again “I did not care to speak.” She claimed that + she remembered being pricked with a pin but that she did + not feel it. She remembered yelling when taken to the tub + (towards end of the marked stupor) and claimed she thought + she was to be drowned. + + When she went home (March 24, 1908) she got into a more + elated condition. She was talkative, conversed with + strangers on the street, said to her mother that she was + now sixteen years old and wanted “a fellow.” When the + mother would not allow her to go out, she said it would be + better if they both would jump out of the window and kill + themselves. She then was sent back to the hospital. In the + first part of this period after her return, she was + somewhat elated and overtalkative, though she did not + present a flight of ideas, and was well behaved. She soon + got well, however, and was discharged, four months after + her readmission, fully recovered. + + After that, it is claimed, she was perfectly well and + worked successfully most of the time with the exception of + a short period in the spring of 1909, when she was slightly + elated. + + In 1910 she had a subsequent attack, during which she was + treated at another hospital. From the description this + again seems to have been a typical stupor (immobility, + mutism, tendency to catalepsy, rigidity). According to the + account of the onset sent by that hospital (it was obtained + from the mother), this attack began some months before + admission, with complaints of being out of sorts, not being + able to concentrate and fearing that another attack would + come on. Finally the stupor was said to have been + immediately preceded by a seizure in which the whole body + jerked. She made again an excellent recovery. + + The patient was seen about two years after this attack, and + described the development of the psychosis as follows: She + claimed she began to feel “queer,” “nervous,” “depressed,” + got sleepless. Then (this was given spontaneously) she + suddenly thought she was dying and that her father’s + picture was talking to her and calling her. “Then I lost my + speech.” As after the first attack, she claimed not to have + any recollection of what went on during a considerable part + of the stupor but recalled that she began to talk after her + brother visited her. It is not clear how she was during the + period immediately following the stupor. + + She made a very natural impression and came willingly to + the hospital in response to a letter and was quite open + about giving information. + + + CASE 2.--_Caroline DeS._ Age: 21. Admitted to the + Psychiatric Institute June 10, 1909. + + _F. H._ The father died of apoplexy when patient was nine. + The mother had diabetes. A paternal uncle was queer, + visionary. + + _P. H._ The patient was always considered natural, bright, + had many friends, and was efficient. + + Some months before admission the patient’s favorite + brother, who is a Catholic, became engaged to a Protestant + girl, and spoke of changing his religion. The family and + the patient were annoyed at this, and the patient is said + to have worried about it, but was otherwise quite natural + until seven days before admission. Then, at the engagement + dinner of the brother, the psychosis broke out. She refused + to sit down to the table, and then suddenly began to sing + and dance, cry and laugh and talk in a disconnected manner. + Among other things, she said “I hate her,” “I love you, + papa” (father is dead), “Don’t kill me.” She struck her + brother. She was in a few days taken to the Observation + Pavilion. + + The patient stated after recovery that what worried her was + that the brother would marry a Protestant and that he would + leave home (favorite brother). + + At the _Observation Pavilion_ she was excited, shouted, + screamed, laughed, called out “Don’t kill me,” again + “Brother, brother,” “You are my brother” (to doctor). + + _Under Observation:_ 1. On admission, and for two weeks, + the patient presented a marked excitement, during most of + which she was treated in the continuous bath. She tossed + about, threw the sheets off, beat her breasts and abdomen, + put her fingers into her mouth, bit the back of her hands, + waved her arms about, sometimes with peculiar gyration, + etc., at the same time shouting, singing, again praying, + laughing or crying, sometimes fighting the nurses and + resisting them. She also talked quite a little as a rule, + but there were periods when, although excited, she would + not talk or answer questions. She was very little + influenced in her talk by the environment. When on one + occasion asked if she had any trouble, she said: “No--I + don’t want, somebody else gave me a book--all right I love + myself, Uncle Mike too--all right too--all right I am in + Bellevue--I love everybody except the Jews all right, all + right--give me water, give me milk, give me seltzer--white + horse uncle--Holy Father, he is killing me, I want my + mother,” or “Wait a minute, say, that’s a lie--oh no, Holy + water--no I didn’t wash the water away--oh, she forgets, I + am sick--mother why don’t you come--look at the baby, they + knocked my head against the wall--wait a minute, isn’t that + terrible?--I was married--I was so--I forgot--April fool--I + kiss you seven kisses and one more--I love papa and mamma, + I like others too--I am papa’s angel child--yes I confess I + love him, but I don’t want to die myself.” On another + occasion, when asked where she was, she said: “I am at the + ball--I am going to Heaven--don’t shoot me” (affectless). + (Why are you afraid?) “Because you see--high water (in the + tub)--white horse.” (What about the water?) “My name is + Caroline--if you love me, father, tickle me under my feet,” + or, rolling her eyes up, “Oh, isn’t that awful, that ring, + that diamond, that is the key to Heaven.” + + 2. For about ten days she was somewhat different. She + became quieter and at first lay muttering unintelligibly, + saying some things about being killed, but speaking little, + often restlessly tossing about and tremulous. She had to be + tube-fed. On one day (July 1) she smiled more and talked + more, said to the physician “You have been arrested for + me--you arrested the first man that I ever--New York + State--let me see that book” (note pad). Then she went on: + “Oh, I am all apart--diamonds--they didn’t know--must I + keep them clean?--what is your name?--that is another thing + I would like to know.” But when asked what house she was in + she said: “This is the same Ward’s Island” and then added, + “How long have I been here?--there is my picture up there + (register), who is that? (listening) it’s Ida ...” She + began to sing softly. Then again she whined. “O mamma, + mamma!” When asked how long she had been here, she said: + “Since Decoration Day, when my father went in my sister’s + house, nobody could catch up with me--somebody blackened + her eyes.” When asked whether she was sick, she said “No, + insane.” + + Although, as was stated, she said at one time, “This is the + same Ward’s Island,” usually questions regarding + orientation were not answered, as she gave few relevant + replies, but she repeatedly said spontaneously that she was + in “Hoboken or Bellevue,” and called the nurse by the name + of a former teacher. A few days after this state had + developed she had a fever. Once this rose to 104°. The + fever lasted two weeks, coming down gradually. It was + associated with a leucocytosis of 15,000 on June 29 (no + differential count) and with coated tongue. No Widal (two + examinations). No diazo (July 1). + + 3. Then while the temperature still lasted she developed a + stupor which persisted for about a year. During this time + her temperature rose to 100° without ascertainable cause. + She lay for the most part motionless, changing her position + but rarely; her expression was stolid; she retained and + drooled saliva, wet and soiled herself. She never answered + any questions; showed no interest whatever. At times she + was quite stiff and very resistive but never cataleptic. + Her extremities were cold and cyanotic. She had to be + tube-fed throughout. During this time she lost much hair. + + After some months she occasionally gazed about furtively, + or later watched everything when unaware of being observed; + at this time she also smiled occasionally at amusing + things, or perhaps said “yes” or “no” to questions, but + usually was stolid when interrogated. + + Then about nine months after admission, while in the + condition just described, she developed a lobar pneumonia. + During it she remained the same. But during convalescence + she began to speak and eat. + + 4. A period followed lasting six months during which she + was up and about, but sat or stood around a good deal. On + the other hand, she helped the nurses a little when urged. + Her face was often stolid, again she looked about. At times + (even nearly to the end) she drooled and soiled. She said + little. At no time was she resistive. On other occasions + she smiled or laughed, not always on provocation, or she + showed little playful tendencies, such as throwing a pillow + about the room, tearing leaves from the plants, taking the + doctor’s arm and walking down the hall, asking him to kiss + her. At such times she often looked quite bright, keen, + alert and amused. Towards the end she would give at times + playful answers, such as “I came to-day,” or “This is the + Hall of Fame.” This tapered off, so that by December, 1910, + she was perfectly well. + + _Retrospectively_, the patient claimed not to remember the + upset at the dinner, or what happened afterward, although + recalling the trip to the Observation Pavilion. She denied + any memory of the journey to the hospital, but could tell + what ward she came to. How well the condition after that + was recalled, was not inquired into, except that she could + or would not explain further the utterances during the + first period. For the stupor period it is stated that she + remembered many external facts, but it is not clear in + which period they occurred. + + _Catamnestic Note._ May, 1913: She has worked efficiently, + and is said to have been perfectly well. + + + CASE 3.--_Mary F._ Age: 21. Admitted to the Psychiatric + Institute June 28, 1902. + + _F. H._ The mother died when the patient was five. The + father was living, an alcoholic and reckless man. Four + brothers and sisters died in infancy. + + _P. H._ The patient was the only surviving child. She was + brought up in a convent and orphan asylum until 11, when + her father remarried. At 12 she had to go to work, hence + she had but little education. She was bright, efficient, + well liked by her employers (in one position five years). + As to her peculiarities, she was thought to be, perhaps, a + little headstrong, and was also described as always very + exact, rather quick-tempered and inclined to be irritable + when crossed. + + She was married six months before admission and had a _baby + three weeks before admission_. The husband stated that when + the father found out she was pregnant, he spoke of killing + him. He frequently upbraided both husband and wife, though + he lived with them. Even after the child was born he + continued to be disagreeable. + + The patient was rather low spirited and quieter after her + marriage. She worried over her illegitimate pregnancy and + the scolding from her father. But nothing was thought of + all this, and it did not interfere with her activity. The + birth was normal. She had no flow, no unfavorable symptoms, + and sat up on the twelfth day. She is said to have appeared + natural mentally. + + A week before admission the family returned from the + christening, having left the patient apparently well. They + now found her sitting in her chair, limp, with closed eyes, + giving no answer to questions. Only after about twenty + minutes could she be aroused. After her father had given + her milk with whiskey in it, she claimed he had poisoned + her. In the evening she was bright and lively, singing and + dancing with the others, but in the night she woke up her + husband, seemed frightened, said somebody was in the room + and that he should get a priest as she was going to die. + The husband went to sleep again. The next forenoon the + patient claimed she had been frightened all night and + thought her father was going to kill her husband. + + On the second day, while sitting at breakfast, she groped + about for the bread plate for some time and then said she + had been blind for a short time. During the day she had + frequent spells in which she would close her eyes, become + perfectly quiet and difficult to rouse. Sometimes at the + beginning of these spells she would say “I am going.” She + was then taken to her aunt and walked there, a distance of + a few blocks. She was there for two days before going to + the Observation Pavilion. In this time she is said to have + been quiet for the most part, often apparently sleeping or + staring. Once she said she was “rather dirty, filthy.” Once + she tried to get out of the window, said it was a door and + that she wanted to get out and take a walk. Above all, she + had, in these two days, repeated peculiar seizures which + the aunt and the husband described as follows: When sitting + on a chair she would close her eyes, clench her fists, + pound the side of the chair, get stiff, slide on the floor, + then thrash her arms and legs about and move the head to + and fro. She frothed at the mouth. After the attack, which + lasted a few minutes, she breathed heavily for a while. + Once she wiped off the froth with a handkerchief and gave + the latter to the aunt, saying “Burn that, it is poison.” + Before the attack she sometimes said that it got dark over + her eyes and that her face felt funny, again that she had a + pain in the stomach which worked towards her right + shoulder. There was no cry in the beginning of the attack, + but once she wet herself. + + After recovery the patient herself told the development of + her psychosis thus: + + There was trouble between the father and the husband, and + she was afraid of her father. On the day of the christening + she took sick: a queer feeling came over her and she + wondered whether she was going to die, “Then I seemed to + lose myself, and when I came to I found my family standing + around me.” Her father gave her whiskey and she thought it + was poison. “That night I had spells of dancing and + singing, it must have been something I took, perhaps the + liquor.” The same night she was frightened, thought her + father might do some harm, and had a vision of a person in + white standing at her bed. After that she had repeated + spells in which she knew nothing until “I came to again.” + “It was a queer trembling.” + + At the _Observation Pavilion_ she was described as in a + state of “intense mental depression,” taking no interest in + things going on about her. She spoke, however; said she + wanted to die, that she had imagined her father had given + her poison, that every one was against her, and that people + were talking about her. + + 1. _On admission_ the patient had a slightly elevated + temperature, which soon subsided, full breasts but without + inflammation. Sordes were not mentioned. + + For a few days she was essentially somewhat restless, + getting out of bed, disarranging her clothes, wandering + about--all in a rather deliberate, aimless way, sometimes + vaguely resistive, again with free movements. She looked, + dazed, sometimes stared straight ahead and looked “dreamy.” + Occasionally there was a tendency to close her eyes. With + the restlessness she looked at times “a little + apprehensive,” or shrank away when approached. She spoke + slowly, with initial difficulty, but answered quite a + number of questions. The mental content of this period was + displayed in the following utterances: She would ask for a + priest, or say “Have I done something?” or “Do people want + something?” or, when asked why she was here, she said “I + have done damage to the city, didn’t I?” (What have you + done?) “I don’t know.” Or she spoke of people watching her. + When asked the day, she said “Judgment Day,” yet she knew + the month. Once when asked what the place was she said, + “This is the hereafter.” When asked what had happened at + home, she said: “Voices told me I was to be killed.” She + was not clearly oriented, called the place Bellevue, asked + “Isn’t this a hospital?” yet again said, “Ward’s Island, + where they work.” On the day of admission she thought she + came “the day before,” but knew she had come in a boat. + When asked her address, she said slowly, “Didn’t I live at, + etc.,” giving the address correctly. To the physician she + said, “Are you my brother?” And on another occasion, “My + God! You are Charlie” (brother). It was difficult to get + her to eat, and she had to be spoon-fed. + + 2. Then she became more preoccupied, the restlessness was + much less in evidence, it became necessary to tube-feed + her, she retained her urine, answered a few questions, and + when asked where she was, she said, “Calvary, ain’t it?” + (What house?) “Heaven, ain’t it?” She still called the + physician by the name of her brother. After a few days this + gave way to a more marked stupor which lasted nearly two + years. This was characterized most frequently by a complete + inactivity. She usually lay or sat motionless, sometimes + with mouth partly open, letting the flies crawl over her + face, gazing in one direction, soiling, wetting, resisting + moderately or markedly any interference, and had to be + tube-fed. But this was not the invariable state. The most + constant feature was her mutism, but even that was a few + times interrupted. Thus, when after a visit from her uncle + (towards the end of July, 1902) she tried to get out of the + window and was prevented, she swore at the nurse. Or in + August, 1902, when she got into another patient’s bed and + was taken out, she resisted and said promptly: “I think it + is a damned shame I can’t get into my own bed.” But this + was the extent of her talk for a year and a half. Nor was + she always totally inactive. In the middle of July, 1902, + she sometimes tried to get out of bed, wandered about, got + into other patients’ beds. It was on such an occasion that + the above incident happened. In August, 1902, she sometimes + tried to get out when the door was opened, and we have + seen that she tried to get out of the window, but she did + not change her placid expression at such times. Her motive + was not known. On two occasions towards the end of 1902, + when she was taken to a dance and was made to take part, + she waltzed with considerable animation but did not speak. + This was quite striking in that these incidents occurred in + a setting of marked inactivity (i.e., a condition in which + she had to be pushed to the table, pushed to the closet). + She did not soil any more, but she sometimes drooled and + had to be spoon-fed. However, on a third occasion when this + was tried, she had to be dragged around. Finally, though + her facial expression showed at times a preoccupied + staring, she more often looked around, sometimes quite + freely and often looked up promptly enough when accosted. + But there was very little evidence of any affect at any + time. We have seen that twice she swore a little when + opposed. On another occasion she slapped a patient when the + latter helped her. Twice she was seen crying a little + without apparent provocation, but she did not laugh, and + the only suggestion of pleasurable emotion was that at the + two dances mentioned she could be led into a certain + animation. Usually, even when she got less resistive + towards the end, she was essentially apathetic. + + Once in January, 1903, she could be made to write her name + but wrote her maiden name. In the end of 1903 she improved + gradually (a condition not well observed), so that by + December she answered some questions in a low tone. Even in + April, 1904, she was still described as apathetic, though + she had begun to do some work. + + 3. Then she improved markedly and began to work, looked + after herself in a natural way, spoke freely, was entirely + oriented and her mood generally presented nothing striking. + But her mental attitude was still peculiar when she was + questioned. She seemed somewhat inattentive, sulky, + sneering. Thus, when asked why she was here, she said, “You + will have to ask those who brought me here.” + + She denied ever having been pregnant, said the nurses on + the ward had spoken of her having had a child and that they + had showed her a child (one was born on that ward about + August, 1903) but that it was not hers. She thought it was + wrong for the nurses to speak on the ward of her having + been pregnant. Again questioned about her marriage, she + first said she had not been married, again that she was + married “a year ago” (was in the hospital then). Again she + spoke of her husband as her “gentleman friend,” claimed she + called herself Mary M. (maiden name) until a girl friend + wrote her a letter addressed to Mrs. F. From then on, she + called herself by her married name. But she thought that + probably they sometimes spoke of her marriage in fun. If + she were Mrs. F. she would be living in Mr. F.’s house. + + On June 29, when again asked about her marriage, she said + she was to have been married in December (correct date). + (Were you?) “So they say.” (Do you remember it?) “In a + way.” (When was the baby born?) “You will have to ask + somebody more superior to me, more experienced.” Then, when + further questioned about the age of the baby, she said, + “The baby I saw in the ward was about a year old,” and she + claimed not to remember ever having a baby. When asked why + she had come here she said, “Well, I don’t know, perhaps + you know better, through sickness I guess,” and later: + “Well, don’t you ever get a cold and want doctors to + examine you?” (What kind of a place?) “This is a nice place + for sensible people who have enough knowledge to know and + realize what they come for.” But she knew the name of the + place, the date, the names of persons. + + Questioned about the trouble with her father or her + husband’s trouble with him, she denied it, “If he did (sc. + have any trouble), I don’t remember.” About her not + speaking, she said, in answer to questions, “I didn’t know + what I was here for, what was the object in keeping me + here”; and to other questions about her condition, “I don’t + know, those who examined me can tell you more about that.” + Finally, she said in reply to the question, why she came + here, “I don’t remember _unless it was through fire_,” but + would not explain what she meant. + + In the beginning of July, she again said that she had no + recollection of her marriage. + + She then improved a great deal and finally appeared very + natural, gave the retrospective account noted in the + history, had a clear appreciation of the fact that she was + married and had a child. She claimed that she had + previously forgotten about her marriage and thought she was + still merely keeping company with Mr. F. She claimed not to + remember coming to the hospital, did not know what ward + she came to, who the doctor and nurses were, in fact + claimed that it was about a year before she knew where she + was. But she remembered having been tube-fed. She could not + say why she did not speak. But she appreciated that she had + been ill. + + Ten years after discharge the husband, in answer to an + inquiry, stated that she had been perfectly well and had + had no trouble at three successive childbirths. + + + CASE 4.--_Mary D._ Age: 20. Admitted to the Psychiatric + Institute September 17, 1907. + + _F. H._ The grandfather and the father of the patient were + alcoholics. The father died three years before the + patient’s admission; he was killed in an accident. The + mother stated that she herself was nervous, but she made a + normal impression. + + _P. H._ The patient was described as bright at school and + efficient in her work as a dressmaker, but she was rather + quiet, inclined to stay at home and had not much + inclination to consort with the other sex. She was rather + proud. As an example of this is stated the fact that she + was always somewhat sensitive, because the family lived in + the basement of the house in which her mother was + janitress. She did not menstruate until 16. It was about + this time that her father was killed in an accident. She + was considerably upset by this, talked a good deal about + the way he was killed, but did not break down. The patient + on recovery stated that it worried her because the father + died without having any chance to get a priest. + + Six weeks before admission the patient was given a + vacation, as there was not work enough in the shop, but she + worked at home. + + Two or three weeks before admission her appetite failed + somewhat, and ten days before admission, without any + appreciable cause, she began to sleep badly, seemed + somewhat nervous, became a little “fidgety” and said she + worried because her mother had to work so hard. Later she + began to speak about people saying that the ambulance would + come for her and she heard voices saying “You will be + dead.” It is not known in what emotional setting these + remarks were made. Her mother took her to a dispensary. On + the way she asked the mother where she was going and said + “I can’t tell the number and I don’t know where I am going. + I think I am losing my mind.” She also said she could not + understand any more what she read. She was put to bed. She + then talked less, appeared stupid, and was inclined to + refuse food. + + Four days before admission she claimed that she could see + her dead father beckoning to her, again she said a certain + young man was God. She was sent to the Observation + Pavilion. On the day she went there she was reported to + have shown a slight jaundice. + + The patient, after her recovery, added to the above account + of the mother, that about two weeks before admission, for + no reason which she could state, she began to feel quiet, + and that after that her father’s death began to prey on her + mind, and that later she had a vision of her father. She + claimed that in this period she had no fear but that her + head felt dizzy and her vision seemed dim. + + At the _Observation Pavilion_ the patient was described as + constrained, refusing food, mute, resistive of attention, + sometimes muttering to herself and having the appearance of + uneasiness. + + _Under Observation:_ 1. On admission the patient had a + slight jaundice, which disappeared in a few days, and the + bile test in the urine was negative on admission. She was + rather thin, but otherwise in good physical condition. Her + temperature was 99.2°. + + For three months the patient was very inactive, moving very + little. She had to be dressed and undressed, when taken out + of bed. She often was markedly constrained, either lying + with her head raised from the pillow, or for long periods + of time holding her arms or hands in rather constrained + positions on her body. But there was at no time any + catalepsy when tested by moving her arms. In the beginning, + however, before she lay so persistently with her head + raised, she was found holding it up from the pillow after + her hair had been fixed. Again, she did not correct other, + rather uncomfortable, positions in which she had been left. + There was also at times a slight or occasionally a somewhat + more marked resistance in her arms and neck, but this never + amounted to a pronounced resistance. She sometimes did not + react to pin pricks, sometimes flinched a little, never + warded off the pin, indeed she would put out her tongue + repeatedly when asked to do so in order to have a pin stuck + into it. She very often wet and soiled, once even + immediately after she had been taken to the closet, on + which occasion she did not urinate. Her face was usually + dull, vacant and immobile, but sometimes, when questioned + or when something obtrusive happened, a little puzzled. + Occasionally she looked slowly about or followed people + with her eyes. There was no evidence of any affect as a + rule, but not infrequently she smiled, even quite freely at + times, when the physician came to her or on other + appropriate occasions. For example, once when a nurse came + into the ward whom she had known outside she flushed and + smiled a little. Once when the mother came to see her a few + tears appeared, the only time this occurred. + + Although for the most part immobile, when she did move, she + was distinctly slow. When asked to do certain things, she + usually did not comply, but now and then, after urging, + would show her tongue after delay, or merely open her + mouth; or she would bring the hand forward slowly when the + physician offered his hand in greeting. Once she fumbled + with her braids slowly. When out of bed, she stood about + aimlessly or sometimes walked somewhat slowly. + + She was almost entirely mute, but a few times she returned + a greeting quite promptly, or on another occasion + (September 23) she said quite promptly, when asked how she + felt, “I feel better. I took off my clothes” (correct--she + had been up and put to bed again). Again she sometimes + answered simple questions by “yes” or “no,” though + sometimes in a contradictory and rather aimless manner, but + promptly enough. Once she said to her mother, “I can’t, I + have to remain here.” There were some other replies which + we shall presently take up. Several times it was possible + to make her write. On these occasions she wrote her name + promptly, or might write only after much delay or stopping + in the middle of a word. + + This leads us to her capacity to think, the defect of which + was perhaps most clear in her writing. Thus, though having + been told to write her name, and having written it quickly + enough, when, immediately after it, she was asked to write + her address or the name of the hospital, she had to be + urged much, and then wrote each time merely a repetition of + her name, this time much more slowly. On October 13, when + she was asked to write her name, she wrote it correctly; + then for the address she wrote the house number correctly, + but for 90th street she wrote “90theath”; and, urged again + for the address, she added “Dr. Wyeth.” Again when asked to + write the word “watch” she was slow, and finally put down + “10.” When on October 23 she was asked to write “Manhattan + State Hospital,” she wrote “Manhatt Hhospshosh,” and for + “Ward’s Island” (which she was told), “Ww Iland.” Then she + was asked to write “I wish to go home.” She wrote “I wish + to go home, go West.” Here again the first part was written + promptly. + + We now can add some of the other replies which she gave. + Once she was asked “Do you know where you are?” She + promptly said, “Yes.” (Where?) No reply. On another + occasion, at the initial examination, she said she was home + or “in papa’s house.” Once when asked “Do you know me?” she + said “Yes.” (What is my name?) “Miss D.” (her name). On the + occasion on which she had stated that she had taken off her + clothes, she was asked “Where have you taken off your + clothes?” She made the irrelevant reply, “That was the girl + the one I had.” + + 2. Then she improved somewhat. On January 5 she walked + about a little more, though slowly, and still looked + slightly puzzled when questioned. She spoke more readily, + counted promptly though once stopped in the middle of the + exercise. In calculation she multiplied correctly 3 × 7, + but for 4 × 9 repeated the 21, and when given 9 × 9 she did + not answer. A few days later, though she lay again + motionless with her head raised as before, and, as she had + sometimes done, smiled brightly when accosted, she gave few + replies, but when asked to write down the month she slowly + wrote “December.” Asked to write it the second time, she + did it promptly. She also replied promptly by saying “Yes” + when asked whether Christmas, and again whether New Year’s, + had passed, but did not reply to the questions how long ago + Christmas, or how long ago New Year’s, had occurred. On + January 23 she was decidedly more free and prompt in her + replies, yet she still wet and soiled (in fact this did not + cease until the end of the month, when great improvement + occurred). At this time she gave quite a number of + calculations promptly, about an equal number wrongly. She + knew where she was, knew the names of a number of people + about her, but thought she had been here about two weeks + (four months), and gave the year and the date, the latter + as the 28th of January. When then told that it was + Thursday, January 23, and that she must remember it, and + asked five minutes later what she had been told, she again + said “January 28” and left out Thursday. To some questions + to which she did not know the answers, since she had an + amnesia for the time of their occurrence (the incidents of + coming here), she simply remained silent. Even on February + 7, when she was much freer, helped the nurses, and said + herself she was “smarter,” she had difficulty in thinking, + said she was 17 (21), gave the date of her birth correctly, + but the current year as 1909 (1908) and still insisted she + was 17. She then did the calculations on paper, and with + considerable difficulty got correctly “22.” But she could + not straighten out the discrepancy. At that time, also, she + still wrote “Hospitital,” calculated even simple + multiplications with some mistakes, could not get the point + of a story, and to retention tests gave poor results. + Indeed, even seven days later, when she wrote a very + rational letter and appeared quite natural, she made some + omissions in her writing, and a few mistakes in spelling. + + However, she now improved rapidly, and by March 31 she made + a very natural impression, was frank, free, had good + insight, calculated well, etc., understood a story, + retention was good. + + She then gave the retrospective account embodied in the + history, and in addition told that she had no recollection + of going to the Observation Pavilion, the coming here, or + the first part of her stay, including presentation of the + case at a staff meeting, a physical examination and a blood + examination, and she claimed for a long time not to know + where she was, “I was in a kind of dazed condition.” She + also said she could not understand the questions which were + asked her. This probably refers, however, to the second + part, i.e., the partial stupor lasting for two months. She + did not “feel like talking,” the limbs “felt stiff-like.” + + + CASE 5.--_Annie K._ Age: 22. Admitted to the Psychiatric + Institute January 7, 1907. + + _F. H._ The father was an alcoholic, who died when patient + was a child. A paternal aunt had a nervous breakdown, with + recovery. The mother appeared to be normal. + + _P. H._ The mother stated that the patient was a rather + delicate child. She attended school irregularly, never felt + much interest in it, and was always glad to be at home and + help the mother take care of the other children. On the + other hand, she is said to have been quite lively, rather a + tomboy, with a temper. She left school at 14; learned + dressmaking for a year, but did not get along well. Then + she took several other positions, which she held for about + a year, getting on pretty well. + + She married at 20. Her husband never supported her well and + often beat her. She had to borrow money to get along and + worried much. During pregnancy she seemed to worry more, + had crying spells, and often seemed absorbed in thought. + + Three weeks before admission she gave birth to a child. The + labor was somewhat difficult, but she had no fever. She got + up on the tenth day, and then seemed to lose all interest, + did not attend to the baby, said she was not strong enough. + She sat about, appearing depressed. The mother then took + her and the baby to her house. There she sat or walked + about, said very little. But she repeatedly came to her + mother, said she had something to tell her, or that she had + “done something,” although she could never be induced to + say what. Once she came to her and said, “You are not going + to die.” She often moaned. Finally, she claimed a neighbor + had been saying she was poisoning the baby. + + The patient herself gave, after recovery, the onset as + follows: When she married she knew her husband was not what + he should be, but not that he was so bad as he proved to + be. He was a gambler, did not support her, and this caused + her much worry. When she became pregnant, eight months + after marriage, this increased her worry, and throughout + the pregnancy she spoke much to a neighbor about her + worries, and said she did not know how she could manage, + pay the doctor, and the like, but she did not say much + about it to her mother (because the latter would have made + such a fuss about it, or would have said, “It serves you + right”). Then the childbirth came. This further accentuated + her worries. She felt her difficult circumstances, wondered + how she could get the necessary money, “I lay there + worrying.” And she claimed she did not sleep at all. About + her statement, mentioned by the mother, that she had done + something, she said that she thought she had poisoned the + child by giving it fennel tea, and that she thought a + neighbor who visited her said she had poisoned it. She was + then put to bed again, and one night she had a vision of + her father. This frightened her. She thought this meant he + had come for her and she wanted to die. + + At the _Observation Pavilion_ she was dull, staring, + resisting attempts at passive motions. + + _Under Observation:_ 1. There was nothing noteworthy in her + physical condition, except for a rise of temperature to + 100° occasionally during the first month of her admission. + For the first four months she was often found lying in bed + with her head half raised from the pillow, or standing or + sitting about in constrained positions, immobile, + frequently she let saliva collect in her mouth. She usually + wet and sometimes soiled the bed. Sometimes, when sitting + in a constrained position, she let herself gradually slide + on the floor. She often began to feed herself when urged, + but would not finish, and had to be spoon-fed, as a rule. + She was never tube-fed. She was often quite stiff and + showed marked resistance. This was manifested either when + passive motions were tried, at which times she usually + resisted passively, i.e., she became more tense; or when + there broke through a more active aggression and she would + strike. Above all, the opposition showed itself towards the + nurses’ attention; in this she also showed either a + passive, aimless opposition and stiffness, or a more active + one; but even in the latter an open show of angry affect, + or plain irritation, though present at times, was by no + means constant. When it was present, she would strike quite + aimfully; once she struck the nurse and said, “You are the + cause of it all,” and once, when the nurse tried to give + her some milk, she said, in an irritated tone, “I wonder + people would not let me alone some time.” Again, she bit a + patient who tried to hold her. On another occasion she + quickly jumped up and pulled the hair of a patient who + evidently disturbed her by her noisy shouting. As was + stated, she usually wet the bed, resisted being taken to + the toilet, or when taken there, would not urinate or + defecate, but would do so as soon as she was returned to + bed; or she urinated while standing. The same perverse + opposition was seen when she would refuse a glass of milk, + but grab it when it was taken away and then refuse to let + go. She often would grasp the bedclothes or other things + and hold on aimlessly. + + She rarely spoke, answered almost no questions, complied, + as a rule, not even with the simplest commands. To pin + pricks she did not react except at times by flushing. But + she did not stare, rather looked about, and was at times + easily attracted by noises or happenings about her, and + would then look in that direction not without some + interest. Often there was then an expression of + bewilderment. Her mood, however, was, as a rule, apathetic, + but at times, as stated, she showed some anger. Once she + wept, and a few times she smiled or snickered. As a rule, + this happened without appreciable cause. But once, when a + cheering remark was made, she smiled; or, when her picture + was taken (to show the peculiar constrained attitude with + the head raised from the pillow), she laughed loudly. + + Although she spoke rarely, she made a few utterances in the + first few days. Thus she suddenly said: “I want to see Mr. + N.--what I said to him was not right,” or “Listen! there + are the priests calling,” or “You are all faking--it is me + that done it--they are all dressing up downstairs,” or “I + told you she was not able to nurse the baby,” or “I have + nobody, I am lost--I want to know the truth--my mamma,” or + she called her sister, “They are dead since last night.” + + Even during the more stuporous state she could, a few + times, be made to write a little. Then she either wrote + very slowly and not more than a letter, or if she wrote + more, it was remarkably mixed up. Thus when asked to write + the date, she wrote, “Jane (mother’s name) to me to + Chrichst,” or when asked to write her name: “Annie take you + ktusto.” + + As to her orientation, nothing could be made out as a rule. + At first, however, a few weeks after admission, she spoke + correctly of the month as January and spoke of the Island. + When at that time she was asked if she had a baby, she + said, in an annoyed tone, “I don’t know.” + + 2. In the beginning of May, i.e., four months after + entrance, her condition changed somewhat, and for two + months she presented the following state: She stood about, + or walked around slowly, usually with her arms folded. She + had a tendency to stand near the door. She had to be + assisted in dressing, pushed rather than led to her meals, + and urged to eat. For the most part, she would not answer + questions, but would either smile in a sneering way, or + just walk away, or say, “Oh, don’t bother me,” or “I don’t + want to talk,” and generally her attitude was rather sulky. + Nor was this only towards the physicians but towards the + husband, sister and child as well. When on May 17 the + sister came, she would not speak to her but said “Go away.” + The baby she simply pushed away sulkily when it was brought + to her. To the husband she said on May 31, “Go away, you + stink.” In the first part of this period, she presented + some bursts of elation, on one occasion turned somersaults, + indulged in a few pranks with laughter, or once, when a + knock at the door was heard, she called out “Holy gee, + cheese it, the cop.” But these occurred only in the first + part of the period. On June 1 she spoke to the nurse, said, + “What is the matter with these people, they must be crazy,” + asked to go home, and was then by the nurse found to be + oriented, and to know the names of people around her. But + when she was asked about the baby she would not answer, and + questioned whether she was not married, she said “I don’t + know.” Yet when the physician desired to talk to her, she + was just the same as before and remained so for two more + weeks. Another somewhat isolated occurrence was when on + June 18 she spoke a little to the physician, but she sat in + a constrained position when taken into the office and + answered many questions by “I don’t know,” namely, those + regarding her condition and feelings, the questions about + orientation, about her mother’s address, and her child’s + age; but when asked how long she had been married she said + correctly “Two years.” + + At the beginning of July she improved quite rapidly, and on + July 5 appeared fairly free and gave a fair retrospective + account, with some urging, and it was thought that she + smiled somewhat too freely. However, on July 27, she seemed + perfectly well, had normal insight, and then gave the + second retrospective account, which, together with the + first, will now be taken up. + + _Retrospectively:_ She claimed to remember things at home, + and at both interviews said she recalled being taken to the + Observation Pavilion. While there she thought she knew + where she was, remembered that she did not talk. She had a + feeling she was going to die and said “I thought I would + die if I kept still.” However, the transfer to this + hospital was vague in her mind, as was the entrance on the + ward, and she claimed not to have known for quite a while + where she was. She added that she used to wonder where she + was, how she had gotten here, and how she could get out, + and thought the questions which were asked were queer. + Individual occurrences, too, specifically inquired into + were not recollected, such as an examination in a special + room. Of the mixed-up writing at the end of the second + week, she had no recollection even when it was shown to + her. She did not recall having her picture taken (with eyes + open) two months after entrance. Yet a sudden angry + outburst ten weeks after admission was remembered. She + stated that she struck the patient because the latter + annoyed her by her shouting. She had a general recollection + of being stiff, having her head raised, and of soiling and + drooling, but could not account for it. She felt stubborn. + She also claimed not to have been hungry and not to have + felt pin pricks. + + In regard to ideas which she had, she claimed to be afraid + at first that she would be cut up. She remembered repeated + visions of her father at night, also once of her dead aunt, + who said “Come to me.” She thought she was in a cemetery, + all the family were dead, the baby dead. In the beginning, + too, she sometimes heard a priest whom she had known, say + “Be good and God will look after you.” + + In regard to the later period, she recalled that she got up + in May and felt cross. She did not answer because she did + not want to be bothered. She pushed the baby away because + she did not think it belonged to her, the husband because + she did not like him. (She did not think she was not + married.) She evidently remembered the visits, thought she + knew where she was, knew she stood near the door “because I + wanted to go home.” Besides the idea that the baby was not + hers, she recalled none, and thought she had no + hallucinations. + + She was discharged perfectly well six months after + admission to the hospital. Soon after that, she left the + husband, once had him arrested in 1908 and sent to the + workhouse. She was again examined in 1913, and was found to + be perfectly well, and she stated she had been well since + the discharge. + +These five cases will have to suffice for the present. They were given +in full in spite of the fact that we shall leave out of our present +considerations the history of the cases and certain of the stages, and +confine ourselves to that stage of each case which is best qualified to +give us a good general survey of the essential features of the stupor +reaction. + +These phases are: stage 1 of Case 1, lasting five months; stage 3 of +Case 2, lasting one year; stage 2 of Case 3, lasting two years; stage 1 +of Case 4, lasting three months; stage 1 of Case 5, lasting four months. + +We gather from these descriptions that the essentials of the stupor +reaction are (1) more or less marked interference with activity, often +to the point of complete cessation of spontaneous and reactive motions +and speech; (2) interference with the intellectual processes; (3) +affectlessness; (4) negativism. + +_Inactivity:_ There is a complete cessation or more or less marked +diminution of all spontaneous or reactive movements. This includes such +voluntary muscle reflexes as contain a psychic component. For instance, +there is, often, an interference with swallowing (letting saliva collect +and drooling), winking, and even with the inhibitory processes used in +holding urine and feces (soiling and wetting). Often there is no +reaction to pin pricks or feinting motions. The inactivity also often +interferes with the taking of food so that spoon-feeding or tube-feeding +has to be resorted to. The patient may keep his eyes covered or stare +vacantly, the face often presenting a remarkably immobile wooden, or +stolid, expression. Complete mutism is the rule. When activity is not +totally interfered with, those movements which are present may be slow. +The patient may have to be pushed around and be able to take a few +steps, but soon relapses. More often they are of normal rapidity. Speech +then may also be slow and low, but usually shows no change except for +the fact that it is diminished in amount. Sometimes awkward positions +are assumed and retained, and there may be catalepsy. + +_Negativism:_ A common symptom is perverse resistiveness. It may consist +in a marked stiffening of the body which is assumed spontaneously or +appears only when attempts at interference are made, or there may be a +more active turning away or even a direct warding off, sometimes with +scowling or anger or even swearing and striking. Retention of urine, +which is seen at times, should, perhaps, be mentioned here. Now and then +we find that a patient is put on the toilet and cannot be induced to +urinate or defecate, while soiling and wetting occur at once on +returning to bed. + +_The intellectual processes:_ Little is known about the intellectual +processes from direct observation in these more pronounced cases, except +for the fact that in Case 5 questions or obtrusive occurrences sometimes +produced a somewhat puzzled facial expression. Moreover, the patient +retrospectively stated that she was unable to understand the questions, +which points to marked difficulty in apprehension. We also find that +occasionally there is evidence of an interference with the intellectual +processes which showed itself in what may be called “paragraphic” +writing when the patient could be induced to write. Above all, we see +that retrospectively very little is remembered of what took place during +the stupor, even of such obtrusive events as the moving from one ward to +another, tube-feeding, physical examination, the presentation at a staff +meeting, and the like. + +_Affect:_ Complete affectlessness is an integral part of the stupor +reaction. Modification of the statement will later be mentioned. The +patient is indifferent so far as his basic condition is concerned, and +it is only by certain stimuli that at times emotional reactions can be +elicitated, some tears at a visit of a relative, an appropriate smile at +a joke or a comical situation when the stupor is not too deep or an +angry reaction called forth by interference. + +_Catalepsy:_ Waxy flexibility or merely a tendency to maintain +artificial positions is a frequent but not an essential symptom. + +_Physical Condition:_ Not infrequently we find in the beginning or in +the course of the stupor an elevation of temperature to 101°, 102° or +even 103°. In one case we found a marked cyanosis in the extremities. +Case 2 showed marked loss of hair. Gain in weight is never observed and +marked emaciation is the rule. This we may attribute to the refusal of +food. + +A perusal of these cases, then, shows that the dominant (and well-nigh +exclusive) symptoms of the stupor are inactivity, apathy, negativism and +disturbance of the intellectual functions. Benign stupor can be defined +as a recoverable psychosis characterized by these four symptoms. The +meaning of such vague physical manifestations as the low fever is not +clear. + + +FOOTNOTES: + +[1] MacCurdy has discussed the psychological phenomenon of a dramatist +depicting a psychosis correctly in “Concerning Hamlet and Orestes.” +_Journal of Abnormal Psychology_, Vol. XIII, No. 5. + +[2] Many of these states seem to be hysterical rather than +manic-depressive stupors, but so far as the unconsciousness goes, there +is probably as much psychological as symptomatic resemblance between the +two types of reaction. + +[3] Kraepelin recognizes, of course, the occurrence of stupor symptoms +or states in the course of manic-depressive psychoses. It is stupor as a +clinical entity, as a separate psychosis, that he regards as one form of +the catatonic, and therefore of the dementia præcox, reaction. + +[4] Kirby, George H.: “The Catatonic Syndrome and Its Relation to +Manic-Depressive Insanity.” _Jour. of Nervous and Mental Disease_, Vol. +40, No. 11, 1913. + + + + +CHAPTER II + +THE PARTIAL STUPOR REACTIONS + + +The cases thus far considered, namely, those of marked stupor, are +fairly well known and have been studied by others. Less well known and +formulated, but even more important from a practical as well as from a +theoretical point of view, are what may be called partial stupors. + +The reader has noted that the states of deep stupor described in the +last chapter, did not end abruptly with a sudden return to health or a +sudden change to another type of psychosis. They all gradually passed +away, not by the disappearance of one symptom after another, but by the +attenuation of all. Sometimes a more or less stable condition persisted +for months, in which there was no stupor in a literal, clinical sense +but when apathy, inactivity, interference with the intellectual +functions and negativism all existed. Had these been the only states +observed in these patients, there might have been some ground for doubt +as to the diagnosis. As it was, it was clear that we were dealing with +mild stages of stupor. When a psychiatrist meets with an undeveloped +manic state, he calls it a hypomania and does not hesitate to make this +diagnosis in the absence of complete development into a florid +excitement. This procedure is not questioned, because the manic +_reaction_ as distinguished from a _mania_ is well recognized. We +believe that there is just as distinctive a _stupor reaction_ which may +be exhibited either in deep stupors or what we may term partial stupors. +Theoretically, complete apathy, inactivity, etc., make up the clinical +picture of a deep stupor. When these symptoms appear rather as +tendencies than as perfect states, a partial stupor is the product. That +partial stupors occur as well-defined psychoses, developing and +disappearing without the appearance of deep stupor, we shall attempt to +show in the following three typical cases: + + + CASE 6.--_Rose Sch._ Age: 30. Admitted to the Psychiatric + Institute August 22, 1907. + + _F. H._ Both parents were living (father 74, mother 68), as + were two brothers and two sisters. All were said to be + normal. + + _P. H._ Nothing was known of the patient’s early + characteristics, except that she herself said she was slow + at learning in school and did not have much of an + education. But when well she made by no means the + impression of a weak-minded person. The husband had known + her for ten years. He married her eight years before + admission, by civil process, keeping this from his own + family because he was a Jew and she a Christian. He said + that this undoubtedly worried the patient at times and that + she often asked him when he would take her to his family. + The patient herself later also said that this used to worry + her. Finally, one and a half years before admission she + agreed, on account of the children, to accept the Hebrew + faith, and they were then married in the synagogue. But he + still did not take her to his family. + + There were four pregnancies: the first child died; of the + survivors one was 8, a second 5 years old. Finally, a year + before admission, she became again pregnant. During the + pregnancy one of the children had whooping cough and she + herself was thought to have caught it. The baby was born + three months before admission. It was a blue baby which + died two days after birth. The patient flowed heavily for + three weeks and was taken to a hospital, where she + continued to flow intermittently for some weeks more. + + Finally, three weeks before admission, a hysterectomy was + performed. Several days after this, when the sister-in-law + visited her, the patient begged her to take her home, said + the doctor wished to shoot her and to give her poison. + Later the patient confirmed this, saying that she thought + they wanted to give her saltpeter, and that she heard them + say they wanted to shoot her. + + When taken home she refused food; gazed about, was + absorbed, seemed obstinate, and several times tried to jump + out of the window. Retrospectively the patient stated that + she heard children on the street call “Katie.” She thought + they meant her child, heard that it was to be taken away + from her, and a similar idea again came out later in her + psychosis, namely, that somebody was going to harm her + children. + + At the _Observation Pavilion_ she appeared stupid, rather + immobile, her attention difficult to attract. + + _Under Observation:_ On admission the patient appeared + sober, impassive, moved very little, was markedly + cataleptic, though not resistive. On the other hand, her + eyes were wide open and she looked about freely, following + the movements of those around her not unnaturally. When + questioned, she looked at the questioner rather intently, + and was apt to breathe a little more rapidly, and made some + ineffectual lip motions but no reply. To simple commands + she made slow and inadequate responses. She flinched when + pricked with a pin, but made no attempt at protecting + herself. She had to be spoon-fed. The catalepsy persisted + only for two days. + + After this she continued to show a marked reduction of + activity, moved very little, said nothing spontaneously, + had at first to be spoon-fed (later ate naturally enough). + But she never soiled herself and went to the closet of her + own accord. + + Emotionally she seemed dormant for the most part, though + for the first few days she appeared somewhat puzzled, and + one night when a patient screamed she seemed afraid and + did not sleep, whereas other nights she slept well. She + answered only after repeated questions and in a low tone. + Very often, though her attention was attracted easily + enough, her answers were remarkably shallow and also showed + a striking off-hand profession of incapacity or lack of + knowledge. This was often without any admission of + depression or concern about her incapacity. She would + usually say “What?” or “Hm?” or repeat the question, but + most often would say, “I don’t know,” this even to very + simple questions. For instance, when asked, “What is your + name?” she answered, “My name? I don’t know myself” (but + she did give her husband’s name), or when asked to write + her name, she said, “I don’t know how to write,” or “Call + Annie, she will write my name.” When requested to read or + write (even when asked for single letters), she would make + such statements as “I can’t read.” However, she finally + named some objects in pictures. This condition was + characteristic of her for two weeks. + + Then her condition changed a little. She spoke a little + more freely but was similarly vague. The following + interview of September 9, is characteristic: When asked how + she was, she said, “Belle.” (Are you sick?) “No.” (Is your + head all right?) “Yes.” (Is your memory all right?) “Yes.” + (Do you know everything?) “Yes.” (Understand everything?) + “Yes.” (Are you mixed up?) “No.” (Do you feel sick?) “No.” + But when asked where she was, how long she had been here, + what the name of the place was, what was the occupation of + those about her, she said, “I don’t know.” (How did you + come here?) “I couldn’t tell how I came up here.” (What are + you here for?) “I am walking around and sitting on + benches,” but finally, when again asked what she was here + for, she said, “To get cured.” She now gave and wrote her + name and address correctly when requested, also gave the + names of her children. Yet when asked about the age of the + girl, said, “I don’t know, my head is upside down.” When an + attempt was made to make her repeat the name of the + hospital, or the date, or the name of the examiner, she did + so all right, but even if this was done repeatedly and she + was asked a few minutes later, she would say “I couldn’t + say,” or “I forget things,” or “I have a short memory,” or + she would give it very imperfectly, as “Manhattan Island,” + or “Rhode Island” for “Manhattan State Hospital, Ward’s + Island.” (How is your memory?) “All right.” But when at + this point the difficulty was pointed out, she cried. + (Why?) “Because I forget so easily.” All this was while her + general activity was much reduced, and she seemed to take + very little interest in her surroundings. + + Then she improved somewhat, asked the husband some + questions about home, and on one occasion cried much and + clung to him and did not want to let him go without taking + her. She also began to work quite well, but still said very + little spontaneously. During this period when asked + questions, she spoke freely enough, but seemed somewhat + embarrassed. What was still quite marked were striking + discrepancies in giving dates, and her utter inability to + straighten them out when attention was called to them, as + well as to her inability to supply such simple data as the + ages of her children. Her capacity was later not gone into + fully but it was certainly less defective on recovery than + at this time. She was rather shallow in giving a + retrospective account during this period. Even later, when + she had developed a clear insight and made, in respect to + her activity and behavior, a natural impression, she was + not able to give much information about her psychosis, + although she apparently tried to do so. + + She was discharged recovered four months after admission, + her weight having risen from 93 lbs. on admission to 133 + lbs. on discharge. For the first two weeks of her stay in + the hospital, her temperature varied between 99° and 100°. + + _Retrospectively:_ She said in answer to questions about + her inactivity and difficulty in answering that she did not + feel like talking, felt mixed up, could not remember well, + did not want to write. + + Before she was quite well she knew of her entrance to the + Observation Pavilion and her transfer to Ward’s Island, of + which she could give some details, but thought she had been + in the Observation Pavilion two weeks instead of three days + and in the admission ward one month instead of a few hours. + As to the precipitating cause of the attack, she spoke of + her flowing so much after childbirth and of her operation. + + She was seen again in March, 1913, when she seemed quite + normal mentally and claimed that she had been well ever + since leaving the hospital. + +With the exception of negativism, which appears only in the anamnesis, +all the cardinal stupor symptoms are found in this history. Particularly +noteworthy is her intellectual deficiency which seemed to be made up of +a real incapacity plus a remarkable disinclination for any mental effort +whatever. It is important to note that her attitude towards this +disability was usually one of indifference and that, in general, there +was no show of affect whatever. Freedom of speech was the last thing for +her to regain. + + + CASE 7.--_Mary C._ Age 26. Single. Admitted to the + Psychiatric Institute April 7, 1907. + + _F. H._ The father had repeated attacks of insanity, from + which he recovered, but he died in an attack at the age of + 60. A sister also had a psychosis, from which she + recovered. + + _P. H._ The patient was rather quiet and easily worried. + When 14 she had some dizzy spells, with momentary loss of + consciousness. After that time she had no such attacks, + except after a tooth extraction when about 24. + + The patient came to the United States six months before + admission. She went to live with a cousin who died a week + after she arrived at his house. She worried and said that + she brought bad luck. Then she took a position, where she + was well liked, but she was not particularly efficient. In + this situation she often felt homesick and lonely. + + Two weeks before admission an uncle died, which affected + her considerably. She spoke of his leaving three children, + and would not go to the funeral. Then she thought she was + going to die. She felt dizzy, weak, walked with a stooped + position, was sleepless. In the midst of this she suddenly + felt frightened and walked into her mistress’ room, to + whom she complained that some one was talking outside but + could not tell what was said. She heard shooting. + Retrospectively, after recovery the patient said that at + that time she suddenly got “mixed up,” and that her “memory + got bad.” + + She was taken to a general hospital, where she thought + there was a fire, and screamed “Fire!” She was soon + transferred to the _Observation Pavilion_, where she + appeared dazed, moving slowly, yet showing a certain + restlessness. She spoke of “the boat” being shut up so that + no one could go out. Again, she said “The boat went down + and all the people keep turning up.” Retrospectively the + patient stated about this condition that she remembered + going to the general hospital but not her stay at the + Observation Pavilion. (The trip to the Manhattan State + Hospital was again clearer to her.) About the ideas she had + at the time, she remembered only that the room seemed to go + around, and that after she had come to the Manhattan State + Hospital and was clearer, she thought she was in Belfast, + was on a ship, and that people were drowning. + + _Under Observation:_ On admission she had a temperature of + 100°, a coated tongue, suffused conjunctivæ. There were + herpes of the lower lip, a general appearance of weariness + and exhaustion, a flushed face, trace of albumen in the + urine, which was absent on the third day, no leucocytosis, + but 41 per cent. lymphocytes. + + Then and henceforth she was inactive and very slow in all + her movements; she never stirred spontaneously, and had to + be pushed to the toilet and to the table; she ate slowly. + She did not speak spontaneously, and her replies were very + slow in coming. She had to be urged considerably before she + would speak and, as a rule, she did not answer. On one + occasion she was for a day totally inactive and looked + duller. That day and on a few other occasions she wet the + bed. There was at times an appearance of dull bewilderment. + When, soon after admission, asked whether she felt cheerful + or downhearted, she said “downhearted,” but this was the + only time. Often she answered “I don’t know,” when asked + whether she was worried, and she could never say what she + was worried about. Again she directly denied worry. + Sometimes she smiled appropriately, and repeatedly, when + asked how she felt, said, “I feel better.” In answer to + questions as to how her head was, she replied several + times, “My memory is gone,” also “I can’t take in my + surroundings,” or “I don’t know where I am,” or “I cannot + realize where I am.” Again, she spoke of being dizzy and + once said it was as though the room went round. Sometimes + she knew where she was or knew names, again said “I + forget,” but she always was approximately oriented as to + time. There were no special ideas expressed and no + hallucinations, except in the very beginning when she still + thought at night, when she heard the boats on the East + River, that people were being drowned. She later, as stated + above, said she thought she was on a boat and people were + being drowned. + + By June, i.e., two months after admission, she began + rhythmical swaying of the body, twisting of the fingers, or + pulling out some of her hair. She ascribed this behavior + simply to “nervousness.” + + On July 16, after a visit from her cousin, who said to her + that if she worked she would soon get better, she began + spontaneously to occupy herself somewhat. She became more + active, said she felt stronger and brighter, and that her + memory was better. By the beginning of August she was + fairly free, but still spoke in a rather low voice, + although answering well. Her capacity to calculate also + remained poor. When asked about the more inactive state, + she said she had been afraid to stir. (What afraid of?) “I + didn’t know where to go or what to do.” Further, she + recalled that she had had a numb feeling in her tongue, + could not speak quickly, and that her mind had felt + confused and “she could not take in things.” Further review + with her of the earlier period of her psychosis showed that + there was a blank for external events and most of the + internal events during this time. + + She made a perfect recovery and was discharged August 7, + 1907, four months after admission. + +This case, although very like the last, differs from it in two +particulars. For one day her symptoms were sufficiently marked to +suggest a deep stupor. Secondly, her intellectual incapacity was not so +marked (always approximately oriented for time) and with this there was +some subjective appreciation of her defect. Apparently, however, this +insight did not cause her any worry. The affectlessness was equally +prominent in both of the foregoing cases, the fact that Mary C. (Case 7) +once admitted feeling downhearted in response to leading questions, +having little significance in the face of her expression, actions and +usual denial of worry. It is interesting to note that, during the bulk +of her psychosis, her only complaints were of mental hebetude and +dizziness. Possibly the latter was merely an expression of her +subjective confusion. + + + CASE 8.--_Henrietta H._ Age: 22. Admitted to the + Psychiatric Institute March 6, 1903. + + _F. H._ The father stated that both parents were living and + well, also eight brothers and sisters. + + _P. H._ The patient came to this country when she was a + baby. She was bright at school and industrious. From the + age of 17 on, she worked in a drygoods store and gave + satisfaction. About her mental make-up no data were + available, except for the statement that she always made a + natural impression. + + When 21 (February, 1902), without known cause, she broke + down and was sent to the Manhattan State Hospital, but was + not observed in the Institute ward. She remained in the + hospital for three months. It was claimed that the attack + came on suddenly two days before she was sent away. She + suddenly appeared anxious, said something had happened and + became excited. This lasted for about a week, and then she + was, as the description says, “depressed and cataleptic.” + She remained in this condition for about a month, during + which time there was a slight rise of temperature. Then she + improved gradually and was discharged three months after + admission. After recovery from the present attack the + patient stated that during the first sickness she had + visions of dead friends. + + She was perfectly well in the interval. + + Six days before admission she suddenly became excited, + refused to eat, and began to talk, repeating phrases over + and over. Then she became elated and excited. + + After recovery the patient described the onset of her + psychosis as follows: Six days before admission, after + having been perfectly well and without any known cause, she + was feverish and vomited, but slept well. Next day she felt + nervous, and her thoughts were clear. She constantly + thought of dead friends, heard them talking, when she tried + to do anything the voices said, “Don’t do that.” She also + thought somebody wanted to harm her people. Soon she + started singing and felt happy. + + Then she was sent to the _Observation Pavilion_, where she + appeared to be in the same condition which was observed in + the Institute. + + _Under Observation:_ 1. On admission she was in good + physical condition, except for her skin seeming greasy. She + presented for nine days the following picture: She was + essentially elated, laughing, singing, jumping out of bed, + good-natured and tractable, and very talkative. Her + productions showed a good deal of sameness and a certain + lack of progression. She spoke at times in a rather + monotonous voice, but again often in very theatrical tones, + with much, rather slow, gesturing. The following are very + representative samples: + + “I have been suffering from my own blood, my own blood sent + all away from home. I just came from Bellevue. I left here + last May (correct) a healthy girl. A sister is a sister--I + wonder why shorthand is shorthand, a stenographer is a + stenographer (seeing stenographer write)--a kind brother, + Bill H.--why H. his wife is a sister-in-law to us, she has + four children--four beautiful children--sister-in-laws and + brother-in-laws--telephone ringing (telephone did + ring)--dear Lord, such a remembrance--remembrance was + remembrance, truth was truth--honesty is honesty--policy is + policy--if she married him, she is my sister-in-law and he + is my brother-in-law--Max knows me--she changed her name to + Mrs. R.--two children who are Rosie and Maud, if names were + given, names should not be mistaken--they are Julia, + Lillian--Rosie and Maud--why should wonders wonder and + wonders cease to wonder, why should blunders blunder and + blunders still blunder; sleep is one dream and dream means + sleep--if move is moving, why not move?” When she + accidentally heard the word wine, she said “Guilty wine is + not in our house--wine is red and women are women, and + women and wine and wine and women and wine and song.” + Again, “You are not Mr. Kratzberger, Mr. Steinberger, Mr. + Einberger--you are not Mr. Horrid or Mr. Storrid--perhaps + you are Mr. Johnson or Mr. Thompson--no, you are Dr. C.” + (correct). + + She was quite clear about her environment. + + Although the mood was throughout one of elation, on the + ninth day in the forenoon she cried at times, wanted to see + her mother, and spoke in a depressed strain (content not + known). A few hours after that she suddenly became quiet. + + 2. Then for four days (March 14-17) she was markedly + inactive, though at times got out of bed. She looked about + in a bewildered manner, did not speak spontaneously, but + could with urging be induced to make some replies. She did + this now fairly promptly, now quite slowly. Questions were + apt to bring on the bewilderment. Thus, when asked where + she was, she merely looked more bewildered, finally said + “Bellevue--I don’t know,” and questioned who the doctor was + whom she had called by name in her manic state, she said, + with some bewilderment, “Your face looks familiar.” (Where + have you seen me?) “In New York.” She claimed to feel all + right. There was no real affect. She made the statement + that at home she heard voices saying “You will be killed.” + + 3. Henceforth this bewilderment ceased, and for 16 or 17 + days she was essentially inactive for the most part, for a + short time with a tendency to catalepsy and some + resistiveness, and at that time lying with eyes partly + closed. As a rule she said nothing spontaneously, but + replied to some questions, usually with marked retardation, + again more promptly. She constantly denied feeling sad or + worried, repeatedly said she felt “better,” only on one + occasion did she cry a little. When asked to calculate she + sometimes did it very slowly, again fairly promptly. The + simple calculations were usually done without error, the + others with some mistakes. As to her orientation the few + answers obtained showed that at times she knew the name of + the place and the day, again she gave wrong answers + (Bellevue). Once asked on March 23 for the day, she said + April. She wrote her name promptly on one occasion, again + a sentence slowly but without mistakes. Once during the + period she sang at night. Once she suddenly ran down the + hall but quickly lapsed into the dull condition. + + On April 4, at the end of this period, she suddenly + laughed, again ran down the hall, said she had done nothing + to be kept on Ward’s Island. But she quickly lapsed again + into the dull state. Later, on the same day, when the + doctor was near, she said, in a natural tone, “Thank God, + the truth is coming out.” (What do you mean?) “That I have + been trusting in a false name and that Miss S. (the nurse) + should not nurse me.” Then she got suddenly duller, + calculated slowly and with some mistakes, 3×17=41, 4×19=56, + and when asked to write Manhattan State Hospital she wrote + (not very slowly) “Mannahaton Hotspalne.” + + 4. Next day it was noted that she was more stuporous, and + she remained so for two weeks, now showing a decided + tendency to catalepsy and more resistance than before, + though not marked, except in the jaw. She lay often with + head raised, sometimes with eyes partly open, or staring in + a dull, dreamy way, neither soiling nor drooling, however; + a few times she looked up when spoken to sharply. There was + no spontaneous speech. Usually she did not answer at all, + but a few times a short low response was obtained. Once she + wrote slowly a simple addition, put down on paper. When, on + one occasion, asked how she felt, she, as before, said, “I + feel better.” + + 5. Then, with the exception of a day at the end of the + month, when the more stuporous state was again in evidence, + she returned to her former condition without catalepsy or + resistiveness and without staring, but essentially with + inactivity or slowness. She now even dressed herself, + answered slowly though not consistently, but she again + denied feeling troubled or sad, “I feel better.” + + On July 7 she got brighter but was still rather slow. She + then even began to do some work. She again denied feeling + sad. + + In a few weeks, while having a temperature of 102° with + vomiting and diarrhea, she suddenly got freer. She then + said, in answer to questions, that she did not speak + because she was not sure whether it would be right, again + because she seemed to lose her speech. She did not move + because she was tired, had a numb feeling. She said she + had not been sad, “but I had different thoughts,” “saw + shadows on the walls of animals, living people and dead + people.” She was not frightened, “I just looked at them.” + People moved so quickly that she thought everything was + moved by electricity. She thought her head had been all + right. + + After a few days she relapsed into a duller state again, + but then got quite free and natural in her behavior. On + August 28 she gave a _retrospective_ account of her + psychosis, a part of which has been embodied in the + history. She had insight in so far as she knew she had been + mentally ill. She claimed to remember the Observation + Pavilion and her coming to the hospital, also the incidents + during the manic state, when she heard cannon and thought a + war was on, and voices she could not recognize nor + understand. Then she became stupid, although neither sad + nor happy. + + Then, she claimed, she got stupid, but neither sad nor + happy. She claimed to have known all along where she was, + but felt mixed up at times, her thoughts wandered and she + felt confused about the people. She thought she was in + everybody’s way, thought others wanted to get ahead of her, + did not speak because she did not know if it were right or + wrong, felt she might cause disturbance if she answered. + (It is not clear whether she had complete insight into the + morbid nature of these statements.) She also claimed again + that all along she “saw shadows on the wall,” “scenes from + Heaven and Earth,” “shadows of dead friends laid out for + burial.” She had insight into the hallucinatory nature of + these visions. Sometimes she thought she was dead also. She + claimed that she began to feel better when these shadows + stopped appearing in June (the actual time of her + improvement). + + She was discharged recovered a month later, after having + been sent to another ward. + +In this case, then, we find that the two months of stupor were ushered +in by a brief state in which, in addition to the usual inactivity, there +was a certain bewilderment, increased by questions, while the +orientation which in the preceding manic state had been good became +seriously interfered with. The psychosis bordered on deep stupor for +brief periods when the inactivity seemed to be complete or she lay in +bed with her head raised from the pillow. On the other hand, there were +occasional sudden spells of free activity even with a certain elation. +She could often be persuaded to answer questions or to write, the +slowness of this spoken or written speech varying considerably. Her +replies revealed the fact that she was essentially affectless and that +her intellectual processes were interfered with, even to the extent of +paragraphic writing. We have, therefore, here again features similar to +those of the preceding cases. In addition we must add as important that +this patient said retrospectively that she thought she was dead, that +she saw “shadows from Heaven and Earth,” “shadows of dead friends laid +out for burial,” all this without any fear. We shall see later that this +is a typical stupor content. + +We will here include state 3 of Anna G. (See Chapter I, Case 1) who +after the pronounced stupor was for two months merely dull, somewhat +slowed and markedly apathetic. Although her orientation was not +seriously affected, there was considerable interference with her +intellectual processes, as shown in her wrong answers or her lack of +answers when more difficult questions were asked. + +A similar picture was presented in state 2 of Mary D. (See Chapter I, +Case 4.) Here, to be sure, there were more marked stupor features in +that the patient wet and soiled, in addition to occasional spells when +she lay with her head raised. But she spoke and acted fairly freely +(even while soiling). By her replies she showed a considerable +intellectual inefficiency, although, like Anna G., her orientation was +not seriously disturbed. Here again there was complete affectlessness. + +This gives us, therefore, five states which may be analyzed for the +symptoms of partial stupor. The pictures of all five are unusually +consistent. There is inactivity, marked but not complete; poverty of +affect without perfect apathy; and a marked interference with the +intellectual processes. The last can be studied better than in the deep +stupors because these partial cases are more or less accessible to +examination. There is a tendency for the patient to think much of death +either in the onset or during the psychosis. Negativism seems much less +prominent than in the deep stupors. + +A natural criticism is that these cases merely had retarded depressions. +Although this topic will be discussed fully in a later chapter, two +differential characteristics should be mentioned now. First, depression +is a highly emotional state in which the sadness of the patient is as +evident from his facial and vocal expression as from what he says, while +these stupor reactions are by observation and confession states of +indifference. Secondly, there is no such disturbance of the intellectual +processes in depression as is here chronicled. Let the retardation once +be overcome so that the will is exercised and no real defect is +demonstrable. In our experience the cases of apparent depression with +intellectual incapacity are found on closer study to be really stupors +as other symptoms show. + + + + +CHAPTER III + +SUICIDAL CASES + + +An important “catatonic” symptom is a tendency to sudden, impulsive, +unexplainable acts. Such actions occur occasionally in benign stupors +and, since we attempt an understanding of the reaction as a whole, an +effort should be made to study these phenomena as well. The cases chosen +showed persistent, quite affectless, yet very impulsive attempts at +self-injury. They characterized the first of the three cases throughout, +were present in one stage (the second) of the second patient, while in +the last for one day there was behavior which can be similarly +interpreted. + +Mention has been made of the prominence, approaching universality, of +the death idea in stupor. This is a subject to be discussed in length +presently, but for the present we may say that there may be a delusion +of death with dramatization of that state or a mere abandonment of the +mental activities of life. It is but a step from corpse-like behavior to +suicidal attempts, psychologically speaking, yet this transition +necessarily modifies the clinical picture, since one necessitates +inactivity and the other activity. Secondarily, other atypical clinical +features appear, as will be seen. + + + CASE 9.--_Pearl F._ Age: 24. Admitted to the Psychiatric + Institute July 26, 1913. + + _F. H._ A paternal aunt was insane. Both parents died long + ago; the mother when the patient was a baby; the father + when she was a girl. She came to this country when 17. In + this country she had generally been a domestic. An older + brother and sister were also in America. + + _P. H._ She was described as sociable, good-natured, bright + enough, not inclined to be depressed. She had little + education. There was no former attack. + + Four months before admission, the patient did not + menstruate but was said not to have worried about this. A + month later she began to show symptoms. She said she did + not want to live, had done something wrong but could not or + would not say what it was. Again she said a young man was + going to sue her, a young Jewish fellow whom she had seen + only a few times. She talked of turning on the gas. She + also complained that people were looking at her and that + the food was poisoned. + + The patient after recovery gave the following version of + the onset: She had a position on 99th St. for 2½ years. + She liked the people there and often went to see them + later. Her next position was in the Bronx. She was there + for nine months. In the same house lived “Harry.” After the + work she used to talk to him in the yard and, after she + left, she used to think of him and long for him. But she + denied, with a very natural attitude, that she worried + about him at the beginning of her psychosis. After the + position in the Bronx she went to one on 96th St., where + she was for four months. In the same house was a girl whom + she liked and who was lively. When she left, the patient + left too. This was a month before the psychosis began. When + she left there, she got word that her employer on 99th St. + had developed consumption and had to go out West, but did + not worry over this news, she claimed. She looked for + another position and had one for two weeks, but felt + lonely, did not care to live. Then her sister took her to + her home. She thought people were looking at her and were + making remarks because she was not working. During this + time she had a dream one night in which her dead mother + appeared to her (in ordinary street clothes) and said to + her that she (the patient) “was going away.” She woke up + frightened. She was worried, thought she had not prayed + enough for her mother, and asked her sister to pray also + and to give money to the poor. She did not recall, or at + any rate denied, speaking of the young man suing her. + + She was then taken to a _private sanatorium_, where she was + for two months preceding her admission to this hospital. + There she was described as quiet, mute, tube-fed, + resistive. + + When well, the patient said that in this sanatorium she was + first spoon-fed, cup-fed, later tube-fed, “I used to be + scared of them, they used to put a spoon way down my throat + and I had no appetite--I did not like them around me, they + were mean to me. They used to let me stand without clothes, + used to spite me.” “If I did not want to dress myself, they + used to hit me.” “I used to feel lonesome for home and I + imagined my people were there and that my sister passed the + place without stopping.” She was afraid of the nurses, + thinking they wanted to kill her. + + At the _Observation Pavilion_ the patient was described as + dull, but brightening up under examination. She made few + spontaneous remarks, but in answer to questions said she + was melancholy, tired of life, because she was in love with + a Gentile fellow who refused to marry her. She also said “I + get peculiar thoughts that I am going to die.” + + _Under Observation:_ The patient’s condition lasted for + about two years. Much of the time she lay in bed, often + with the covers pulled over her, sometimes with her legs + drawn up, again in a more natural, comfortable position, or + she sat up with her head bowed. She obeyed almost no + commands. For months she soiled and wet herself, but never + drooled. For a time she refused food consistently, lost + flesh and had to be tube-fed. For the most part she said + very little and, when one accosted her, she was apt to turn + away. A few times, when further urged, she swore at the + examiner. There was also persistent marked resistance + towards any interference, sometimes merely passive or quite + often, especially at first, with wriggling or severe + scratching of her own body. There was often with this + evidence of irritation or she moaned. Again she was + described as quite affectless. One of the most striking + features throughout a large part of the course were her + suicidal attempts. She would try to strike her head against + the iron bedpost, throw herself out of bed, throw herself + about generally, try to strangle herself with the sheets, + try to pull out her tongue, all of which seemed to be done + with great impulsiveness. Almost her only utterances had to + do with death. She said she wanted to die, wanted to drop + dead, did not want to live, wanted to kill herself, that + she did not eat because she wanted to die. When once she + was found tossing about and was asked whether she worried, + she said “I know I am going to die.” (You mean you will be + killed?) “I don’t care.” + + There were a few episodes which still have to be mentioned. + Quite early in the course of the stupor, when she was + restless, scratching herself and moaning, she once spoke + quite freely. She said “Give me that fellow (Harry), I + don’t care, I can’t help it. I must have him, even if it + costs me my life.” “I would feel happy if I could get him. + O God, I love him--I will never get him even if I drop + dead, I know I won’t get him, the darling” (cries). (What + if you did get him?) “I know I would lose him again.” Then + with shame she claimed she had had sexual relations with + him (when well, denied). At the same interview, when the + doctor sneezed, she said “Gesundheit.” In June, 1914, she + was seen smiling at times. But the first was the only + episode when she spoke more freely, and the two occasions + the only ones when she showed a frank affect. + + The improvement commenced in April, 1915. Although still + very inactive, she sometimes began to laugh and sing and + talk a little to other patients. She also answered a few + questions on April 22, 1915. Thus, when asked whether she + wanted to go home, she said “No, I want to stay here.” (Do + you like it here?) “Yes” (smiles), “I can’t get no other + place; I have got to like it here.” She smiled freely. To + orientation questions, she knew the place, month, but not + the year. + + She continued inactive and above all diffident, but + improved steadily and, when examined by the writer on + November 15, she made a very natural impression and gave + the retrospective account of the onset embodied in the + history. She was quite frank, thanked the doctor for the + interest he took in her case, and said for example, “You + know I never thought I would get well. I quite gave up--I + am very glad I am well now.” + + When questioned about her stay here, the patient evidently + remembered much. She was able to say which wards she had + been in and approximately how long she had been in each + one. She claimed that at first it “seemed strange.” “I did + not eat, I did not want to eat, I used to tell them to + poison me and that I wanted to die, I was _disgusted_, I + thought I would never go home.” She also says she felt + _angry_, wanted to kill herself. She bit and scratched + “because I was nervous.” She remembered talking about + Harry, “I said I was in love with him, I thought I wanted + to die because I could not have him.” She also talked of + having been _stubborn_. Sometimes she felt like running to + the river. She also claimed she imagined people were false + to her. + + In one of the wards she said she thought people were there + on her account, were waiting for her death. She did not + care for a time whether she died or not. She knew she tried + to choke herself occasionally. Asked how she behaved, she + first said she was quiet. (Were you not restless?) “I used + to get tired and have backache and roll around in bed.” She + also felt like running away sometimes, wanted to get out of + bed and wanted to walk about. (What about going to the + river?) “I used to say that.” She claimed not to have been + mixed up at any time and to remember everything. Remarkable + is the fact that she claimed she _did not worry at all_, + “_I felt I was lost and would not worry._ I used to worry + at home and at Dr. M.’s (the private sanatorium) but not + here. Here I never worried, I did not care where I went.” + She said she did not talk because she was bashful in the + presence of doctors, sometimes she felt afraid of them, + afraid they would kill her, put poison in her food when + they fed her. “When my people came, I said I did not want + to live, wanted to kill myself. I used to cry.” Again asked + why she did not talk, she admitted she really did not know. + Once she said she was bashful because she soiled her bed. + She did not want to go to the closet because she was afraid + of the nurse. She denied hearing voices. + +In addition to the activity incidental to her attempts at self-injury, +this patient showed an unusual degree of resistiveness and with this +some affect, for she appeared to be irritated and at times moaned. Still +more unusual were the appearances of delusions not associated with +death but with a vivid form of life, namely, a love affair. Occasionally +she spoke of her imaginary lover “Harry.” Another atypical feature was a +fair memory for the period when she was in stupor. She claimed to +remember much of her movements and this claim was substantiated by her +answers to questions after recovery. + + + CASE 10.--_Margaret C._ Age: 23. Single. Admitted to the + Psychiatric Institute November 13, 1913. + + _F. H._ Heredity was absolutely denied. The mother is + living and made a natural impression. The father died at + 65, nine months before patient’s admission, of cardio-renal + disease. Two brothers and one sister died of acute + diseases. One sister died in childbirth. Three brothers and + one sister were said to be well. + + _P. H._ The patient was bright and passed successfully + through high school. For seven years prior to the psychosis + she worked for the same company as clerk. She was described + as efficient, conscientious, systematic, though sometimes + upset by her work; as lively, talkative, cheerful, with + somewhat of a temper and easily hurt, also as quite + religious. She was more attached to her mother than to her + father, but still more to her older sister, whose death + precipitated her psychosis. She never had any love affair + and was said not to have cared for men. Two months before + admission, when her favorite sister was confined, the + patient was quite worried about her, but relieved when she + heard good news. A few hours later, however, the sister + died suddenly. When the patient learned of the sister’s + death, she screamed, and screamed several times at the + funeral. She did not cry, said she could not. After this + she slept poorly, seemed nervous, went to church more, but + there was no other change. She continued to work and, + according to the employer, worked well. + + Nine days before admission she would not get out of bed in + the morning, said little and refused food. A few days later + she was induced to take a walk, but she seemed to have no + interest in anything. When she talked at all it was about + her sister and of wanting to go to a convent. When asked + to do anything she said she would if it were God’s will. + She did not menstruate after her sister’s death. When + practically recovered, the patient attributed her breakdown + to this tragedy. She added to the description above given + that, soon after losing her sister, she had a fright at + home. “It was the house in which my father died and one day + when I was in bed I thought somebody came in.” But she + denied a vision and could not further explain. + + At the _Observation Pavilion_ she was very inactive, so + that she had to be fed and cared for in every way, mute, + often covering her head with a sheet, turning away when + questioned and resistive when the physical examination was + attempted. But at times she smiled or laughed. + + _Under Observation:_ 1. For two months the patient was + generally inactive, sometimes lying in bed with her eyes + tightly closed, or with her face covered by the sheets or + buried in the pillow; or she sat inactive, staring, or with + eyes closed, or her head buried in her arms. On one visit + she had to be brought into the examining room in a wheel + chair and lifted into another seat. A few times she was + observed holding herself very tense with her head pressed + against the end of the bed. But this inactivity was often + interrupted by her going quickly into various rooms to + kneel down, though she was never heard praying. Or she ran + down the hall for no obvious reason. Or, again, she was + found lying on the floor face down. She ate very poorly and + had to be tube-fed a considerable part of the time. When + this was done, she sometimes resisted severely, as she did + in fact most nursing attentions. Thus she soon began to + struggle when her hair was combed. She also resisted being + taken to the toilet or being brought back. She did not soil + or drool, however, but sometimes seemed to be in + considerable distress before she finally literally ran to + the closet. This resistance just spoken of consisted + chiefly in making herself stiff and tense. Sometimes at the + feeding she pulled up the cover when preparations were made + and held to it tightly. Quite striking was the fact that + with such resistance she sometimes, though by no means + always, laughed loudly, as she did occasionally when she + was talked to, or even without any external stimulation. + This laughter always was one of genuine merriment and quite + contagious, and by no means shallow or silly. + + Usually the patient was totally mute. The exceptions + occurred mostly when her resistance was called forth. Thus + one day when fed she said, “I wish you people would have + more to do,” or on another occasion, when she had resisted + being brought into the examining room, she said, “I will + get out of here if I break a leg.” But once when the nurse + accidentally tickled her, she said, “Since I am ticklish, I + must be jealous--I should worry.” She also answered very + few questions and such responses as she made were chiefly + expressions of resentment. Thus, when one kept urging her, + she finally would say “stop,” or after much urging “I am + going to hurt you pretty quick.” Sometimes she said “Go + away,” or “Let me alone.” She was just as silent with the + mother and the priest as with the physicians. On one + occasion she told the nurse that the priest had told her to + talk to the doctors, but that she had nothing to say. + Sometimes she did not even look at the visitors, but turned + away from them, as she did from the physicians, but at one + visit from a priest, though she scarcely said anything, she + held on to him when he was about to depart and would not + let him go. Throughout this period, since scarcely any + answers were given, nothing was known about her + orientation, except when on admission she gave a few + answers. She then thought she was at the Observation + Pavilion, seemed unable to tell even that the physician was + a doctor, but knew the date. When asked how she came to + Ward’s Island, she said “By ambulance.” The physical + condition presented nothing of note, except for a certain + sluggishness of the skin with marked comedones. + + 2. By _January_, 1914, the picture changed somewhat and she + then presented the following state for an entire year: The + mutism persisted and indeed became even more absolute, and + she began to wet and soil constantly. This commenced as + what seemed to be an act of spite as a part of her + resistiveness, for the first time she soiled she seemed to + do it deliberately when the nurses insisted that she allow + them to put on a dress. Later this explanation no longer + held. Tube-feeding too was for the most part necessary, the + resistiveness continuing as before. But the inactivity was + broken into much more than before by constant impulsive + attempts to hurt herself in every conceivable way--by + bumping her head against the wall, putting her head under + the hot water faucet, trying to pound the leg of the + bedstead on her foot, striking herself, pinching her + eyelids, pulling out her hair, trying to pick her radial + artery, throwing herself out of bed, knocking her head + against the bed rail, etc. This was done in silence but + with what appeared a great determination that occasionally + showed itself in her face. She also sometimes scowled and + frowned. With the difficulty in feeding her and the + constant impulsive excitement in which bruises could not + always be avoided (once an extensive cellulitis developed + in the arm which had to be lanced), the patient got weak, + emaciated and exhausted; much of her hair fell out, + although some she pulled out. It should be stated that + during this entire impulsive state she could not be taken + care of in the Institute ward, but was sent to a special + ward in the Manhattan State Hospital, where suicidal + patients are under constant watch. These impulsive attempts + at self-injury lessened only towards the end of the period. + Her laughter, which had been such a prominent trait, + disappeared almost entirely during this entire phase. With + all this, the general resistiveness, as has been stated, + remained towards feeding or any other interference. It was + only in the beginning associated with laughter as in the + previous stage. + + Although there were, as a rule, no spontaneous remarks and + no replies, she on one occasion said spontaneously, + probably referring to her unsuccessful attempts to kill + herself: “I can’t do it, I have no will.” During the same + period she once said: “I don’t want to eat, I don’t want to + get well, I want to do penance and die.” + + By _January_, 1915 (i.e., a year after the second phase had + commenced), she began to dress herself and eat, and also + became clean. But she remained for the most part very + inactive, sitting stolidly about all day and still without + interest in her environment. The impulsive attempts at + killing herself disappeared. Although she remained for + months to come still inactive, she gradually began to talk + a little, began to play a little on the piano, but said + little to any one. + + By _August_, 1915, she still was inactive, shy, standing + about, or sitting picking her fingers, occasionally going + to the piano, but evidently unable to finish anything. She + had to be coaxed to come to the examining room and talked + in a low tone. Often she commenced vaguely to speak and + then stopped and could not be made to repeat what she had + been saying. Affectively she was remarkably frank, + sometimes a little surly, or she showed a slight empty + uneasiness. She could, however, be made to laugh heartily + at times, or did so spontaneously on very slight + provocation. + + Some of her utterances were in harmony with her apparent + indifference. It was difficult to get her to say how she + felt even when thorough inquiries were made. Once she said, + when asked about worrying, “I don’t worry,” or again “I get + angry sometimes,” or “I used to worry about my health, I + don’t now,” or, when asked what her plans were, she said + directly: “I don’t care what happens.” Again she said “I + guess I am disagreeable,” or “I guess I am a crank.” + Another interesting indication of her state was expressed + in her repeated statement, “I don’t know what I want.” But + she was oriented in a way, though not sure of her data. She + would give most of her answers with a questioning + inflection, “This is the Manhattan State Hospital, isn’t + it?” or she would say, “I don’t know exactly where I am, + it’s Ward’s Island, isn’t it?” and in the same way she gave + the day, date and year correctly. But she did not know the + names of the physicians. At that time she could give many + data about her family correctly, but was slow, even if + correct, in calculation, and, though she got the gist of a + test story, she left out some important details. + + A retrospective account at that time showed she was + uncertain about the Observation Pavilion, that she was not + certain how she came to Ward’s Island, “On a boat, I + believe.” It was clear that she did not remember the + admission ward, about the Institute ward (in which she had + been for the first two and a half months and in which she + was again examined); she said it was familiar to her, but + she was not certain that she had been in it. About the + physician who saw most of her in these first two and a half + months, she said that his voice seemed familiar, and she + asked him whether he had tube-fed her (she had been + tube-fed by him many times), but she again said, “No, you + are not the one,” and described as the man who had fed her + the one who did it on the second ward where she was for a + year. But she knew that she had been sent to the second + ward, because she constantly tried to injure herself. These + injuries she recalled but was unable to say why she + attempted them, “I suppose I didn’t know what I was doing.” + She claimed she heard voices and had “all sorts” of + imaginations, but could not be gotten to tell about them. + When it was difficult for her to give an answer, she was + apt to keep silent and then could be prodded without much + success. + + In _October_, 1915, there was further improvement, inasmuch + as she began to converse some with other patients, played + the piano and seemed able to carry a piece through. She was + put in the occupation class and did quite well. At the + interview with the physician she was still apt to laugh + boisterously at slight provocation. Even now she had great + difficulty in describing her condition and at the + examination was often still quite vague. Thus, when asked + how she felt, she said, “I do know I feel + ridiculous--sometimes I feel kind of angry--I don’t + know--they say I am crazy but I am not, but I am hungry--I + don’t know whether I am or not, I don’t know what I can do + well,” etc. This is quite characteristic. When asked + whether she was worried, she said: “I don’t know, am I + worried?--yes, a little sometimes, I am to-day--I am so + untidy--don’t know what is the matter with me.” Again: + “Sometimes I lose my speech--I can’t say what I feel, I + don’t know what it was.” Later, half to herself: “I don’t + know what is the matter with me--I don’t care anyway.” + + In _December_, 1915, there was still further improvement, + and on the ward and in superficial conversation she made, + towards the end of the month, in many ways a natural + impression, though the laughter before described was still + somewhat in evidence. It usually came not without occasion, + but was, as a rule, quite out of proportion to the + stimulus. She again said she could not explain why she + tried to injure herself, claimed she did not feel it, and + even claimed she did not remember doing it in the Institute + but only in the second ward. + + The defect in thinking which still remained is very + difficult to formulate. She was now entirely oriented, no + longer with any hesitation about the correctness of her + information. She subtracted 7 from 100 very quickly and + could from memory write a long poem, but there was a + certain vagueness about her which partly may have been due + to a still existing indifference. This vagueness consisted + chiefly in a difficulty of attention or in her capacity to + grasp fully what was wanted. It is best illustrated by a + few examples: After she had been asked about the _onset_ of + her sickness and she had said that what was on her mind + then were prayers for the salvation of her relatives, she + was asked exactly when it was that she thought of this; she + answered “Now?” (What period were we talking of, the + present or past?) “The present.” (What did I ask you?) + “About this period of my sickness.” (Which one?) “What + sickness?” She said herself at this point, “I am rather + stupid” (quite placidly). Or again she said she did not + know why she pounded her head, but finally said, “To get + better and go home.” (Do you think if you pounded your head + against the wall you would go home sooner?) “I don’t + know--maybe.” (How would it help you?) “You mean to go to + the city?” (Yes.) “I don’t know.” Again when asked how her + mind worked, she said, “Pretty quickly sometimes--I don’t + know.” (As good as it used to?) “No, I don’t think so.” + (What is the difference?) This had to be repeated several + times, at which she said, “There is no difference.” (What + did I ask you?) “The difference.” (The difference between + what?) “You did not say.” Equally striking was the fact + that when she was jokingly told “If it snows to-night, we + shall have a black Christmas,” she did not grasp the + absurdity at once, but in a rather puzzled way asked, + “Why?” + + She was then discharged on parole, two years and one month + after admission. Soon after discharge her menstruation, + which had been absent throughout her psychosis, returned. + On her discharge she had regained her normal weight, and + during the two subsequent months gained fifteen pounds. + + She then recovered completely, so that three months after + discharge she made a very natural impression. She said, on + looking back over her state with impulsive excitement, that + she constantly had the idea that she wanted to punish + herself, but that _she did not know why_, and did not think + she was sad or worried. + +Considering only the second phase of the psychosis, this deep stupor +showed many interruptions, due not merely to her suicidal efforts but +also to her resistiveness. The condition, too, was not so completely +affectless as one expects a deep stupor to be. In the first stage there +was much sudden laughter, reminding one of dementia præcox (except for +its never being shallow or silly) and this persisted into the first part +of the second phase. The actual attempts at self-injury brought out +emotion, for with them she scowled and frowned as well as showing +considerable energy. + +To these may be added the following case. It is not unlike the ordinary +stupor in the fact that there was intense inactivity and mutism with +great tenseness. The remarkable trait was, however, that for a whole day +she forcibly held her breath until she got blue in the face. The case in +detail is as follows: + + + CASE 11.--_Rosie K._ Age: 18. Admitted to the Psychiatric + Institute January 24, 1907. + + _F. H._ Both parents were living. The father was a loafer. + Nine brothers and sisters were said to be well, with the + exceptions of one brother who had an irritable temper, and + of a markedly inferior sister. + + _P. H._ The patient was a Galician Hebrew, a shirtwaist + operator. Not much was known about her make-up, but it is + certain that she was a bright girl. The patient herself + said after recovery that her father was nagging her + constantly with complaints that she was not making enough + money, although he himself did not work and she contributed + much to the support of her family. She disliked him very + much and claimed that all her relatives worried her, except + her mother. + + Nine weeks before admission a messenger came into the shop + where she worked and said, “Rosie, your father is dead” + (the message was intended for a fellow worker). In spite of + the fact that the matter was explained, she was upset and + nervous enough to be taken home. Though she continued to + work for over two weeks, she worried over many trivial + matters and talked much about this. She also said that + everything looked queer at her home and complained of + having difficulty in concentrating her mind. Finally she + became elated and talkative. Nothing is known of any + special ideas. + + At the _Observation Pavilion_ she appeared to be typically + manic. + + Then she was sent to an institution where she remained for + six weeks. The report from there stated that she was for + ten days “elated, excited, talkative, with flight of + ideas.” Then her condition suddenly changed to a marked + reduction of activity, in which she neither spoke + spontaneously nor answered questions. She “appeared to + sleep,” but was said to have talked to her people. When + interfered with, she was resistive and sometimes let + herself fall out of bed. On the other hand, she + occasionally wandered about at night. It should be added + that during the stupor an alveolar abscess developed which + discharged pus. It was washed out and healed. + + Then she was sent to the Manhattan State Hospital and + admitted to the service of the Psychiatric Institute. + + _Under Observation:_ 1. On the first day she lay in bed + with cyanotic extremities, weak pulse, grunting, moaning + and not responding in any way when examined. After this the + moaning and grunting ceased and she was essentially + indifferent, and for the most part kept her eyes closed. + Often she wet and soiled herself. She was resistive to any + care or examination. She would not eat, as a rule, but + again gulped down milk offered her. For a considerable time + she had to be tube-fed. During the early part of this + stupor she once took a paper from the doctor, examined it, + and then gave it back without saying anything, or again she + peered around silently, or asked to go home, or again, on a + few occasions, answered a question or two or spoke some + unintelligible words. Orientation could not be established. + + 2. After a few weeks she became more rigid, a condition + which continued for six months. She let saliva collect in + her mouth, and drooled. She had to be tube-fed. She lay + very rigid, with very pronounced general tension, with her + lips puckered, hands clenched, sometimes holding her eyes + tightly closed, and often with marked perspiration. For one + day she held her breath until she was blue in the face. On + the same day she was extremely rigid, so that she could be + raised by her head with only her heels resting on the bed. + Her eyes were tightly shut and she was in profuse + perspiration. Sometimes she interrupted this by a deep + breath, only again to resume the forcible holding of her + breath. On another day towards the end of the period, while + quite stiff, she kept grunting and screaming “murder.” The + soiling continued. She never spoke. + + _Physical condition during the stupor:_ At first she had a + coated tongue, foul breath and a fetid diarrhea. The latter + was treated with high colonic flushing and mild diet. Urine + normal--gynecologically normal. General neurological and + physical examination not possible. At the same time she had + for two weeks a temperature which often reached 100° or a + little above, a weak, irregular but not rapid pulse, a + leucocytosis of 17,500 and 80% hemoglobin. When she began + to refuse food and before she was tube-fed regularly, she + twice had syncopal attacks and lost considerable flesh + which was gradually regained under tube-feeding. After the + diarrhea she was habitually constipated. Cyanosis of the + extremities seemed to have been present only at first. + + 3. Six months after admission she began to make very free + facial movements--winking, raising the eyebrows--and soon + developed an excitement with marked elation. She had to be + kept in the continuous bath, talked continuously, whistled, + sang, was markedly erotic towards the physician, careless + in exposing herself and often obscene in her talk. Most of + her productions were determined by the environment. She was + therefore quite distractible, very alert; sometimes she was + meddlesome, again irritable, irascible. The following + illustrates her productions: “Send for my husband, S.--He + had one sister as big as that. She likes candy.... My + father is underneath and my mother is on top because she is + fat and he is skinny.... Wait till the sun shines, + Nellie--we will be happy, Nellie--don’t you sigh, + sweetheart, you and I--wait till the sun shines by and + by.... Come in (as noise is heard)--I bet that is my + husband--my name is Regina K. (mother’s name)--my mother’s + name is the same--I got a little sister named Regina--she + is my husband.” When she heard the word pain, she said, + “Who says paint, Pauline used paint, I used paint,” etc. + + Towards the end of August she had pneumonia, which did not + change her condition. + + By October she was well, having gradually settled down. She + had good insight. + + _Retrospectively:_ She laid very little stress on the false + report of the father’s death. She claimed to remember being + at the Observation Pavilion, but to recall very little of + the other hospital. Unfortunately an inquiry was not made + regarding her memory during the stupor period under + observation with the exception of the fact that she said + she wanted to die and therefore refused food. + + She was seen in March, 1913, appeared perfectly well, and + stated she had been well during the entire interval. + +If this forced holding of the breath had been the only anomaly, one +would, perhaps, not be justified in drawing any conclusions as to its +significance. But the deep stupor was interrupted again for a day by +grunting and screaming of “murder.” This is certainly indicative of a +compulsive death idea and retrospectively she spoke of having refused +food in order to die. The latter seems to indicate some connection +between her negativism and death. Consequently, even if we regard the +breath holding as resistiveness, it would still be related to her idea +of dissolution. Her negativism went beyond ordinary limits in that it +affected the expression of the face. + +When we consider these three cases together, we see that what would +otherwise have been deep stupors with profound inactivity, were modified +by activity in two directions: suicidal and resistive. Presuming that +the symptoms of stupor are all interrelated, we can see a reason why the +affect should also have been altered. When one is modified, this should +influence the other. When the activity is increased, the emotional +concomitants of impulsive acts tend to break through as well. Hence the +changes observed in these cases in facial expression and tone of voice. +It is noteworthy, too, that all three showed a tendency for laughter to +appear, as if, the emotions once stirred, it was possible for them to be +exhibited in other than unpleasant forms. So, too, it was possible for +ideas unrelated to the stupor picture, such as those of lovers, to occur +sporadically. Finally, since activity must imply some contact with +environment, the first of these cases at least showed less interference +with the intelligence than is usual. In general, one may conclude that +any aberration from the pure type of stupor tends to allow other +impurities to appear. + + + + +CHAPTER IV + +THE INTERFERENCES WITH THE INTELLECTUAL PROCESSES + + +This is one of the most interesting and important of the stupor +symptoms. We are accustomed to think of the functional psychoses having +symptoms to do with emotions and ideas in the main, and, conversely, +that disorientation, etc., observed in such cases is merely the result +of distraction, poor attention or coöperation. But in stupor the deficit +in understanding, incapacity to solve simple problems and failure of +memory seem deep-rooted and fundamental symptoms. So far is this true +that Bleuler[5] looks on “schizophrenic” cases with this symptom of +“Benommenheit” as organic in etiology. It may be said at the outset that +we do not share this view for many reasons. One at least may now be +stated as it seems to be final. In benign stupor purely mental stimuli +may change the whole clinical picture abruptly and with this produce a +change in the intellectual functioning such as we never see in organic +dementias or clouded states. We find it more satisfactory to attempt a +correlation of this with the other symptoms on a purely functional +basis, as will be explained later. + +For the study of the interferences with the intellectual processes +during stupor reaction, we have two sources of information: The first is +derived from the account which the patient is able to give in regard to +what he remembers as having taken place around him or in his mind during +the stupor period; the second is the direct observation of partial +stupor reactions. + + +1. Information Derived from the Patient’s Retrospective Account + +We will start with the cases of marked stupor mentioned in Chapter I. +Anna G.’s (Case 1) psychosis commenced at home, and under observation +lasted with great intensity for five months. She remembered only vaguely +the carriage going to the Observation Pavilion, had no recollection of +the latter, nor of her transfer to the Manhattan State Hospital and of +most of the stay at the Institute ward, including the tube- or +spoon-feeding which had to be carried on for four months. She also +claimed that she did not know where she was until four or five months +after admission. She was amnesic for her delusions and hallucinations. +Of Caroline DeS. (Case 2) we have no information. Of Mary F. (Case 3), +whose stupor began at home and under observation lasted two years, we +find that she had no recollection of coming to the hospital, what ward +she came to, who the doctor and nurses were (with whom she became +acquainted later), in fact she claimed that for about a year she did +not know where she was. But she remembered having been tube-fed (this +took place over a long period). Mary D.’s (Case 4) stupor also commenced +at home, and under observation lasted for three months. She had no +recollection of going to the Observation Pavilion, of the transfer to +Manhattan State Hospital, and of a considerable part of her stay here, +including such obtrusive facts as a presentation before a staff meeting, +an extensive physical and a blood examination, and she claimed not to +have known for a long time where she was. Annie K.’s (Case 5) stupor +commenced at home. Although she recalled the last days there and some +ideas and events at the Observation Pavilion, the memory of the journey +to Ward’s Island was vague, as was that of entrance to the ward, and she +claimed not to have known where she was for quite a while. Specific +occurrences, such as the taking of her picture (with open eyes two +months after admission), an examination in a special room, her own +mixed-up writing (end of second week) were not remembered. But it is +quite interesting that an angry outburst of another patient within this +same period, which was evidently not recorded, is clearly remembered. + +We shall later show that when the patient comes out of a stupor the +condition may be such that, for a time at least, retrospective accounts +are difficult to obtain. It must also be remembered that not +infrequently the more marked stupors may be followed by milder states, +and it is important, if we wish to determine how much is remembered, +not to confuse the two states or not to let the patient confuse them. +For example, Mary D. (Case 4), who showed two separate phases, while she +claimed not to know of many external facts, also added that she could +not understand the questions which were asked. From observation in other +cases it seems that in marked stupor any such recollection about the +patient’s own mental processes would be quite inconsistent. We have to +assume, therefore, that this remark referred in reality to the second +milder phase, for which, as we shall see, it is indeed quite +characteristic. It is not necessary to burden the reader with other +cases, all of which consistently gave such accounts. + +We see, then, that in the marked stupor the intellectual processes are +regularly interfered with, as evidenced by almost complete amnesia for +external events and internal thoughts. In other words, this would +indicate that the minds of these patients were blank. Inasmuch as direct +observation during the stupor adduces little proof of mentation, we may +assume that such mental processes as may exist in deepest stupor are of +a primitive, larval order. + +Before we examine more carefully the milder grades of stupor, it will be +necessary to say a few words about the retrospective account which the +patient gives of intellectual difficulties during the incubation period +of the psychosis. As a matter of fact, we find that these accounts are +remarkably uniform. While some patients, to be sure, speak of a more or +less sudden lack of interest or ambition which came over them, others of +them speak plainly of a sudden mental loss. Mary. C. (Case 7) claimed +she suddenly got mixed up and lost her memory. Laura A. spoke at any +rate of suddenly having felt dazed and stunned. Mary D. (Case 4) said +she felt she was losing her mind and that she could not understand what +she was reading. Maggie H. (Case 14) began to say that her head was +getting queer. We see from this that the interferences with the +intellectual processes may in the beginning be quite sudden. + +In some instances a more detailed retrospective account was taken, which +may throw some light upon the interferences with the intellectual +processes with which we are now concerned. Emma K., whose case need not +be taken up in detail, had a typical marked stupor which lasted for nine +months, preceded by a bewildered, restless, resistive state for five +days. She was in the Institute ward for the first four months, including +the five days above mentioned; later in another ward. When asked what +was the first ward which she remembered, she mentioned the one after the +Institute ward, and when asked who the first physician was, she +mentioned the one in charge of the second ward. However, when taken to +the Institute ward, she said it looked familiar, and was able to point +to the bed in which she lay, though somewhat tentatively. The same +rousing of memory occurred when the first physician, who saw her daily, +was pointed out to her. She remembered having seen him, and then even +recalled the fact that he had thrown a light into her eyes, but +remembered nothing else. This observation would seem to show that with +some often repeated or very marked mental stimuli (throwing electric +light into her eyes) a vague impression may be left, so that it may at +least be possible to bring about a recollection with assistance, whereas +spontaneous memory is impossible. In another instance, the patient was +confronted with a physician who had seen a good deal of her. She said +that he looked familiar to her, but she was unable to say where she had +seen him. Here then again evidence that a certain vague impression was +made by a repeated stimulus. + +Another feature should here be mentioned, namely, that isolated facts +may be remembered when the rest is blank. We have seen above that Annie +K. (Case 5), while very vague about most occurrences, recalled a sudden +angry outburst in detail. Another patient, though the period of the +stupor was a blank, recalled some visits of her mother. At these times, +as she claimed, she thought she was to be electrocuted and told her +mother so, “Then it would drop out of my mind again.” These facts are +very interesting. We can scarcely account for such phenomena in any +other way than by assuming that certain influences may temporarily lift +the patient out of the deepest stupor. In spite of the fact that stupors +often last for one or two years almost without change, a fact which +would argue that the stupor reaction is a remarkably set, stable state, +we see in sudden episodes of elation that this is not the case, and +other experiences point in the same direction. A similar observation was +made on a case of typical stupor with marked reduction of activity and +dullness. A rather cumbersome electrical apparatus (for the purpose of +getting a good light for pupil examination) was brought to her bedside. +Whereas before, she had been totally unresponsive, she suddenly wakened +up, asked whether “those things” would blow up the place, and whether +she was to be electrocuted. During this anxious state she responded +promptly to commands, but after a short time relapsed into her totally +inactive condition. We have, of course, similar experiences when we try +to get stuporous patients to eat, who, after much coaxing may, for a +short time, be made to feed themselves, only to relapse into the state +of inactivity. + +Such variations are paralleled, as we shall later show, by a suddenly +pronounced deepening of the thinking disorder. We have already seen that +the onset may be quite sudden. All this indicates that, in spite of a +certain stability, sudden changes are not uncommon. Finally, we know +that, in spite of the fact that stupor is an essentially affectless +reaction, certain influences may produce smiles or tears, or, above all, +angry outbursts, which again can hardly be interpreted otherwise than by +assuming that those influences have temporarily produced a change in the +clinical picture, in the sense of lifting the patient out of the depth +of the stupor. All these facts suggest that inconsistencies in +recollection are correlated with changes in the clinical picture. + +As is to be expected, the cases with partial stupors remember much more +of what externally and internally happened during their psychoses. Rose +Sch. (Case 6), who had a partial stupor during which she answered +questions but showed a great difficulty in thinking, said +retrospectively that she felt mixed up and could not remember. Although +she recalled with details the Observation Pavilion and her transfer, she +was not clear about their time relations (how long in the Observation +Pavilion, how long in the first ward). Mary C. (Case 7), whose activity +was not entirely interfered with and who showed some thinking disorder, +said retrospectively that she could not take in things. Henrietta H. +(Case 8), who had a partial stupor, claimed to have known all along +where she was, but that she felt mixed up, that her thoughts wandered +and that she felt confused about people. In the cases where a partial +stupor was preceded by a marked one, such as in phase 2 of Anna G. (Case +1) and phase 2 of Mary D. (Case 4), we have no retrospective account +regarding the partial stupor, because emphasis in the analysis was +naturally laid on the period comprising the most marked disorder. +However, we can gather from the few cases at our disposal that the +patients retrospectively lay stress chiefly on their inability to +understand the situation. + +We finally have to consider the group of suicidal cases. We have +information only in regard to two cases, namely, Margaret C. (Case 10) +and Pearl F. (Case 9). In both of these, we find that a good many things +that happened during the period under consideration were remembered, as +were also the patients’ own actions. In Rosie K. (Case 11) we have at +least the evidence that she remembered her own impulses, namely, that +she refused food because she wanted to die. In other words, in these +partial stupors with impulsive suicidal tendencies the interference with +the intellectual processes seems to be moderate, and memory for external +events not markedly affected. + + +2. Information Derived from Direct Observation + +The evidence can best be presented by considering the details of some +cases. + +Rose Sch. (Case 6) was remarkable, in connection with the present +problem, in her unusually poor answers. She either merely repeated the +questions, or made irrelevant superficial replies, or said she did not +know, this even with very simple questions. When better, too, though not +quite well, she showed striking discrepancies in time relations and +incapacity to correct them. It would seem that in this case there was +something more than an acute interference with the intellectual +processes, such as we are here discussing. As a matter of fact, we have +the statement in the history that the patient herself said she was slow +at learning in school and had not much of an education. A congenital +intellectual defect and the attitude which it creates may, however, as +my experience has repeatedly shown me, very greatly exaggerate an acute +thinking disorder. The case, therefore, while it shows us an +unquestionably acute interference with the intellectual processes, does +not give us useful information about its nature. More information can be +gathered from Mary D. (Case 4). Even toward the end of her marked stupor +some replies were obtained chiefly by making her write. When asked to +write Manhattan State Hospital, she wrote Manhatt Hhospshosh, and for +Ward’s Island, Ww. Iland. Again, instead of writing 90th Street, she +wrote 90theath Street. These are plainly reactions of the path of least +resistance or, in these instances, of perseveration. Of the same nature +are some of her other replies in writing or speaking. After she had been +asked to write her name, she was requested to add her address, or the +name of the hospital; she merely repeated the name. Similarly, when +asked whether she knew the examiner, she said “Yes,” but when urged to +give his name, she gave her own. In the partial stupor at a time when +she knew where she was, knew the names of some people about her, the +year and approximately the date, she made mistakes in calculation and +could not get the point of a test story. Moreover, she failed in +retention tests without there being any evidence of anything like a +marked fundamental retention disorder, such as we find in Korsakoff +psychosis. It seems that these results are best termed defects in +attention, which chiefly interfere with the apprehension of more +difficult tasks. As we shall see later, this seems to be rather +characteristic of these cases. Another point which should be mentioned +is the fact that her reaction to questions which she was unable to +answer (such as matters which referred to her amnesic periods) was +peculiar, inasmuch as she did not only not try to think them out, but +seemed indifferent to her incapacity, simply leaving the question +unanswered. This too, as we shall see later, is characteristic. Laura +A., at a time when she could be made to reply, merely repeated the +question, again a reaction of least resistance. The same patient +sometimes asked, “Where am I?” Mary C. (Case 7) made similar queries. +Although she was at times approximately oriented, she would say, “I +don’t know where I am,” or “I can’t realize where I am,” or more +pointedly, “I can’t take in my surroundings.” She often did not answer +and sometimes seemed bewildered by the questions. Henrietta H. (Case 8) +again showed some defect of orientation and mistakes in calculation, and +above all, marked mistakes in writing (for Manhattan State +Hospital--Manhaton Hotspal). A special feature here is that this +occurred immediately after she had been quite talkative, but suddenly +had relapsed into a dull state. Anna G. (Case 1), during the third phase +of her psychosis, showed the following: Although she was approximately +oriented and answered promptly simple questions; e.g., about orientation +or simple calculation, she, like these other patients, simply remained +silent when more difficult intellectual tasks were required of her +(more difficult calculations); or when she was asked how long she had +been here (which involved data that could not be available to her, owing +to her amnesia); or when questions were put to her regarding her +feelings or the condition she had passed through. On the other hand, she +sometimes gave appropriate replies in the words “yes” or “no,” but it +was difficult to say whether these answers did not also represent the +path of least resistance. + +We will finally take up the last phase of Margaret C. (Case 10). +Although she was entirely oriented, there was a certain vagueness about +her answers which is difficult to formulate. She was telling about the +onset of her sickness and said that at that time her mind was taken up +with prayers about the salvation of her relatives. She was asked exactly +when it was that she thought of this and she answered “Now?” (What +period are we talking about?) “The present.” (What did I ask you?) +“About this period of my sickness.” (Which one?) “What sickness?” She +said herself at this point, “I am rather stupid.” Again when asked how +her mind worked, she said, “Pretty quickly sometimes--I don’t know.” (As +good as it used to?) “No, I don’t think so.” (What is the difference?) +“There is no difference.” (What did I ask you?) “The difference.” (The +difference between what?) “You did not say.” In this the shallowness of +her comprehension and thinking is well shown, and it seems here again +perhaps justifiable to formulate the main defect as one of attention, +which prevents completion of a complicated process of comprehension. A +feature of further interest in this case is that automatic intellectual +processes, such as those necessary for the writing of a long poem from +memory, were not interfered with. + + +Summary + +In the most pronounced stupor we have evidently a more or less complete +standstill in thinking processes. Practically no impressions are +registered and consequently nothing is remembered except events that +occurred in some short periods when some affective stimulus, or a brief +burst of elation, lifts the patient temporarily out of the deep stupor. +It is impossible to say whether the statement of a complete standstill +has to be qualified. In some stupors repeated environmental stimuli +sometimes make at least a vague impression, so that while spontaneous +recollection is impossible a feeling of familiarity is present when the +patient is again confronted with this environment. This might be an +exception to the dictum of complete mental vacuity, or it may be that +there are somewhat less pronounced stupor reactions. When more is +perceived, there is often a retrospective statement of having felt mixed +up, being unable to take in things, or, directly under observation, the +patient may say, “I cannot realize where I am,” “I cannot take in my +surroundings.” In harmony with this is the fact that questions often +produce a certain bewilderment. In quite pronounced states in which +some replies can still be obtained, we find that the intellectual +processes may be interfered with to the extent of a paragraphia, i.e., a +remarkably mixed-up writing in which perseveration (one form of +following the path of least resistance) plays a prominent part. This +same principle is also seen in such reactions as the repetition of the +question or the senseless repetition of a former answer. These phenomena +remind us of what we see in epileptic confusions, in epileptic +deterioration and in arteriosclerotic dementia. + +In milder cases difficulties in orientation may be more or less marked; +or there may be incapacity to think out problems, although the +orientation is perfect. The more automatic mental processes may run +smoothly (memory and calculation may be excellent) and there may yet be +a certain shallowness in thinking, a defect of attention (a purely +descriptive term) which is most obvious in the patient’s inability to +grasp clearly the drift of what is going on or the meaning of +complicated questions. I am inclined to think that poor results in +retention tests are entirely due to this attention disorder, for we have +no evidence of any fundamental retention defect such as we find in the +totally different organic stupors. From a practical point of view it is +important at this place to call attention to the fact that such mild +changes are particularly seen in end stages. Even when pronounced +negativistic tendencies do not play a prominent rôle, the patient is +then apt to be silent chiefly as a result of the residual disorder in +the intellectual processes. Still more striking are the conditions which +are on a somewhat higher level and in which the shallowness of the +responses, due to the residual disorder of attention, together with the +last traces of the affectlessness, are apt to create the impression of a +dementia. In such cases the opinion is often held that the patient has +reached a defect stage from which recovery is impossible, whereas a +thorough knowledge of these end stages teaches us that they are not only +recoverable but quite typical for the terminal phases of stupor. + +Considering these data, especially those gathered in the end stages, it +would appear that there is no tendency in this intellectual disorder +associated with the stupor reaction for any special side of mental +activity to be most prominently affected. It looks rather as if it were +a question of a general diminution of the capacity to make a mental +effort which in its different intensities accounts for the symptoms. + + +FOOTNOTES: + +[5] See Chapter XV. + + + + +CHAPTER V + +THE IDEATIONAL CONTENT OF THE STUPOR + + +_Brief survey of the ideas associated with stupor:_ Having thus +described the formal manifestations of the various stupor reactions, it +will now be interesting to see what ideas seem to be associated with +these reactions. It is, of course, impossible to obtain during a +considerable part of the stupor any statement of the patients’ thoughts. +We therefore have to depend on their utterances during periods when the +inactivity temporarily ceases, or on the retrospective account which the +patient gives after the stupor has completely disappeared; and as we +shall see, we also may obtain considerable information by studying the +ideas which occur in the period preceding the stupor. These last may be +autogenous delusions or thoughts about actual events which precipitated +the psychosis. + +It is not likely that many observers have a very clear conception about +what sort of ideas to expect. We have, as a rule, not been in the habit +of paying much attention to the content of delusions, hallucinations, +and the like. So far as we could judge, therefore, the ideas expressed +might be expected to be fairly multiform, and it was distinctly +interesting to us when we found a marked tendency for the trends of +ideas to remain within a certain small compass.[6] It was possible, to +state this at once, to show that in by far the majority of cases the +same set of ideas returned, and that these ideas had among themselves a +definite inner relationship, being concerned with thoughts of “death.” +In isolated instances other ideas were found as well, and they will have +to be discussed later. For the present we shall take up more habitual +content. + +In addition to the eleven cases already described, it may be well to +cite four others which present material now of interest to us. + + + CASE 12.--_Charlotte W._ Age: 30. Admitted to the + Psychiatric Institute October 21, 1905. + + _F. H._ The father was alcoholic and quick-tempered; he + died when the patient was a child. The mother was alcoholic + and was insane at 40 (a state of excitement from which she + recovered). A brother had an attack of insanity in 1915. A + maternal uncle died insane. + + _P. H._ The patient was described as jolly, having many + friends. She got on well in school and was efficient at her + work. + + She was married at 23 and got on well with her husband. The + latter stated, however, that she masturbated during the + first year of her married life. The first child was born + without trouble. + + _First Attack at 25:_ Two or three days after giving birth + to a second child, her mother burst into the room + intoxicated. The patient immediately became much + frightened, nervous, and developed a depressive condition + with crying, slowness and inability to do things. During + this state she spoke of being bad and told her husband + that a man had tried to have intercourse with her before + marriage. This attack lasted six months and ended with + recovery. + + When 29, a year before her admission, she had an abortion + performed, and four months later another. Her husband was + against this, but she persisted in her intention. Seven + months before admission she went to the priest, confessed + and was reproved. It is not clear how she took this + reproof, but at any rate no symptoms appeared until three + weeks later, after burglars had broken into a nearby + church. Then she became unduly frightened, would not stay + at home, said she was afraid the burglars would come again + and kill “some one in the house.” The patient herself + stated later, during a faultfinding period, that at that + time she was afraid somebody would take her honor away, and + that she thought burglars had taken her “wedding dress.” + “Then,” she added, “I thought I would run away and lead a + bad life, but I did not want to bring disgrace to the + family.” + + The general condition which she presented at this time is + described as one of apprehensiveness when at home. For this + reason she was for five weeks (it is not clear exactly at + what period) sent to her sister, where she was better. + About a month before the patient was admitted, the husband + moved, whereupon she got depressed, complained of inability + to apply herself to work, became slow and inactive, and + blamed herself for having had the abortion performed. She + began to speak of suicide and was committed because she + bought carbolic acid. She later said that while in the + _Observation Pavilion_ she imagined her children were cut + up. + + _Under Observation_ the condition was as follows: + + 1. For the first three days the patient, though for the + most part not showing any marked mood reaction, was + inclined at times to cry, and at such times complained + essentially that this was a terrible place for a person who + was not insane. + + 2. On the fourth day the condition changed, and it will be + advisable to describe her state in the form of abstracts of + each day. + + On _October 24_ the patient began to be preoccupied and to + answer slowly. A few days later she became distinctly dull, + walked about in an indifferent way or lay in bed immobile. + Twice on _October 27_ she said in a low tone and with + slight distress, “Give me one more chance, let me go to + him.” But she would not answer questions. At times she + lapsed into complete immobility, lying on her back and + staring at the ceiling. When the husband came in the + afternoon, she clung to him and said: “Say good-by forever, + O my God, save me.” Again, very slowly with long pauses and + with moaning, she said: “You are going to put me in a big + hole where I will stay for the rest of my life.” _On + October 28_ she was found with depressed expression and + spoke in a rather low tone, but not with decided slowness + as had been the case on the day before. She pleaded about + having her soul saved; “Don’t kill me”; “Make me true to my + husband”; once, “I have confessed to the wrong man the + shame of my life.” Later she said she did not tell the + truth about her life before marriage. Again she wanted to + be saved from the electric chair. At times she showed a + tendency to stare into space and to leave questions + unanswered. + + 3. From now on a more definite stupor occurred, which is + also best described in summaries of the individual notes. + + _Oct. 29._ Lies in bed with fixed gaze, pointing upward + with her finger and is very resistive towards any + interference. She has to be catheterized. + + _Oct. 30._ Can be spoon-fed but is still catheterized. + During the morning she knelt by the bed and would not + answer. At the visit she was found in a rather natural + position, smiling as the physician approached, saying “I + don’t know how long I have been here.” Then she looked out + of the window fixedly. At first she did not answer, but, + when the physician asked whether she knew his name, she + laughed and said, “I know your name--I know my name.” Then + she would not answer any more questions but remained + immobile, with fixed gaze. When her going home was + mentioned, however, she flushed and tears ran down her + cheek, though no change in the fixedness of her attitude or + in her facial expression was seen. + + _Nov. 1._ Lies flat on her back with her hands elevated. + She is markedly resistive. + + _Nov. 2._ Free from muscular tension and more responsive. + When asked whether she felt like talking, she said in a + whining tone, “No, go away--I have to go through enough.” + Then she spoke of not knowing how long the nights and days + were, of not having known which way she was going. When + asked who the physician was she whimpered and said, “You + came to tell me what was right.” She called him “Christ” + and another physician “Jim” (husband’s name), though, later + in the interview, she gave their correct names. When asked + about the name of another physician, she said: “He looks + like my cousin, he was here, they all came the first night. + I did not take notice who it was till I went through these + spirits, then I knew it was right.”--She paused and added: + “My God--mother it was; she is here on Earth, somewhere in + a convent--Sister C. (who actually is in a convent) she was + here, too, I could hear her.” She said they all came to try + to save her. When asked whether she had been asleep, she + said: “No, I wasn’t asleep, I was mesmerized, but I am + awake now--sometimes I thought I was dead.” (When?) “The + time I was going to Heaven.” Again: “I went to Heaven in + spirit, I came back again--the wedding ring kept me on + Earth--I will have to be crucified now.” (Tell me about + it.) “Jim will have to pick my eyes out--I think it is him. + Oh, it is my little girl.” (Who told you?) “The spirits + told me.” Again: “Little birds my children--I can’t see + them any more--I must stay here till I die.” (Why?) “The + spirits told me--till I pick every one of my eyes out and + my brains too.” When asked what day it was, she said, “It + must be Good Friday.” (Why?) “Because God told me I must + die on the cross as he did.” When asked why she had not + spoken the day before, she said that “Jesus Christ in + Heaven” had told her she should not tell anything, “till + all of you had gone, then I could go home with him, because + that is the way we came in and it was Jim too all the + time.” Finally she said crossly, “Go away now, you are all + trying to keep me from Jim” (crying). + + _Nov. 3._ Knelt by bed during the night. This morning lies + in bed staring, resistive, again she is markedly + cataleptic. She has to be spoon-fed, and is totally + unresponsive. In the afternoon she was found staring and + resistive. Presently she said with tears: “I am waiting to + be put on the cross.” + + _Nov. 4._ Still has to be catheterized. She sits up, + staring, with expressionless face, but when asked how she + felt she responded and said feebly: “I don’t know how I + feel or how I look or how long I have been here or + anything.” (What is wrong?) “Oh, I only want to go to a + convent the rest of my days.” (Why?) “Oh, I have only said + wrong things, I thought I would be better dead, I could not + do anything right.” Later she again began to stare. + + _Nov. 5._ During the night she is said to have been + restless and wanted to go to church. To-day she is found + staring, but not resistive. When questioned she sometimes + does not answer. She said to the physician, “I should have + gone up to Heaven to you and not brought me down here.” She + called the physician “Uncle James.” Again she said, “I want + to go up to see Jim.” Sometimes she looks indifferent, + again somewhat bewildered. + + _Nov. 6._ She eats better, catheterizing is no longer + necessary. She is found lying in bed, rigid, staring, + resistive, does not answer at first, later appears somewhat + distressed, says “I want to go and see Jim.” (Where?) “In + Heaven.” She gave the name of the place and of the + physician, also the date. + + _Nov. 8._ In the forenoon, after she had presented a rather + immobile expression and had answered a few orientation + questions correctly, she suddenly beckoned into space, then + shook her fist in a threatening manner. When later asked + about this, she said: “Jim was down there and I wanted to + get him in.” (And?) “You was up here first.” (And?) “I + thought we was going down down, up up--the boat-- --you + came in here for--to lock Jim out so we wouldn’t let him + in.” Later she said, when asked whether anything worried + her, “Yes, you are taking Jim’s place.” + + _Nov. 9._ During the night she is reported to have varied + between stiffness with mutism and a more relaxed state. + Once, the nurse found her with tears, saying “I want to go + down the hall to my sister--to the river,” and a short time + later with fright: “Is that my mother?” Again she said: “Oh + dear, I wish this boat would stop--stop it--where are we + going?” In the forenoon she was quiet and unresponsive. In + the afternoon she said in a somewhat perplexed way, “We + were in a ship and we were ’most drowned.” (When was that?) + “Day before yesterday it must have been”--Again she said in + the same manner: “It was like water. I was going down. I + could hear a lot of things.” She claimed this happened + “to-day.” “I saw all the people in here, it was all full + of water,” “I have been lying here a long time--do you + remember the time I was under the ground and it seemed full + of water and every one got drowned and a sharp thing struck + me?” “I was out in a ship and I went down there in a + coffin.” When asked whether she had been frightened at such + times, she said: “No, I didn’t seem to be, I just lay + there.” She also said: “the water rushed in,” and when + asked why she put up her arms, she said, “I did it to save + the ship.” + + _Nov. 10._ She is still fairly free. She said that when she + was on the ship things looked changed, “the picture over + there looked like a saint, the beds looked queer.” (How do + things look now?) “All right.” (The picture too?) “The same + as when I was going down into a dark hole.” When asked + later in the day where she was, she said, “In the Pope’s + house, Uncle Edward is it?” but after a short time she + added, “It is Ward’s Island, isn’t it?” + + _Nov. 11._ Inactive, inaccessible, but for the most part + not rigid. + + _Nov. 14._ Varies between mutism with resistance and more + relaxed inactivity. To-day lies in a position repeatedly + assumed by her, namely, on her stomach with head raised, + resistive towards any interference, immobile face, totally + inaccessible. + + _Nov. 15._ Freer. She said: “One day I was in a coffin, + that’s the day I went to Heaven.” She also said she used to + see “the crucifix hanging there” (on the ceiling)--“not now + but when I was going to Heaven.” (When was that?) “Over in + that bed” (her former bed). Later she added, “The place + changed so ... things used to be coming up and down + (dreamily)--that was the day I was coming up on the ship or + going down.” She is quite oriented. + + _Nov. 17._ Usually stands about with immobile face, + preoccupied, but she eats voluntarily. + + _Nov. 24._ When the husband and sister came a few days ago + she said she was glad to see them, embraced them, cried and + is said to have spoken quite freely. To-day she speaks more + freely than usually. When asked why she had answered so + little, she said she could not bring herself to say + anything, though she added spontaneously, “I knew what was + said to me.” When shown a picture of her cataleptic + attitude with hands raised, she said dreamily, “I guess + that must have been the day I went to Heaven, everything + seemed strange, things seemed to be going up and down.” + (Did you know where you were?) “I guess that was the day I + thought I was on the ship.” When the sister spoke to her, + she seemed depressed and said, “If only I had not done + those things I might be saved, if I had only gone to church + more.” + + _Dec. 3._ Seems depressed. She weeps some, says she is sad, + “There seems to be something over my heart, so I can’t see + my little girls.” Again: “I should have told you about it + first--I should not have bought it”--(refers to buying + carbolic acid). She wrote a natural letter but very slowly. + + 4. There followed then a state lasting for six months, + during which the patient was rather inactive, preoccupied, + even a little tense at times. Sometimes she did not answer, + again at the same interview spoke quite promptly. For the + most part the affect was reduced, at other times she + appeared a little uneasy, bewildered, or again depressed. + She said that sometimes a mist seemed to be over her. Now + and then spoke of things looking queer and she asked, when + the room was cleaned, “Why do they move things about?” and + she added irrelevantly: “I thought the robbers broke into + my house and stole my wedding dress and my children’s + dresses” (refers to the condition during the onset of her + psychosis). In the beginning of this state, when asked + about the stupor, she spoke again of the “ship” and about + going “down, down,” but also said that on one occasion she + heard beautiful music, was waiting for the last trumpet and + was afraid to move. Moreover, she had some ideas referring + to the actual situation which were akin to those in the + more marked stupor period. Although she admitted she was + better, she said on December 8 that she still had queer + ideas at times, “I sometimes think the doctor is Uncle Jim” + (long dead). She also spoke of other patients looking like + dead relatives, and added, “Are all the spirits that are + dead over here?” “We never die here, the spirits are here.” + But after that date no such ideas recurred, in fact this + whole period seems to have been remarkably barren of + delusions. Exceptionally isolated ones were noted. Thus, on + January 28 it is mentioned that she stated she sometimes + felt so lonely, and as though people were against her; and + on February 13 she said she felt as though the chair knew + what she was talking about. It is also mentioned in January + that she wept at times, but this seems not to have been a + leading feature at all. In March, when asked why she was + not more active and cheerful, her lips began to quiver and + she said, “Oh, I thought my children would be cut up in + Bellevue.” “I don’t know why I feel that way about them.” + She sometimes cried when her friends left her. + + 5. Then followed a week of a rather faultfinding, + self-assertive state, during which she demanded to be + allowed to go home, saying indignantly that she was not a + wicked woman, had done nothing to be kept a prisoner here; + she wanted justice because another patient had called her + crazy. But in this period also she said that after the + robbery (at home) she felt afraid that her honor would be + taken away. When told that her husband had been with her, + she said “Yes, but I was afraid they would get into a + fight.” (You mean you were afraid the other man would kill + him?) “No, he is not dead.” She further talked of a + disagreement she had at that time with her husband, and + that she felt then like running away and leading a bad + life, but thought of the children. With tears she added: “I + would not do anything that is wrong. I have my children to + live for.” Quite remarkable was the fact that she then told + of various erotic experiences in her life, though with a + distinctly moral attitude and minimizing them. + + 6. On _June 16_ another state was initiated with peculiar + ideas, the setting of which is not known, as she told them + only to the nurses. She said that she was not Mrs. W. but + the Queen of England, again that she was an actress, or + again the wife of a wealthy Mr. B., and that she was going + to have a baby. But at night she is said to have been + agitated and afraid she was to be executed. She asked to be + allowed to go to bed again, then stopped talking, and + remained in this mute condition for about a week. She often + left her bed and went back again, remained much with a + perplexed expression. On one occasion she put tinsel in her + hair saying it was a golden crown. + + 7. At the end of that time she became freer and more + natural, and remained so for three weeks. She occupied + herself somewhat. When asked what had happened in the + condition preceding, said she thought she was a queen or + was to be a queen. + + 8. Towards the end of this period she had again three more + absorbed days, but when examined on the third of these days + got rather talkative and somewhat drifting in her talk on + superficial topics. + + 9. Two days later she began to sing at night, kissed + everybody, said it was the anniversary of her meeting her + husband, again cried a little, and on the following morning + began to sing love songs, with a rather ecstatic mood, and + at times stood in an attitude of adoration with her hands + raised. This passed over to a more elated state, during + which she smiled a good deal, often quite coquettishly; she + sang love songs softly; on one occasion put a mosquito + netting over her head like a bridal veil; or she held her + fingers in the shape of a ring over a flower pinned to her + breast. But even during this state she said little, only + once spoke of waiting for her wedding ring, and again, when + asked why she had been singing, said “I was singing to the + man I love.” (Why are you so happy?) “Because I am with + you” (coquettishly). + + This, however, represented the end of the psychosis. She + improved rapidly. At first she smiled rather readily, but + soon began to occupy herself and made a perfect recovery. + + She gave a rather shallow retrospective account about the + last phase: at first she said it was natural for people to + feel happy at times, and that she did not talk more because + the inclination was not there. The only point she added + later was that she held her fingers in the shape of a ring + because she was thinking of her wedding ring. + + She was discharged on _October 11_. + + The patient was seen again in _September, 1915_. She then + stated that she had been perfectly well until 1912, when + she had a breakdown after childbirth. (A childbirth in 1910 + had led to no disorder.) The attack lasted six months. She + slept poorly, lost weight, and felt weak, depressed, “my + strength seemed all gone.” In _July, 1915_, following again + a childbirth, she was for about six weeks “despondent, weak + and tired out.” + + At the interview she made a very natural, frank impression, + and displayed excellent insight. + + + CASE 13.--_Johanna S._ Age: 47. Admitted to the Psychiatric + Institute January 23, 1904. + + _F. H._ It was claimed that there was no insanity in the + family. + + _P. H._ The patient was said to have been bright and rather + quick-tempered. She came to the United States from Ireland + at the age of 20, worked as a servant, was well liked, and + retained her position well. + + She was married at 24. After a second confinement, at the + age of 26, the patient had her first attack of manic + excitement, from which she recovered in four months. She + had, subsequently, at the ages of 28, 30, 32, 35, 43, and + 45, other attacks of the same nature, each one lasting + about four months. No precipitating cause was known for any + of them. Only one of the attacks, the fifth, (none were + well observed) seems to have shown features different from + an elated excitement with irritability. At the end of this + attack she was said to have been “dull” for a month. + + Her husband died four years before the present admission, + evidently soon after her sixth attack. + + The present attack: + + About two months before admission the patient began, + without appreciable cause, to be sleepless, complained of + headaches and appeared downhearted and sad. She sat about. + + After a week she would not get out of bed and remained in + bed until she was sent to the Observation Pavilion, getting + up only to go to the closet. She said very little and would + not eat much. About a month before admission she began to + say that she did not want to live, begged her daughter to + throw her out of the window. About two weeks before + admission she began to insist that she heard the voice of + her brother (living in Ireland) calling her. She got out of + bed to look for him. + + At the _Observation Pavilion_ she was described as slow, + looking about in an apprehensive manner, bewildered, dazed, + saying “I am dead--there is poison in it (not clear in + what)--I am dead, you are dead.” + + _Under Observation:_ 1. On admission the patient had a + coated tongue, foul breath, constipation, lively knee-jerks + and a pulse of 110. She appeared dull, inactive, lay in bed + with her eyes closed. She would open them when urged but + appeared drowsy and her face was strikingly immobile. At + times she moaned a little. She could be made to respond in + various ways such as shaking her head, or making some + motions as though to indicate that she could not give any + explanations. All movements were slow. She also responded + to a few questions by “I don’t know.” + + Two days after admission the condition was not essentially + different except that she was a little uneasy when urged to + speak, corrugated her forehead, said “Everything is dark,” + again “I am very sick,” or she turned away her head. + + On the fourth day, i.e., January 26, the picture altered, + inasmuch as she was much more responsive. She was found + sitting up in bed and, at times, a little uneasy. She was + slow in her movements and answers, speaking in a whisper + and sometimes a little fretfully. The answers, though slow, + were, however, by no means given in the shortest possible + manner, but with variations, e.g., from “I don’t know,” to + “I could not tell you,” or “I can’t tell that either.” She + said herself that everything had “been so dark--it is light + now, but it gets so dark sometimes.” She denied knowing + where she was, even in what city, also denied knowing the + month, adding to the latter answer “the nurse can tell + you.” She could not tell where she had been before coming + to the hospital, or how she came. Finally, she also claimed + not to know her age, her birthday or the date of her + marriage; but she gave the current year correctly, the + place where she went to school, the names of some of her + teachers, and the year of her arrival in the United States. + She also stated in answer to questions that she came to the + hospital “to get well.” She repeatedly said “I am so sick,” + or “I am so stupid,” or “My mind is mixed up, twisted,” or + “My mind is not so good,” or “I am so tired.” What could be + obtained of a content was as follows: When she spoke of + being “twisted,” she said, “I got all kinds of medicine.” + (How does it affect you?) “Through my head and it made me + hot inside.” Again, when asked whether anybody had done + anything to her, she said “No, I have done wrong myself, by + speaking bad of my neighbors.” She claimed to hear voices + “all over,” but could not tell what they said. When, in the + evening of that day, the nurse asked her why she did not + talk more, she said, “God damn it, I am all twisted, my + brain is mixed up, my system is all upset, the doctor made + me stupid with questions, and the medicine I have taken + made me all stupid and I am inhaling gas now.” Then she + again settled into a dull state and was found by the + physician with immobile expression, slow motions and mute. + + 2. For about ten days, i.e., from January 27 to February 8, + her condition was of a more pronounced character. For the + most part she lay in bed with often quite immobile face and + with eyes closed, or she looked about in a bewildered + manner. She was very inactive, presented a marked + resistance in her arms and jaw when passive motions were + attempted, or, again, exhibited decided catalepsy. She had + to be tube-fed. Once on the 27th of January, when the nurse + tried to feed her, she pushed her away and said, “I am + dead--I am not home.” Sometimes she turned her hands about + with slow tremulous movements, looking at them in a + bewildered manner. + + She usually was mute, except on the few occasions to be + mentioned later, as well as on February 3, when she was + generally a little more responsive. At that time she could + be made to open her eyes, and then replied to a few + questions slowly and in a low tone; others were left + unanswered. (To the questions where she was and how long + she had been here, she replied with “I don’t know,” but to + questions about who the physician and the nurse were, by + saying “You are a doctor,” and “she is a nurse.”) + + In the general setting just described there occurred at + various times changes in behavior which were as follows: On + the evening of the 27th of January she got out of bed and + walked about with slow restlessness, saying: “They say I am + going to be cut up.” On February 1, she was seen for a time + making peculiar slow swimming motions with her hands. Again + on the 3d of February she got out of bed, walked about + slowly, with peculiar steps, as though avoiding stepping on + something. Next day (the 4th) she sat up in bed--again made + at times her peculiar slow swimming motions. She presented + at the same time a peculiar dazed bewildered uneasiness + and, when questioned what was the matter, said: “I am--I + am--at the bottom of the deep--deep water--oh--oh--the + deep--deep--dark water.” And when further urged she added + with the same manner, “I can’t swim--I don’t know--but the + place”--She did not finish but later again muttered “the + deep--deep--dark water.” (Do you really think you are in + the water?) “I don’t know--my head is so bad.” + + For the following five days this behavior was repeated + from time to time, when she would sit up and with + bewildered uneasiness make slow swimming motions and mutter + when questioned, “I am in the deep, dark water.” + + Some other emotional responses in reaction to external + events must still be mentioned. They were rare. On February + 1 the patient’s daughter came while she was lying + motionless in bed. She slowly extended her hands, tried to + speak, and then her eyes filled with tears. Again, at the + end of the interview of February 3, after she had made a + few replies, she settled down to her usual inactivity and, + when further urged to answer, her eyes filled with tears. + + 3. From about February 9 to February 24 the condition again + presented a different aspect, inasmuch as while there was + still a marked reduction of activity, she showed this to a + decidedly lesser degree. Moreover, there was no + bewilderment at any time. No resistance, but cataleptic + tendencies were still seen occasionally. There was at no + time the peculiar dazed uneasiness and slow restlessness + associated with the idea of being in the deep, dark water. + + She now dressed herself very slowly, ate slowly but of her + own accord, and spoke, though her voice was consistently + slow, in a low tone and her words were few. + + At the beginning of this period on February 9, when asked + how she was, she said “I--I am sick.” To the questions as + to where she was, how long she had been here and how she + had been taken sick, she replied by saying “I don’t know.” + But she knew she was in a hospital, had been here before + “many times.” (Correct.) She was then again asked for the + name of the hospital, but replied “I don’t know.” So the + physician pointed out of the window and asked her what it + was that she could see there (the East River). She replied, + “It is the dark water. Sometimes I go there and don’t come + back again--and--something throws me up and I come back.” + (What has been the matter with you?) “I have been sick all + this time.” Again, “I can’t tell--I am not a good woman--I + am very sick.” (Why do you say you are not a good woman?) + “Oh, I did not do things right.” + + At a later interview, during the same period, she knew the + doctor’s name, knew she had seen him at Ward’s Island, + knew she was in a hospital, but somehow could not connect + the present place with Ward’s Island. She said she didn’t + know, when asked where she was, and when questioned about + the season, said, after a pause “Summer” (February 15). + + We have seen above that she once spoke of not having been a + good woman. She repeated this on February 10, said “I have + done lots of harm, I have been a bad woman all my life.” + Again: “I had bad thoughts.” (What kind?) “I have forgotten + all about them.” It should be added that at this interview + she also said, “My mind is better now.” + + On February 25 there was a sudden change. She laughed when + a funny remark was made on the ward. Later, when the + physician came to her, she still lay in bed inactive and + had to be urged considerably at first, but presently began + to laugh good-naturedly and quite freely commented on the + funny remark she had heard earlier in the morning, and on + peculiarities of some patients. She spoke quite freely and + without constraint. But it was striking how little account + of the condition she had gone through could be obtained + from her. She either turned the questions off by flippant + remarks, or said she did not know. The only information + obtained was that she had been sick since Christmas, felt + like a dummy, that she had lost track of time, and did not + know how she had felt during that period. When asked why + she had not spoken, she said, “I couldn’t, I had a jumping + toothache,” or she said, “Ask the nurse, she put it down in + the book.” Or again she said, “Did you ever get drunk? That + is the way I felt. I felt like dead.” + + She soon developed a lobar pneumonia and died. + +The following typical case of partial stupor is quoted as an example of +delusions appearing only during the onset. + + + CASE 14.--_Maggie H._ Age: 26. Admitted to the Psychiatric + Institute February 8, 1905. + + _F. H._ The father died when 33. The mother was living. + Psychopathic tendencies were denied. + + _P. H._ The husband and brother stated that the patient + was natural, capable, rather jolly. She married about a + year before admission and shortly became pregnant. During + the pregnancy she was rather nervous and had various + forebodings, among which were that the child might be born + deformed, or that she would die in childbirth. + + The baby was born three weeks before admission. The patient + seemed much worried immediately after the childbirth, + fretted about not having enough milk, was quite concerned + about her husband and did not want him to leave her side. + The brother stated that about this time the patient heard + that the husband was out of work. She worried about this + and told her sister so. She also began to say that her head + was getting queer. On the fifth day after childbirth, a + change came over the patient. She cried and said she was + going to die. She also spoke of poison in the food and + accused the husband of unfaithfulness. The next day she + became silent, “did not seem to want to have anything to do + with anybody,” lay in bed, had a tendency to pull the + covers over her head and scarcely ever spoke. But during + this period she continued to look after the baby + faithfully. Sometimes she clung to her husband, saying she + was afraid he was going to die. + + After recovery the patient said that while she was at home + she thought she saw bodies lying about. + + At the _Observation Pavilion_ she was quiet and apathetic, + indifferent to environment and could not be induced to + speak. She soiled, refused food, and was resistive when + anything was done to her. + + _Under Observation:_ 1. On admission the patient was fairly + well nourished but looked rather anemic and weak. The + temperature was normal, the pulse a little irregular but of + normal frequency, the tongue coated. She lay inactive but + looked about, and the facial expression sometimes changed + as she did this. Any interference met with intense + resistance. There was no catalepsy. In contradistinction to + this inactivity and resistance, natural, free motions were + observed at times, as, for example, when she arranged her + pillows. She did not speak and could not be made to answer. + + For the rest of the first week she made no attempt to + speak, except once when she seemed to attempt to return a + “good morning,” or on another occasion, when the nurse + tried to feed her, she said, in quite a natural tone, “I + can feed myself.” The resistance to interference remained + in a variable degree, and was at times quite strong. It was + largely passive, though not infrequently associated with a + scowl, or she moved away when approached. She sometimes + looked dull and stared, again she looked determined, + “disdainful,” or scowled; or she looked about watching + others, sometimes only out of the corners of her eyes. She + had to be spoon-fed at times, again she ate naturally when + the food was brought. Repeatedly, when taken out of bed, + though she resisted at first, she dressed with natural free + motions. She always retracted promptly from pin pricks. + + Towards the end of the week she even complied at times with + a request to do some work, but on the same day she would + remain passive, with a look of disdain, or resist intensely + when interfered with, e.g., when an attempt was made to + make her sit down. She never soiled and never showed any + catalepsy. + + 2. Then the condition changed, inasmuch as the marked + resistance ceased entirely, and the mutism gave way first + to slow and low answers, and later to much freer speech, + though the inactivity improved only gradually. Thus at the + examination on February 19, though she was quite inactive, + she answered some questions, albeit in whispers and + briefly. This was the case when questioned about the year, + month and date, which she gave correctly, but she merely + shook her head when asked how long she had been here, why + she was here, what was the matter with her. Once she smiled + appropriately. Later she became freer in speech, with a + more natural tone, although her answers continued to be + short. Not infrequently, when asked to calculate or to + write, she would not coöperate, saying “This has nothing to + do with my getting well,” or (later) “What has that got to + do with my going home?” or she would simply say she did not + want to. Improvement in her listlessness and inactivity was + more gradual. + + The prevailing affective state was indefinite. She denied + repeatedly that she was depressed, though later she + admitted once being downhearted, yet it seems that even + then her mood was not so much one of sadness as of a slight + resentment. On one occasion, however, she showed some tears + when asked about the baby. She repeatedly expressed the + wish to go home, but not in a pleading, rather in a + resentful, way, saying she would never be better here, that + the questions which were asked had nothing to do with her + going home, that she would be all right if she went home. + She never admitted that she had ever been sick enough to be + taken to a hospital, though she quite appreciated that + there had been something the matter with her head at home + and in the hospital. She stated, in answer to questions, + that she had a peculiar feeling in the head which she could + not explain, that she could not remember so well as + formerly. Once she said, “I hear so much around here that + my head gets so full.” + + When towards the end she was questioned about her + condition, i.e., the reason for her resistance, her mutism, + and her refusal of food, she said that then she “wanted to + be left alone”; that she did not eat “because she did not + want food,” and she also spoke of not having had any + interest. + + She was discharged on April 29, i.e., about ten weeks after + admission before she had become entirely free. + +The last case is interesting in that a depressive onset to a deep stupor +was observed in the Institute. It was characterized by constant +repetitions of a request to be killed. + + + CASE 15.--_Meta S._ Age: 16. Admitted to the Psychiatric + Institute June 26, 1902. + + _F. H._ The father was dead, and the mother living abroad. + Not much could be learned about them and the immediate + family. + + _P. H._ An aunt who gave the anamnesis had known the + patient only since she came to the United States, a year + before admission. After her arrival the patient at once + went to work as a servant. It was claimed that her employer + liked her, but that she was rather slow about the work. The + only trouble known was that she sometimes complained of + indigestion. She went to see her aunt about once every two + weeks. + + Three weeks before admission, when the patient visited her + aunt, she seemed quieter than usual. Further, she spoke + about sending money home on the _Kaiser Wilhelm der + Grosse_, which was thought peculiar because she had no + money, and on a walk through a cemetery said “I would like + to be here too.” At the time this did not impress the aunt + as very peculiar. The patient continued to work until nine + days before admission. The employer then sent for the aunt + and said the patient had been very quiet for about two + weeks, and that she now had become more abnormal. She + suddenly had begun to cry, said the police had come, + claimed, without foundation, that she had “stolen,” and + kept repeating “I have done it, I will not do it again.” + The aunt took her home with her. There she was quite + dejected, cried, spoke of killing herself (wanted to jump + out of the window, wanted to get a knife). On the whole, + she said very little, but when the aunt pressed her to say + why she was so worried, she said she had allowed men to + kiss her and had taken money from them. It is claimed that + she never menstruated. + + After recovery the patient herself described the onset as + follows: Ever since she came to this country she had been + homesick, and felt especially lonesome for some months + before admission. She knew, however, of no precipitating + cause, in spite of what she had said to the aunt and what + she said at first under observation. She consistently + denied that anything had happened with young men. A short + time before she left her place (she left it nine days + before admission) she could not work, began to accuse + herself of being a bad girl and of having stolen. Then she + was taken to the aunt’s house. There she wanted to die. + + _Under Observation:_ 1. On admission the patient appeared + depressed, sat with downcast expression, looking up rarely. + She spoke in a low tone and slowly. But, in spite of delay, + she answered all questions, knew where she was and gave an + account of the place where she had worked. When questioned + about trouble with men, she claimed that a man who lived in + the same house where she worked had tried to make her “lie + on the bed,” but that she refused; that later a man had + assaulted her and had after that repeatedly come to her + room when she was alone. Yet when asked whether she worried + about this, she denied it. + + 2. For eight days her condition was sometimes one of marked + reduction of activity, with preoccupation. She sat in a + dejected attitude, and had to be urged to do anything. + Sometimes she was very slow in greeting and slow in + answering, and said very little. But whenever spoken to she + was apt to cry and this might lead to such distress that + the reduction of activity was no longer to be seen. Thus on + June 28, when greeted, she began to cry and say, “Oh, what + have I done!--Oh, just cut my head off--Oh, please what + have I done--I have given my hand.” (Tell me the whole + story.) Imploringly and with hands clasped: “No, I can’t do + it--just cut my head off, please, please.” (Why can you not + tell me?) “Oh, what have I done!” The imploring to cut her + head off was then several times repeated, and she could not + be made to answer orientation questions. On June 29 she + became agitated spontaneously and cried loudly, saying, + “Oh, let me go home and die with my father.” She was then + put to bed, and when seen she could not be made to answer + orientation questions. But when asked whether she had seen + the physician before, she said, “I saw you yesterday.” She + could not be made, however, to say how long she had been + here, “I think a”--not finishing the sentence. Although she + would not answer further, she presently began to say “Oh, + cut my head off--oh, where is my papa and mamma?” When told + that her people were in Germany and that she could go back + to them, she said “I haven’t any money to pay it.” Then she + wanted to know if she was to pay for her board and bed and + said she could not do it. + + Again, on July 1, although she had been quite preoccupied, + inactive and silent, she began to say when greeted, “Oh, + please cut my head off.” But she then answered some + questions, said she had not worked enough. On questioning, + she explained it was not that the work had been too much, + but that she had been nervous, had tried to work as much as + the servant next door, but could do only half as much, “Oh, + I ought to have worked.” + + Repeatedly on other occasions she begged, with distress, to + have her head cut off or to be killed. Frequently there + were statements of self-blame: she ought to have worked + more, was lazy or “I am not worthy”; or she said she had + lied and stolen; or again, “I have not paid for these beds + and I cannot,” or “I am a bad girl.” + + 3. For a month she presented a more marked reduction of + activity. She sat about with a dejected look, often gazed + in a preoccupied manner, or she stood or walked around + slowly. Sometimes she had to be spoon-fed. At other times + she ate slowly. Toward the latter part of this period, a + distinct tendency to catalepsy appeared. During this + period, too, as a rule (though not always), she would cry + when spoken to. A few times she would make some ineffectual + motions when questioned, but she scarcely ever spoke. + + 4. Then followed a period again lasting about one month in + which the picture was at times one of still greater + inactivity. She would retain uncomfortable positions, allow + flies to crawl over her face. She presented resistance in + the jaws, did not react to pin pricks. She sometimes sat + with eyes closed or, with an immobile face, the eyes stared + with little blinking. The catalepsy was more decided. She + often would not swallow solid food but swallowed fluid. + Again she held her saliva, sometimes drooled. Once she held + her urine and had to be catheterized. When spoken to she + once smiled at a joke, sometimes there was no response, but + as a rule there were tears or flushing of the face. On the + physical side, there were marked dermatographia and, for a + time, towards the end of the period, profuse sweating. + Throughout the stupor proper her temperature was between + 99° and 100° as a rule. + + 5. The period which followed and which lasted about two + months was characterized, like the one just described, by + marked stupor symptoms, associated, however, with more + resistance, while the crying practically disappeared. On + the other hand, a number of plainly angry reactions were + seen and, towards the end, smiling and laughing. She lay in + bed, on her back, staring, allowing the flies to crawl over + her face; retained uncomfortable positions without + correcting them, and her arms often showed a decided + tendency to catalepsy. Sometimes she soiled. She constantly + held saliva in her mouth, though she did not often drool. + She was totally mute, did not respond in any way except in + the manner to be presently indicated. She had to be + tube-fed a good part of the time, was quite resistive when + an attempt was made to open her mouth. When attended to by + the nurse, she was apt to make herself stiff. But as a + rule, she was not resistive to passive motions when tested. + On a few occasions she had, as was stated, marked angry + outbursts. Thus on one occasion when her temperature was + taken she angrily pushed the nurse away and then struggled + vigorously. On another occasion, when the bed-pan was put + under her, she threw it away angrily and struck the nurse; + once she did the same with the feeding tube. She struck a + patient, on another occasion, when the latter came to her + bed. On two occasions she suddenly threw herself headlong + on the floor. Towards the end of the period, when the + blood-pressure was taken, she smiled and then laughed out + loud. She could be made to smile again later. + + 6. The last period, before the more definite improvement, + lasted about a month. She was inactive and slow, ate slowly + (feeding no longer necessary), and was mute. But she did + not stare, was no longer resistive, no longer held saliva. + She appeared indifferent, but could be made to smile quite + readily when spoken to. On one occasion she laughed out + loud when a comical toy was shown her, again was amused at + a party. In the beginning of the period she was once seen + to cry a little when sitting by herself, and at the same + time wept a little when spoken to, but this was now + isolated. Towards the end of the period she spoke a little, + asked for paper and pencil and wrote: “Dear Mother.--I only + take up the pencil in order to write you a few lines. We + are all cheerful and in good health and hope that you are + the same and we congratulate you on your birthday 19th of + December that I have not written to you for a long time + were in the same ...” (Translated.) This was written very + slowly. + + On the day after this letter she was distinctly freer, + talked a little to the nurse and then improved rapidly. A + week after this, January 16, she is described as quite free + in her talk and activity, but when asked about the + psychosis she merely shrugged her shoulders. However, mere + extensive retrospective accounts were taken later. + + The retrospective accounts were obtained on January 24 and + March 13. As these two accounts do not seem to be + fundamentally different for the period of the psychosis, + they may here for the sake of brevity be combined. + + She remembered clearly going to the Observation Pavilion, + and feeling frightened, as she did not know where she was + going and what they were going to do with her. She knew + when she was in the Observation Pavilion and had a good + recollection of the place, also of the transfer to the + hospital, the ward she came to, who spoke to her, etc. She + did not know what the place was until the doctor told her a + day or two after admission. Unfortunately definite + incidents were inquired into only for the first part + (July). But she remembered those clearly. She also claimed + to remember all visits which were made to her by her + friends, but it was not specifically determined whether + there was a period of less clear recollection or not. + However, she remembered the tube-feeding, which occurred + only during the more marked stupor. Her desire to be + killed, to have her head cut off, she recalled but claimed + not to know why she wanted to be killed. However, she + remembered worrying about being bad, about the fact that + she could not “pay for the beds,” etc. + + Her mutism and refusal of food she was unable to account + for. She could not talk, her “tongue would not move.” As + regards ideas during the more stuporous period, she claimed + that (when quite inactive) she heard voices but did not + recall what they said. But she remembered having dreams at + that time “of fire,” “of her dead father and of home.” + +In a survey of thirty-six consecutive cases of definite stupor, literal +death ideas were found in all but one case. They seem to be commonest +during the period immediately preceding the stupor, as all but five of +these cases spoke of death while the psychosis was incubating. From this +we may deduce that the stupor reaction is consequent on ideas of death, +or, to put it more guardedly, that death ideas and stupor are +consecutive phenomena in the same fundamental process. Two-thirds of +these patients interrupted the stupor symptoms to speak of death or +attempt suicide, which would lead us to suppose that this intimate +relationship still continued. One-quarter gave a retrospective account +of delusions of being dead, being in Heaven, and so on. From this we may +suspect that in many cases there may be a thought content, although the +patient’s mind may seem to be a complete blank. It is important to note +that when a retrospective account is gained, the delusions are +practically always of death or something akin to it, such as being in +prison, feeling paralyzed, stiff, and so on. + +In the one case of the thirty-six who presented no literal death ideas, +the psychosis was characterized essentially by apathy and mild +confusion, a larval stupor reaction. It began with a fear of fire, +smelling smoke and a conviction that her house would burn down. It is +surely not straining interpretation to suggest that this phobia was +analogous to a death fear. When one considers the incompleteness of +anamneses not taken _ad hoc_ (for these are largely old cases) and that +the rule in stupor is silence, the consistence with which this content +appears is striking. + +To exemplify the form in which these delusional thoughts occur we may +cite the following: Henrietta H. (Case 8) said, retrospectively, that +she thought she was dead, that she saw shadows of dead friends laid out +for burial, that she saw scenes from Heaven and earth. Annie K. (Case 5) +claimed to have had the belief that she was going to die, and to have +had visions of her dead father and dead aunt, who were calling her. She +also thought that all the family were dead and that she was in a +cemetery. Rosie K. (Case 11) said she had the idea that she wanted to +die and that she refused food for that purpose, and during the stupor +she sometimes held her breath until she was cyanotic. Mary F. (Case 3), +before her stupor became profound, spoke of the hereafter, of being in +Calvary and in Heaven. In this case, as well as in the above-mentioned +Henrietta H., we find, therefore, associated with “death” the closely +related idea of Heaven. Whether Calvary merely referred to the cemetery +(Mt. Calvary Cemetery) or leads over to the motif of crucifixion, cannot +be decided. It is, however, clear that this latter motif may be +associated with that of death, as is shown in Charlotte W. (Case 12), +who, during intervals when the inactivity lifted, spoke of having been +dead, of spirits having told her that she must die, of having gone to +Heaven, of God having told her that she must die on the cross like +Christ. But this patient also showed in a second subperiod of her stupor +another content. She said: “It was like water. I was going down.” Or +again, she spoke of having gone “under the ground”; “I went down, down +in a coffin.” She spoke of having gone down “into a dark hole,” “down, +down, up, up”; again, of having been “on a ship.” We shall see in the +further course of our study that this type of content occurs not at all +infrequently. + +_The internal relationship among the different ideas associated with +stupor:_ Before we go any further it may be advisable to examine the +meaning of such ideas when they arise in other settings than those of +the psychoses. If we consider these ideas of death, Heaven, of going +under ground, being in water, in a boat, etc., we are impressed with the +similarity which they bear to certain mythological motifs. This is, of +course, not the place to enter into this topic more than briefly. We are +here concerned with a clinical study, and therefore, among other tasks, +with the interrelationship of symptoms, but for that purpose it is +necessary to point out how these ideas seen in stupor can be shown to +have, not only a connection amongst each other, when viewed as +deep-seated human strivings, but also are closely related to, or +identical with, ideas found in mythology. + +To one’s conscious mind death may be not only the dreaded enemy who ends +life, but also the friend who brings relief from all conflict, strife +and effort. Death may, therefore, well express a shrinking from +adaptation and reality, and as such may symbolize one of the most +deep-seated yearnings of the human soul. But from time immemorial man +has associated with this yearning another one, one which, without the +adaptation to reality being made, yet includes a certain attempt at +objectivation, the desire for rebirth. We need not enter further into +possible symbols for death _per se_, but it is quite necessary to speak +briefly of the symbolic forms in which the striving for rebirth has ever +found expression. The reader will find a large material collected in +various writings on mythology, for the psychological interpretation of +which reference may be made to Jung’s “Wandlungen und Symbole der +Libido” and Rank’s “Mythos von der Geburt des Helden.” From them it +appears how old are the symbols for rebirth, and how they deal chiefly +with water and earth, and the idea of being surrounded by and enclosed +in a small space. Thus we find a sinking into the water of the sea, +enclosure in something which swims on or in the water, such as a casket, +or a basket, or a fish, or a boat; again, we find descent into the +earth. The striving for rebirth might be assumed to have adopted these +expressions or symbols on account of the concrete way in which the human +mind knows birth to take place. The tendency for concrete expression of +abstract notions causes the desire for another existence to appear, +first as a rebirth fantasy and then as a return to the mother’s body. +One thinks of Job’s cry, “Naked came I from my mother’s womb and naked +shall I return thither,” as an example of the literal comparison of +death with birth. We need only refer to the myths of Moses and the older +one of Osiris, and the many myths of the birth of the hero, to call to +the mind of the reader the examples which mythology furnishes. There is +probably not one of the ideas expressed by these patients which cannot +be duplicated in myths. We have, therefore, a right to speak of these +ideas as “primitive,” and to see in them, not only deep-seated strivings +of the human soul, but to recognize in them an essential inner +relationship. It is especially this last fact to which at this point we +wish to call attention: that without any obvious connection the +fantasies of our forefathers recur in the delusions of our stupor cases. +We presume that in each case they represent a fulfillment of a primitive +human demand. In one of our cases a vision of Heaven and a conscious +longing to be there was followed by a stupor. On recovery the patient +compared her condition to that of a butterfly just hatched from a +cocoon. No clearer simile of mental rebirth could be given. + +_Brief survey of the ideas associated with the states preceding the +stupor:_ If we now return to the study of the further occurrence of such +ideas in the cases described, we find motifs, similar to those seen in +the stupor, in the period which immediately precedes the more definite +stupor reaction. Indeed we find the ideas there with greater regularity. +In Meta S. (Case 15) the stupor followed upon six days with reduced +activity and crying, with self-accusation, but also with entreaties to +be allowed to go home and die with her father. At the very onset of her +breakdown, the desire for death had also occurred. Anna G. (Case 1) +expressed a wish to be with her dead father, and, at the visit of a +cousin, she had a vision of the latter’s dead mother. A second attack of +this same patient began with the idea that the dead father was calling +her. Maggie H. (Case 14) saw dead bodies, and during outbursts of +greater anxiousness, she thought her husband was going to die. In +Caroline De S. (Case 2) the psychosis began with a coarse excitement, +with statements about being killed, with entreaties to be shot, with the +idea of going to Heaven, again with frequent calling out that she loved +her father (who was dead since her ninth year), while immediately before +the stupor the condition passed into a muttering state in which she +spoke of being killed. Mary D. (Case 4) began by worrying over the +father’s death (dead four years before), had visions of the latter +beckoning, and she heard voices saying, “You will be dead.” Mary F. +(Case 3) had a vision of “a person in white,” and thought she was going +to die. In Henrietta H. (Case 8) the stupor was preceded by nine days of +elation, with ideas of shooting and of war, but this had commenced with +hearing voices of dead friends, and with ideas that somebody wanted to +kill her family. In the case of Annie K. (Case 5) we find before the +stupor a state of worry, with reduction of activity, and then a vision +of the dead father coming for her. In Charlotte W. (Case 12) the stupor +was preceded by a state of preoccupation, with distress and entreaties +to be saved, partly from being put into a big hole, partly from the +electric chair. + +We see, therefore, in the introductory phase of the stupor in almost +every case ideas of death, and in one case an idea belonging to the +rebirth motif, namely, of being put into a dark hole. In well-observed +cases apparently we do not find the stupor reaction without either +coincident or preceding ideas of death. + +_Relation of death and rebirth ideas with affect:_ In order to +investigate the relation of these ideas to the affective condition +associated with them, it will be necessary to study not only the +abstract ideational content but the special formulation in which the +content appears. In looking over the enumeration of the ideas given +above, it is very clear that these formulations differed considerably +from each other. A priori we would say that it is, psychologically, a +very different matter whether a person expresses a desire to die, or has +the idea that he will die or is dead, or says he will be killed. We +associate the first with sadness, the last with fear, while our daily +experience does not give us so much information about the delusion of +being dead. A vivid expectation of death is usually accompanied by +either fear or resignation. + +In studying the ideas which we obtained from the patients by +retrospective account after the psychosis or from a retrospective +account during freer intervals, it is, of course, difficult, especially +in the former case, to say whether they have persisted for any length of +time. Probably in most instances this was not the case, and we must +remember in this connection that in a considerable number of cases the +patients recalled no ideas whatever. + +Of the five cases which we may consider as types, Henrietta H. (Case 8) +and Mary F. (Case 3) formulated their ideas simply as _accepted facts_ +during the stupor. The former thought she was dead, saw dead friends +laid out for burial, and scenes from Heaven and earth. The latter spoke, +during the stupor, of being in “Calvary,” “the hereafter,” or “Heaven.” +We have seen that these stupors were essentially affectless reactions +and we can therefore say that, so far as these two cases are concerned, +the ideas thus formulated were not associated with any affect. + +Annie K. (Case 5) was a little different. During the stupor she made a +few utterances about priests and “all being dead,” and retrospectively +she said that she had thought she was in the cemetery, was going to die, +that she had repeated visions of her dead father and once of a dead aunt +calling her; that she had thought her family were dead, again that the +baby (who was born just before the psychosis) was dead. The formulation +is therefore less one of fact than of something prospective, something +which is coming--the _going_ to die. Correlated, perhaps, with this +anticipation were slight modifications of the usual apathy. The patient +often had an expression of bewilderment. She was also more in contact +with her environment than many stuporous patients are, for, not +infrequently, she would look at what was going on about her. Her apathy +was also broken into in a marked degree by her active resistiveness, +which was sometimes accompanied by plain anger. It seems that a prospect +of death may occur in other instances in a totally affectless state. We +have recently seen it in a partial stupor during which the patient spoke +and had this persistent idea in a setting of complete apathy. We see +here also, as in one of the former cases, the idea of other members of +the family being dead. + +More difficult and deserving more discussion are the two remaining +cases, Rosie K. (Case 11) and Charlotte W. (Case 12). Rosie K. showed a +peculiar condition. She said, retrospectively, that during the stupor +she had the desire to die and that for this purpose she refused food. +Moreover, she was repeatedly seen to hold her breath with great +insistence, though without affect. This is worth noting. We are in the +habit in psychiatry to say in a case like this that “there is no +affect,” and yet there is evidently a considerable “push” behind the +action. We shall later have to mention in detail a patient whom we +regard as belonging in the group of stupor reactions, and who for a time +made insistent, impulsive and most determined suicidal attempts, yet +with a peculiar blank affectless facial expression and with shouting +which was more like that of a huckster than one in despair. Here also, +then, there was a great deal of “push,” yet not associated with that +which we call in psychiatry an affect. In both instances we see acts +which we are in the habit of calling for this very reason “impulsive.” +Evidently this is an important psychological problem which leads +directly into the psychology of affects and deserves further study. For +the present it is enough to say that with a different formulation--that +of wishing to die--there is here not, as in other psychoses, a definite +affect, such as sadness or despair, but no affect, though there may be a +good deal of “push” or impulsiveness. + +The case of Charlotte W. (Case 12) is a complicated one, for she had +short stupor periods with inactivity, catalepsy, resistiveness, etc., +which were interrupted with freer spells. A careful analysis of her +history has been instructive and justifies a detailed and lengthy +discussion. For the purpose in hand it is necessary to separate the +ideas which she expressed only in the freer periods (during which some +affect was at times seen) into those which referred retrospectively to +the stupor phase and those which referred to the freer periods +themselves. + +We find that the time during which more marked stupor symptoms appeared +may be divided into two subperiods. This is not possible in regard to +the manifestations belonging to the general reaction, which seem to have +undergone no decided change, but only in regard to the form of the +delusions. In this we find there was a first phase in which ideas of +death and Heaven (and crucifixion) occurred, and a second phase in which +ideas were present which belonged essentially to the motif of rebirth +but which were also associated with ideas of Heaven. + +About the first subperiod she said: “I was mesmerized,” or “I thought I +was dead,” or “God told me I must die on the cross as He did,” or “I +went to Heaven in spirit.” About the second subperiod she said +retrospectively: “We were on a ship and we were ’most drowned.” “It was +like water, I was going down, down.” She said she saw the people of the +hospital and “it was all full of water”; or again, “I went under the +ground and it was full of water and every one got drowned and a sharp +thing struck me”; or “I was out on a ship and I went down in a coffin.” +She claimed she put up her arms to save the ship. Again she spoke of +having gone into a dark hole. She also said: “One day I was in a +coffin--that was the day I went to Heaven.” “They used to be coming up +and down, that was the day I was coming up in a ship or going down.” And +when shown her picture in a cataleptic attitude, she said: “That must +have been when I went to Heaven--everything seemed strange, things +seemed to go up and down--I guess that was the day I thought I was on +the ship.” Finally she also said: “Once I heard beautiful music--I was +waiting for the last trumpet--I was afraid to move.” + +We see, therefore, that most of the ideas which she thus spoke of +retrospectively as having been in her mind during this stupor, and which +belonged both to the death and the rebirth motifs were formulated as +facts (as in the cases of Henrietta H. and Mary F. above mentioned). It +was, moreover, a condition which was accepted without protest. Here +again an affect was not associated with these ideas, and when the +patient was asked whether she had not been frightened, she said herself, +“No, I just lay there.” The idea that God told her she would have to die +on the cross like Christ, is, in the religious form, like the beckoning +of the father with Henrietta H. The only exception to the claim that the +ideas were formulated as facts and accepted as inevitable seems to be +the statement that she held up her arms to save the ship. This would +seem to be, in contradistinction to the rest, a formulation as a more +dangerous situation. However, this was isolated and we can do no more +than to determine main tendencies. We must expect, especially in such +variable conditions as we see in this patient, to find occasional +inconsistencies. + +In summing up we may say, therefore, that so far as the stupor itself +is concerned, the ideas are formulated as a rule:-- + + 1. As accepted facts (being dead, being in a ship, etc.). + + 2. As accepted prospects (going to die). + + 3. As the wish to die. + +In the first two types the ideas are not associated with affect; in the +third, though not associated with affect, they are combined with +“impulsive” suicidal attempts. + +In order not to tear apart the analysis of Charlotte W. (Case 12) too +much, we may begin our study of the intervals and the conditions +preceding the stupors with the ideas which this patient produced when +the stupor lifted somewhat. We shall see that the ideas are closely +related to those mentioned above but formulated differently. + +It will be remembered that Charlotte W. had freer intervals when she +responded and was less constrained generally, and that it was in these +that the ideas above mentioned were gathered. Since they were spoken of +in the past tense, we regarded them as not belonging to the actual +situation but to the more stuporous period. It seems tempting now to see +whether the ideas which are expressed in the present tense are different +in character, the general aim being to discover whether any tendencies +can be found in regard to the types and formulations of delusions +associated with different clinical pictures. We see that on November 2 +the patient, when speaking much more freely than before, said she had +felt that she was mesmerized, was dead, and that she had gone to Heaven, +ideas which we have taken up above as belonging to the stupor period. In +addition to speaking much more freely in these intervals, she showed at +times some affect. Thus to the physician whom she called Christ, she +said, with tears, “You came to tell me what was right,” or again with +tears, “I will have to be crucified,” or she spoke in a depressed manner +about her children, “I can’t see them any more,” “I must stay here till +I die,” and she spoke of having to stay here till she picked her eyes +and her brains out; or she claimed her husband or her children had to +pick them out. Once she exclaimed crossly and with tears, “You are +trying to keep me from Jim” (husband). Another idea was not plainly +associated with affect. She said she had come back from Heaven, “The +wedding ring kept me on Earth.” What strikes one about these +formulations is that they are, on the one hand, sometimes associated +with an affect, and that, on the other hand, they refer much more to her +actual life, her marriage, her husband, her children. At least this +seems to be a definite tendency. A similar tendency may be seen later: +On November 4, while generally stuporous, this suddenly lifted for a +short time, and with feeble voice she uttered some depressive ideas. She +said she wanted to go to a convent, that it would be better if she were +dead, that she could not do anything right. On November 5 and 6 she +said she wanted to go to Jim in Heaven (in contradistinction to the +retrospective statements that she had gone to Heaven), and on the 8th, +when she had the idea of being in a boat, she said with some anger that +she had wanted to get her husband into the boat, but that the doctor +kept him out and took his place. + +Later there were at times ideas expressed which referred to the actual +situation or essentially depressive ideas in a depressive setting. Thus +on December 3 she appeared sad, retarded, and spoke of not being able to +see her children and that she had done wrong in buying carbolic acid +(her suicidal attempt). So far as this case is concerned, therefore, we +do find a distinct tendency for the ideas which refer to the more +stuporous condition to differ from those which refer to the actual +situation in the freer intervals, a difference which we may formulate by +saying that, though primitive ideas are expressed, the tendency seems to +be to connect them more with actual life, or that the primitive +character is lost and the ideas take on a more depressive character with +a depressive affect. A few words should be added in regard to the +peculiar ideas that she or her husband or her child had to pick out her +eyes (or her brain). It is probable that this idea belongs to the motif +of sacrifice (the _Opfer motiv_ of Jung) into which we need not enter +further, except to say that in this instance it was plainly connected, +like some of the other ideas just spoken of, with the real situation of +her life (husband, children). + +It will now be necessary to examine the earlier state of Charlotte W. +The condition preceding the stupor set in with pre-occupation, slow talk +and slight distress. During the time she asked to be given one more +chance, she said to the husband she would not see him again. Then +followed a day when she was very slow and with moaning said she was +going to be put into a dark hole. Again on the next, when speaking more +freely, she begged to be saved from the electric chair, and also said, +“Don’t kill me, make me true to my husband,” etc. [Again the connection +with real life!] We see here the idea of death and especially an idea +pertaining to the rebirth motif in a setting of distress and slowness, +as an introduction to the stupor which had in it both of these motifs. +We must leave it undecided whether it is accidental or not that the +distress was associated with more slowness (i.e., more marked stupor +traits) when she spoke of the dark hole than when she spoke of the +electric chair or death. But what interests us is that distress and +reduction of activity (not sadness and reduction of activity, which +seems as a rule to have a different content) are here associated with +ideas seen in stupor but formulated as prospective dangers. We know from +experience that we often find associated with the fear of dying +considerable freedom of action, and we see at times in involution states +conditions with freedom of motion and marked anxiety, whereas the ideas +seem to belong to the motif of rebirth; e.g., the fear of being boiled +in a tank.[A] + +In this connection, however, two other cases should be taken up which +show a condition which reminds one somewhat of that we have just +discussed, but in which the rebirth motif appeared, not as prospective, +but, as in the stupor, as an actual situation. At the same time this +situation was not passively accepted but conceived as a dangerous +situation. The significant phenomenon in both these conditions was that +there was not anxiety with freedom of action but a bewildered uneasiness +with marked reduction of activity. + +The first case is that of Johanna S., whose history has been given in +this chapter. It will be observed that in the fourth period the patient +presented two days of typical stupor with the idea that she was dead. We +are familiar with this. But this was followed by several days of +bewildered uneasiness and slow restlessness, with ideas that she was at +the bottom of the deep, dark water and for a time she made attempts at +stepping out of the water or swimming motions. All of this was in a +general setting of reduction of activity with bewildered uneasiness. In +the ideas about being at the bottom of the deep, dark water, we +recognize again the rebirth motif, yet the situation is not accepted +but attempts are made by the patient to save herself, i.e., the attitude +is one in which the situation is taken to be one of danger. It is +interesting in this connection that immediately following this state +there was one day of ordinary retardation with sadness and ideas of +being bad and sick. That is, when the element of anxiety, the +uneasiness, disappeared and sadness supervened, the rebirth ideas were +no longer present. + +In Mary C. (See Chapter II, Case 7) we have, unfortunately, not a direct +observation, but we have, at any rate, a description from the +Observation Pavilion which seems so plain that we should be justified in +using it here. The condition we refer to is described as a dazed +uneasiness, with ideas of being shut up in a ship, of the ship being +closed up so that no one could get out, of the boat having gone down, of +the people turning up. We should add here that the condition was not +followed by a typical stupor. Essentially it was a retardation, in which +only on one occasion was a definite akinesis observed. During this phase +she soiled her bed. Perhaps the persistent complaint of inability to +take in the environment belonged also more to the retardation of stupor +than to that of depression. We have again, therefore, in this initial +phase, a similar situation, namely, ideas belonging essentially to the +rebirth motif, formulated as of a threatening character if not as +actually dangerous. + +We can say, therefore, that what characterizes these three cases, and +brings them together, is the fact that all three had ideas belonging to +the rebirth motif, but formulated as dangerous situations. Associated +with this there was not a typical anxiety with the relative freedom of +activity belonging to this state, but an anxiety or distress or +uneasiness with traits of stupor reaction, namely, slow movements, lack +of contact with the environment, and a dazed facial expression. It would +seem that these facts could scarcely be accidental but that they must +have a deeper significance. As a discussion of this belongs, however, +more into the psychological part of this study, we shall defer it for +the present, and be satisfied with pointing out here the clinical facts +of observation. + +In brief, then, our findings as to the ideational content of the benign +stupor are as follows: From the utterances during the incubation period +of the psychosis, from the ideas expressed in interruptions of the deep +stupor, as well as from the memories of recovered patients, we find an +extraordinary paucity and uniformity of autistic thoughts. They are +concerned with death, often as a plain delusion of being no longer +alive, or with the closely related fancy of rebirth. The rule is a +setting of apathy for these ideas, but when they are formulated so as to +connect them with the real life and problems of the patient, or when +rebirth is represented as a dangerous situation, some affect, usually +one of distress, may appear. + + +FOOTNOTES: + +[6] Kirby, _loc. cit._, pointed out that stupor showed resemblance to +feigned death in animals, that the reaction suggested a shrinking from +life and that ideas of death were common. + +[A] We may mention that since this study was made we risked a prediction +of stupor, which events justified, in the case of a patient who showed +expectation of death without affect. Such opportunities are rare, +however, since we usually do not see these cases till the stupor +symptoms are manifest. It would be unsafe to dogmatize on the basis of +such meager material. + + + + +CHAPTER VI + +AFFECT + + +The most constant and significant symptom in the stupor reaction is the +change in affect. This extends from mere quietness in the mildest phases +of the disease through the stage of indifference where apathy replaces +the normal reactions of the personality, to the final condition of +complete inactivity in the vegetative stupor where all mental life seems +to have ceased. It seems as though there were, as a pathognomonic sign +of the morbid process, a lack of energy and loss of the normal _élan +vital_. + +We may say, in fact, that the establishment of a specific type of +emotional change is justification for classifying all milder stupor +reactions with the deep stupors. In other words, our reason for the +enlargement of the stupor group to include all apathetic reactions +(except those of dementia præcox) is the belief that this dulling of the +emotional response is as specific a type of emotional change as is +anxiety, depression or elation. Perhaps it would be more accurate to say +that this clinical group is founded on the symptom complex which is +built around apathy. There is never any resemblance between apathy and +the mood of elation or anxiety. A discrimination from depression is the +only differentiation worth discussion. + +The first point that should be made is that there is a difference +between marked depression and the mood of stupor. In the former we get a +retardation with a feeling of blocking, rather than of an absence of +energy. The expression of the patient is one of dejection, not of +vacancy, which bespeaks a mood of sadness, even when the patient is so +retarded as to be mute and therefore incapable of describing his +emotions. Running through all the stages of stupor, however, there is an +emptiness, an indifference that is in striking contrast to the positive +pain that is felt or expressed by the depressed patient. It may be +objected, of course, that this apathy really represents the final stage +in the emotional blocking of the depressed individual, but the +development of stupor and recovery from it shows an entirely different +type of process. A deep depression recovers by changing the point of +view from a feeling of unworthiness and self-blame to one of normality. +The stuporous case, on the other hand, evidences merely less and less +indifference, and more and more interest in his environment and in +himself as he gets well. + +The associated symptoms are no less dissimilar. The difficulty in +thinking which troubles the depressed patient is slight in proportion to +his emotional gloom, and he feels himself to be much more incompetent +intellectually than examination proves him to be. On the other hand, in +the stupor reaction we find that the thinking disorder runs hand in +hand with the apathy and that the intellectual capacity of the patient +is really markedly interfered with, as can be shown by more or less +objective tests. A mere slowing of thought processes accompanied by +subjective feeling of effort is the limit reached in true depression, +while it is merely the beginning of the intellectual disorder in stupor, +for one meets with retardation symptoms only in the partial stupors. The +slowing in these cases seems to represent an early stage of the +intellectual disturbance which reaches its acme in the mental vacuity +and complete incompetence of the deep stupor, just as slow movements in +the partial stupors seem to represent a diluted inactivity reaction. +This actual thinking disorder is not present in those forms of +manic-depressive insanity which are characterized by elation, anxiety or +depression but is seen only in stupors, occasionally in absorbed manic +states (manic stupor) and sometimes in perplexity states. The +psychological mechanisms of this last group are probably analogous to +those of stupor, but this is not the place for a discussion of this +topic. + +Another associated symptom whose manifestations differ in depression and +stupor is that of unreality. In the former there is frequently a feeling +of unreality that is purely subjective, whereas the stupor case does not +usually complain of this but does exhibit a difficulty in grasping the +nature of his environment, which the typical depressive case never has. + +The occurrence of other mood reactions than apathy in the same patient +is also characteristic. Manic states (usually hypomanic) frequently +occur during the phase of recovery from the stupor. This is an unusual, +although not unknown, phenomenon in recovery from severe retarded +depressions. The circular cases who swing from depression to elation +usually show the milder types of depressive reaction which would never +be confused with stupor. On the other hand, deep stupors very frequently +are terminated by manic reactions, and if not by such means, recovery +seems to occur merely in virtue of a gradual attenuation of the stupor +symptoms. Rarely do we see a change to depression or anxiety heralding +improvement. This tendency of the stupor reaction to remain pure or +change to hypomania is a peculiarity which seems to put stupor in a +class by itself among the manic-depressive reactions, as all the other +mood reactions frequently change from one to the other. + +Although apathy is the central pathognomonic symptom of stupor +conditions, there are other mood anomalies to be noted. One of these is +the tendency for inconsistency in, as well as reduction of, the +expression of emotion. For instance, in the states where one would +expect anxiety during the onset of stupor or in its interruptions, +manifestation of this anxiety is often reduced to an expression of dazed +bewilderment. In the anxiety states associated with stupor one does not +meet with the restlessness and expressions of fear which would be +expected. Quite similarly, when a manic tendency is present, it occurs +either in little bursts of isolated symptoms of elation (such as smiling +or episodic pranks), or some of the evidences of elation which we would +expect are missing. For instance, Johanna S. (Case 13) terminated her +stupor with a hypomanic state which was natural except for her always +wearing an expressionless face. Sometimes laughter occurs alone and +gives the impression of a shallow affect, raising a suspicion of +dementia præcox. In fact, such evidences of affect as do appear in the +course of the stupor are apt to be isolated, queer and “dissociated.” It +does not seem as if the whole personality reacted in the emotion as it +does in the other forms of manic-depressive insanity. For example, we +may think of the resistiveness which is so frequently present when the +patient seems in other respects to be psychically dead. One may recall +the case of Meta S. (Case 15), who, otherwise inert, was occasionally +seen with tears or smiles. Anna G. (Case 1), too, was often seen smiling +or weeping. It was noted once of Charlotte W. (Case 12) that she ceased +answering questions and remained immobile with fixed gaze, but when some +mention was made of her going home she flushed and tears ran down her +cheeks, although no change in the fixedness of her attitude or facial +expression was seen. When Johanna S. was visited by her daughter and was +lying motionless in bed, she slowly extended her hands, apparently tried +to speak, and then her eyes filled with tears. Two days later, at the +end of an interview when she had made a few replies, she settled down +into her usual inactivity and, when further urged to answer, her eyes +filled with tears. Similarly, too, in fairly deep stupor pin pricking +may result in flushing, in tears or an increased pulse rate without the +patient giving any other evidence of the stimulus being felt. These +examples seem to show a larval effort at normal human response which, +failing of complete expression, appeared as single isolated features of +emotion suggesting true dissociation. We should also in this connection +bear in mind the impulsive suicidal acts which occur either as +unexpectedly as the impulsiveness in a true dementia præcox patient, or +in a setting of coarse animal-like excitement that seems quite unrelated +to the personality. One is reminded of the patient who made suicidal +attempts during the period when she shouted like a huckster, giving no +evidence whatever by her expression or the tone of her voice of feeling +anxiety, sorrow or any other normal emotion. + +All these queer and larval affective reactions remind one strongly of +dementia præcox. The resemblance of the benign stupor to certain +dementia præcox types is not merely a matter of identity with catatonic +features (catalepsy, negativism). In these anomalous mood reactions it +seems as if there were a definite dissociation of affect, and so there +is. How then can we differentiate these emotional symptoms from the +“dissociation of affect” which is regarded as a cardinal symptom of +dementia præcox? The answer is that this term is used too loosely as +applied to the latter psychosis. It is a particular type of dissociation +which is significant of the schizophrenic reaction, for in it there is +an acceptance of what should be painful ideas evidenced either by +incomplete manifestations of anxiety or depression or actually by +smiling. We never see in dementia præcox the reverse--a painful +interpretation of what would normally be pleasant. It is the pleasurable +interpretation of what is really unpleasant that gives the impression of +queerness in the mood of these deteriorating or chronic cases. In +stupor, on the other hand, although this dissociation takes place, the +mood is never inappropriate, merely incomplete in that all the +components or the full expression of the normal reaction are not seen. + +Our description of the mood reactions in stupor would be incomplete if +we omitted to mention the occasional appearance of an emotional attitude +not unlike that seen in many cases of involution melancholia, which +reminds one in turn of the reactions of a spoiled child. The commonest +of these manifestations is resistiveness that may occur when an +examination is attempted, feeding is suggested, or a sanitary routine +insisted upon. One also meets with resentfulness. One patient, who +frequently showed this reaction, explained it retrospectively by saying +that she wanted to be left alone. Quite analogous to this is sulkiness +that occasionally appears. Then we have, particularly as recovery +begins, other childish tricks, such as flippancy in answering questions +or the playing of pranks. Such tendencies naturally lead over to frank +hypomanic behavior. + +Finally, a peculiar characteristic of the stupor apathy must be +mentioned. This is its tendency to interruptions, when the patient may +return to life, as it were, for a few moments and then relapse. Such +episodes occur mainly in milder cases or towards the end of long, deep +stupors. It is interesting that the occasion for such reappearance of +affect is frequently obvious. We usually observe them in response to +some special stimulus, particularly something that seems to revive a +normal interest. Visits of relatives are particularly common as such +stimuli, in fact recovery can often be traced to the appearance of a +husband, mother or daughter. It is also important to recognize that with +this revived interest, other clinical changes may be manifest, that the +thinking disorder may, for instance, be temporarily lifted. Helen M., +for example, when visited by her mother was so far awakened as to take +note of her environment, and remembered these visits after recovery like +oases in the blank emptiness of her stupor. She further remembered that +definite ideas were at such a time in her mind that ordinarily was +vacant. She then had delusions of being electrocuted. + +In summary, then, we may say that the _sine qua non_ of the stupor +reaction is apathy in all gradations, and that this apathy is as +distinct a mood change as is elation, sorrow or anxiety. Incidental to +this loss of affect there is a dissociation of emotional response +whereby isolated expressions of mood appear without the harmonious +coöperation of the whole personality which seems to be dead. Thirdly, +there tends to be associated with the stupor reaction a tendency to +childish behavior. Finally, the apathy and accompanying stupor symptoms +may be suddenly and momentarily interrupted. An explanation of these +apparently anomalous phenomena will be attempted in the chapter on +Psychology of the Stupor Reaction. + + + + +CHAPTER VII + +INACTIVITY, NEGATIVISM AND CATALEPSY + + +1. INACTIVITY. We must now turn our attention to the other cardinal +symptoms of the stupor reaction, and quite the most important one of +these is the inactivity. It is convenient to include under this heading +both the reduction of bodily movement and the diminution or absence of +speech. This inactivity is, of course, related to the apathy which we +have just been discussing, in fact it is one of the evidences of the +loss of emotion. We presume that a patient is apathetic when there is no +expression in the face and when he does not respond to external stimuli, +whether these be physical or verbal, by movement or by word. + +Bodily inactivity is present in all degrees, and in some forty +consecutive cases was recognizable in every one. In its most extreme +form there is complete flaccidity of all the voluntary muscles, and +relaxation of some sphincters. As a result of the latter we see wetting, +soiling and drooling. Even those reflexes which are only partially under +voluntary control, like those of blinking and swallowing, may be in +abeyance; for instance, saliva may collect in the mouth because it is +not swallowed, and tube-feeding is frequently necessary on account of +the failure of the patient to swallow anything that is put into his +mouth. The eyes may remain open for such long periods of time that the +conjunctiva and sclera may become quite dry and ulcerate. In these +extreme cases there is, of course, no response to verbal commands. What +is more striking, no reaction appears to pin pricks, so that it seems as +if consciousness of pain were lost. + +This deep torpor does not usually persist indefinitely. The commonest +evidence of some form of consciousness persisting is probably to be seen +in blinking when the eye is threatened or the sclera or cornea actually +touched. A very large number of patients, when otherwise quite inactive, +showed considerable response in their muscular resistiveness, the +phenomena of which will be discussed shortly. The relaxation of the +sphincters is apt to persist even after control of the rest of the body +is exercised to the point of permitting the patient to stand or walk +about. + +The first phase of obvious conscious control is seen in those patients +who will retain a sitting posture in bed or in a chair. The next stage +is reached where the stuporous case can be stood upon his feet but +cannot be induced to walk. The next degree is that of walking only when +pushed or commanded. Finally spontaneous movement is observed in which +the inactivity is evidenced merely by a great slowness. + +No correlation can be established between restrictions of speech and +motion other than that present in the extremes. With complete inactivity +there is almost always consistent mutism, and perfect freedom of speech +does not, as a rule, appear until the movements are free. In between +these extremes all variations are possible, even the deepest stupors are +occasionally interrupted by one or two words; for instance, a patient +may remain comatose, as it were, and absolutely mute for six months, +then to every one’s surprise say one or two words and relapse into a +year of silence. Again one sees cases where movements have become fairly +free and yet the patient says nothing. This is another example of that +inconsistency in reaction which we have already noted in connection with +the mood or affect. + +In so far as inactivity is merely an expression of apathy, its causation +will be considered in connection with the psychology of the stupor +reaction as a whole. In so far as there may be specific factors, +however, it may be of interest to consider what information the patients +themselves give us from time to time as to what determined their +inactivity. It is really surprising how frequently something can be +gained either from careful notes taken during the stupor or from the +retrospective accounts of the psychotic experiences. Of course when one +considers the degree of amnesia which is usually present and the extent +of the intellectual defect in general, it becomes obvious that one +cannot think of getting anything like a complete explanation of the +behavior of any given case. Nevertheless this material is quite +suggestive in the mass; it gives one some idea of the mental state as a +whole. + +Among 40 cases, 27 offered some explanation either during or following +the psychosis. Of these, 20 spoke of feeling dead, numb or drugged, or +feeling as if paralyzed or having lockjaw. This group, just half of all +the cases, apparently ascribed their disability to something which +seemed physical. One might call them somatopsychic cases. The other 7 +gave more allopsychic explanations: 3 attributed their inactivity to +outside influence; 3 more said they were afraid (one of these because +she imagined herself to be in prison), which is analogous to the outside +influence; the 7th case thought she would injure people if she moved. + +The following are some examples of the statements of the somatopsychic +group: Laura A.: “I can’t move,” and retrospectively, “My arms were +stiff.” Bridget B. claimed retrospectively that she felt dead or +drugged, that her limbs were lifeless, she felt as if she had lockjaw. +Johanna B. remembered being pricked with a pin on several occasions but +claimed that she did not feel the pain at any time. This suggests a +definitely hysterical mechanism. Anna L. (Case 16) said retrospectively +that she felt as if she were dead, although walking around, and also +that she thought she was a ghost and not supposed to speak. Anna M. said +she had tried to speak but everything stuck in her throat. Alice R. said +that she had no energy, did not want to talk. Meta S. (Case 15) claimed +that while stuporous her tongue would not move. Isabella M. in +intervals claimed that during the stuporous periods she felt as if dead +and said retrospectively when the whole psychosis was over that it was +“an effort to speak.” Johanna S. (Case 13), while stuporous when pressed +with questions would say: “I can’t think,” “I don’t know,” “I am +twisted.” When food was offered her she protested, “I am dead.” +Charlotte W. (Case 12), in reviewing her case, said: “I was mesmerized,” +“I thought I was dead.” Anna G. (Case 1), in retrospect said: “I don’t +think I could speak,” again “I made no effort,” or “I did not care to +speak.” Henrietta H. (Case 8) said, “I lost speech.” She claimed that +she did not move because she was tired and had a numb feeling. Mary C. +(Case 7) said that her tongue had been thick and that she felt dull. +Rose Sch. (Case 6) said during the psychosis that her head was upside +down and retrospectively that she had been mixed up, could not remember +well, did not feel like talking. Mary D. (Case 4) said that she had been +dazed, that she had not felt like talking, and that her limbs “were +stiff like.” We should probably also include here as a delusion of death +the statement of Annie K. (Case 5) who wanted to die and thought she +would do so if she kept still enough. + +It is rather striking that among all the forty cases only one spoke of +being sick--“I am so sick.” Only one evaded questions with “that was my +illness.” One would expect a priori that these patients would offer some +vague explanations or make complaints of weakness. If these stupors +were purely physical in origin, one would expect such explanations as +weakness or illness to be offered in accounting for the inactivity. That +there is a rather definite type of explanation offered is, we think, +distinctly suggestive. If one tries to correlate and group the death +ideas, one sees that they are all delusions of death or of loss of +energy or complaints of hysterical symptoms that look like sham death. +If the lack of energy complained of be looked upon as lifelessness, one +can conceive of these explanations being variations of one theme, +namely, that of death. In the last chapter it has been shown that a +delusion of dying, being dead, or having been dead is extremely frequent +in the stupor group. It would seem only natural then to regard the +inactivity, in so far as it may be specifically determined, as an +expression of some such delusion. + +Psychiatrists are more or less aware of there being typical ideational +contents in the different manic-depressive psychoses. For instance, +every one is familiar with ideas of wickedness and inadequacy in +depression, ideas of violence in anxiety, or expansive and erotic +fancies in manic states. Quite similarly we have seen that death is a +dominant topic in a stupor. Now in addition to these typical ideas we +often hear expressed what we might term non-specific delusions, ideas +that seem to have nothing to do with a peculiar type of reaction which +the patient presents. It is therefore not surprising to find that +inactivity is not consistently ascribed to death or a related delusion. + +For instance, Henrietta B. had much talk of higher powers that were +controlling her, also said that it was fear which kept her quiet. +Josephine G. said retrospectively that she had thought she would injure +people if she moved and that if she opened her eyes she would murder the +people around her. Johanna B. was afraid to talk because she fancied she +was in prison. Laura A.: During her stupor was more vague, saying, “I +can’t move, they won’t let me be,” without betraying any suggestion of +whom “they” might be. Finally Mary C. (Case 7) was still more +indefinite, ascribing her immobility merely to fear. When one considers, +however, that these five were the only ones who gave any atypical +explanation of their inactivity among the thirty-seven cases, the +preponderance of the death idea becomes striking. + +2. NEGATIVISM. The next of the cardinal symptoms to be considered is +negativism. This term, which is often loosely used, we would define as +perversity of behavior which seems to express antagonism to the +environment or to the wishes of those about the patient. Naturally it is +only in the minor stupors that we see it in well-developed form as +active opposition and cantankerousness. For example, Harriett C., who +stood about until her feet became edematous, would spit out food when it +was placed in her mouth but would eat if she were left alone with the +food. Josephine G., in a milder state, would turn her back on people. +When more inactive once rolled out of bed and lay on the floor. At this +time also she tried to keep people out of her room. Rarely, patients may +have angry outbursts, as did Annie K. (Case 5) who would strike at the +nurses. + +Very often the failure to swallow and anomalous habits of excretion seem +to be negativistic in their nature. One thinks at once of the necessity +for tube-feeding, which is so common even when patients seem otherwise +fairly active. Naturally this form of treatment is necessary only when +the patient refuses to swallow. Quite frequently a refusal to urinate is +met with so that catheterization is necessary, or a patient may never +use the toilet when led to it, but will defecate or urinate so soon as +he leaves it. These latter, like some other perversities, suggest +reactions of a petulant, spoiled child. + +By far the commonest manifestation is muscular resistiveness, often +spoken of as “resistiveness.” It was present in thirty-two out of +thirty-seven of our cases. Usually it takes the form of a contraction of +the whole system of voluntary muscles when the patient is touched or the +bed approached. Often it appears only when any passive movement of the +limb is attempted. All muscles of the limb then stiffen, making the +member rigid. Sometimes the negativism is expressed by quite isolated +symptoms, such as stiffness in the jaw muscles alone. One patient showed +no opposition except by holding her urine for two days. Another kept her +eyes constantly directed to the floor. The reaction of another showed +no irregularity except for stiffness in the neck and arms and wetting +herself once after she had been taken to the toilet. One displayed +merely a slight stiffness in her arms. An interesting case was that of +Annie G. (Case 1) who kept one leg sticking out of bed. If this were +pushed in, she would protrude the other. Mary F. (Case 3) sometimes +expressed her antagonism to the environment by slapping other patients. +She spoke only twice in a year and a half, and each time it was when +interfered with. By far the commonest cause of muscular movement in +these inactive cases is resistiveness, and as a rule the inactivity is +interrupted only by negativistic symptoms. + +If we look for some explanation or correlation of these symptoms, we +find that chance references to conduct seem to point in the same +direction, namely, to the desire to be left alone. This resentment +against interference again reminds us of the reactions of a spoiled +child. For instance, Laura A., in manic spells during which she was +still constrained and drooled, said, “I don’t want to have my face +washed.” In the intervals she showed an intense muscular resistiveness. +Mary G. used to say, “Leave me alone,” and covered her head or buried it +in the pillows. Maggie H. (Case 14) said in retrospect that she had +wanted to be left alone. Similarly Alice R. thought she did not want to +talk. Emma K. thought that she was in prison and apparently resented +this. Henrietta B. combined in her behavior tendencies both to +compliance and opposition. When her arms were raised they retained the +new position for a minute. Then she dropped them and said, “Stop +mesmerizing me.” But then she put them up again of her own accord, and +when she had done this presented intense resistiveness to any movement. +Later she extended her arms in front of her and said, “I am all right,” +in a theatrical manner, and then added, “Why don’t you go away?” + +There seems to be some correlation between inaccessibility and muscular +resistiveness. For example, Charlotte W. (Case 12), whose condition +varied a great deal, always lost the resistiveness when she became +accessible, during which periods she also showed some facial expression. +The resistiveness would invariably return when the inaccessibility +reappeared. Caroline DeS. (Case 2) lost her resistiveness as she became +more accessible, although the inactivity and apathy persisted. This +tendency, which is quite common, suggests that muscular resistiveness +represents a lower level of expression of opposition which patients put +into words or purposeful actions when there is other evidence of some +contact with the environment. Sometimes one observes both general +resistiveness and specific acts. For instance, Mary G., who said, “Leave +me alone,” and covered her head or buried it in the pillows, accompanied +her muscular resistiveness with laughter. This shows the affective +nature of the apparently purposeless muscular tension. The case of Annie +K. (Case 5) is more instructive. In the stage of deeper stupor she had +the automatic type of resistiveness but also outbursts of anger, +particularly toward the nurses, striking one of them she said, “You are +the cause of it all.” When food was offered her, she said, “I wonder +people would not leave me alone sometimes.” Again, when her bed was +approached, she would clutch and hold the bed clothes in an apparently +aimless way as if the impulse to resist never reached its goal. +Retrospectively she could not account for her muscular rigidity on the +basis of definite ideas, and could recall only that she felt stubborn. +In a later period when more accessible, she felt cross and did not want +to be bothered. This emotional attitude was quite conscious with her, +whereas the acts and speech of the earlier period, when her stupor was +more profound, seemed more automatic and impulsive. In other words, the +resistiveness looks like a larval attempt to express an idea which is +probably not fully conscious and therefore gives the appearance of being +aimless. As another example of this we may cite the case of Pearl F. +(Case 9), who said when she recovered, “I was stubborn.” In addition to +the muscular resistiveness she had shown, she would often bite the bed +clothes or scratch herself when she was approached. Mary F. (Case 3), +while in a stupor, slapped at nearby patients quite aimlessly. When +somewhat better, this conduct appeared in a more conscious form, as +sullenness, indifference and smearing of feces (again the behavior of a +naughty child). Here one might quote Laura A. once more, whose +resistiveness when stuporous was intense but who in her manic spells +expressed her negativism in a definite idea, “I don’t want my face +washed.” + +To summarize, then, we may say that negativism is apparently the result +of a desire to be left alone, and that muscular resistiveness is a +larval exhibition of the same tendency. But the appearance of this +attitude in such aimless, impulsive acts or habits reminds us strongly +of the dissociation of affect, which was commented on in the previous +chapter. It would seem to be another example of this rather fundamental +tendency of the stupor reaction, not merely to diminish conative +reactions in general, but to reduce their appearance to that of +isolated, partial and therefore rather meaningless expression. + +3. CATALEPSY. The last of the cardinal symptoms to be considered is +catalepsy. It occurred in thirteen of thirty-seven cases, although it +was present only as a tendency in three of these. If we define it as the +maintenance of position in which a part of the body is placed regardless +of comfort, we can see that sometimes it is difficult to differentiate +from the phenomenon of resistiveness with its rigidity. It is most +frequently observed in the hands and arms, perhaps because it is, as a +rule, most convenient to demonstrate the retention of awkward positions +in the upward extremities. But any part or even the whole body may be +involved; for example, Charles O. retained standing positions even where +balance was difficult. This phenomenon is often accompanied by “waxy +flexibility,” where the joints move stiffly but retain whatever bend is +given them, like a doll with stiff joints. + +The significance of catalepsy is best studied by considering its +relationship to other symptoms and by noting remarks made by the +patients in reference to it. The most important observations which we +have made seem to indicate that it never occurs with that degree of deep +inactivity which suggests a complete lack of mentation on the part of +the patient. One is therefore forced to conclude that back of this +phenomenon there must be some purpose, some kind of an ideational +content, although this may be of a primitive order. This is demonstrably +true in some cases, at least such as that of Isabella M., who left her +arm sticking up in the air but took it down to scratch herself and then +put it back. Somewhat similarly, Charlotte W. (Case 12), when she was +shown during convalescence a photograph of herself in a cataleptic +state, said that that was when she was waiting to go to Heaven and was +afraid to move. Again she remarked, “I was mesmerized.” Josephine G., +who showed only a tendency to catalepsy, said that she feared the devil +would get control of those about her if she moved. Sometimes there is a +development of this symptom from others which seem to be ideational in +their origin. For instance, Charles O. began making flail-like +movements. These passed over into slow circular motions which finally +subsided into the maintenance of fixed position. + +References to hypnotism are not infrequent, and in many cases there is +evidence of a delusion that the posture is desired by those in charge of +the patient. Annie G. (Case 1) said so directly. In retrospect she +explained the holding of her arms in the air by saying, “I thought you +wanted me to have them up.” Henrietta B. at one examination kept her +arms raised in the position in which they had been put for a minute and +then dropped them, saying, “Stop mesmerizing me.” But she then put them +up again of her own accord and now presented intense resistance to any +motion. Later she extended her arms in front of her and said, “I am all +right,” in a theatrical manner. Some patients give evidence in other +symptoms of larval efforts at coöperation with the actual or supposed +wishes of the physician and in such cases it is not impossible that +passive movements are interpreted as orders. One must remember in this +connection that the more primitive are the mental operations of any +individual, the more important do signs, rather than speech, come to be +a medium of communication with other people. As an example of this type +we might mention Rose Sch. (Case 6), who flinched from pin pricks +(showing that she felt them) but made no effort to get away. When +somewhat clearer she said that she was “here to be cured.” Similarly +Mary D. (Case 4), who showed no catalepsy from ordinary tests, kept her +head off the pillow for a long time after it was raised to have her hair +dressed. She showed such perseveration in many constrained positions. +She too flinched from pin pricks but not only made no effort to prevent +them but would even stick out her tongue to have a pin stuck in it. + +The relationship of catalepsy to resistiveness is interesting but +unfortunately complicated and unclear. In only one of our cases was +catalepsy definitely present without resistiveness, and in one other a +“tendency to catalepsy” was noted without muscular rigidity being +observed. In this latter case, when the catalepsy became unquestionable, +resistiveness also appeared. It is one thing to note this coexistence +and another to explain it adequately. All that we can offer are mere +speculations as to the real meaning of the association of these +phenomena. It may be that the tension of muscles that occurs when +resistiveness is present gives the idea to the patient of holding the +position. There would be two possible explanations for this. We might +think there is a dissociation of consciousness, like that of hysteria, +where the feeling of tenseness in the muscles that comes from the +resistance to gravity is not discriminated from the resistance to the +movements made by the examiner. On the other hand, there might be a +similar dissociation where the perception of contraction in the +antagonistic muscles is interpreted as the action of the examiner in +placing the limb in a given position. This latter view would seem, on +the face of it, ridiculous, inasmuch as its presumes the existence of +two directly opposed tendencies, namely, those of opposition to the will +of the physician and compliance with it. But ambivalent tendencies are +frequently present in psychopathic states, and moreover we find +occasionally some evidence in the behavior of the patient to +substantiate this view. For example, at one stage of the stupor of Annie +G. (Case 1), her arm could be moved without resistance. Then the elbow +would catch and at this moment the position would be maintained. Such +observation is highly suggestive of the resistance being signal for the +catalepsy. In Isabella M. the catalepsy appeared when resistance to +passive movements also developed. On the other hand, when the resistance +became extreme, the catalepsy was reduced, and vice versa. This makes +one think of two tendencies: suggestibility on the one hand, and +opposition on the other. We might presume that when both are present and +equally strong, stiffness with passive movements results as a kind of +compromise, but when there is a greater development of one, the other is +inhibited. + +Such speculations remind one strongly of the psychology of conversion +hysteria and of hypnotism. In some cases of stupor hysterical symptoms +are quite definitely present. For instance, Celia G. began her psychosis +with hysterical convulsions which would terminate with short periods of +stupor. Later the stupor became persistent and during this stage she had +catalepsy (and restiveness as well) in her left arm only. On recovery +from her stupor she complained of stiffness in her hands, which +examination proved to be a purely hysterical difficulty. + +This whole subject is without question obscure and many more and very +careful observations are needed before really satisfactory explanations +can be given for these phenomena. That it is a reaction which is related +to the primitiveness of the mental content and the intellectual deficit +in stupor would seem to be a reasonable view, inasmuch as quite similar +phenomena have been observed in a large number of animals, even among +crustaceans. As a result of our own observations the only thing we feel +at liberty to state with real confidence is that catalepsy is presumably +a phenomenon mental in origin rather than somatic, because it always +occurs in conditions which show other evidence of mentation. + +Whatever may be the origin of the idea of the posture assumed, there can +be little doubt that its indefinite maintenance is a phenomenon of +perseveration. The conception of the position being in the patient’s +mind, it is easier to hold it than elaborate another idea. This, of +course, is part of the intellectual disorder in stupor. In fact, it is +difficult to imagine any one whose critical faculty was functioning +coöperating in a test for catalepsy. + + + + +CHAPTER VIII + +SPECIAL CASES: RELATIONSHIP OF STUPOR TO OTHER REACTIONS + + +We have described typical cases of benign stupor and isolated certain +interrelated symptoms which, when they dominate the clinical picture, we +believe establish the diagnosis of stupor, regardless of the severity of +the reaction. These symptoms are apathy, inactivity, a thinking disorder +and, quite as important as these, an absorbing interest in death. It is +typical that the patient contemplates his dissolution with indifference +or, at most, with mild or sporadic anxiety. There seems little reason to +doubt that when these four symptoms occur alone, we are justified in +making a diagnosis of stupor. The next problem is to consider the +meaning and classification of cases where these symptoms occur in +conjunction with others. This naturally introduces the subject of +relationship of stupor to other manic-depressive reactions. + +It is probably best to begin with presentation of three such cases. + + + CASE 16.--_Anna L._ Age: 24. Admitted to the Psychiatric + Institute August 21, 1916. + + _F. H._ Maternal grandmother temporarily insane during + illegitimate pregnancy, thereafter a little odd. Mother + high strung and emotional. Father high strung, impulsive + and irritable. + + _P. H._ As a child she was quick tempered, quite a spitfire + and given to tantrums. At the age of 14 she became a + vaudeville actress in Cleveland, which was the home of her + childhood. When 17 she married a Jew, although she was + herself a Catholic. Her husband noted that she was fretful, + sensitive, resentful and quick tempered, although apt to + recover quickly from her rages. Previously healthy, + neurotic symptoms began with marriage, taking the form of + stomach trouble and a tendency to fatigue. Shortly after + marriage an abortion was induced. After being married for + two years she had a quarrel and separated from her husband. + They were reconciled later, but in the meantime she had + been having relations with another man. When 20 an + abdominal operation was performed in the hope of relieving + her gastric symptoms, but no improvement occurred. The + patient after recovery stated that she continued to be + nervous, shaky and dizzy, at times trembling when going to + bed at night. Two years later, however, she took up + Christian Science and showed objectively some improvement + in her health, although according to her later accounts she + continued to feel somewhat nervous and fatigable. Her + husband stated that at this time she also began to ponder + much about such questions as the difference between life + and death, what “matter” was, and also studied “grammar” + and “etiquette.” According to the patient some five or six + months before admission she began to have peculiar + sensations following intercourse--a feeling of bulging in + the arms, legs and back of the neck. One evening after an + automobile ride there were peculiar sensations on her right + side like “electricity” or as if she were inhaling an + anesthetic. She gasped and thought she was dying. Two + months before her admission she went with her husband and + his family to a summer resort where she felt increasingly + what had always been a trouble to her, namely, the nagging + of this family. + + Just before her breakdown, because she went daily to the + Christian Science rooms in order to avoid the family, they + suspected her of immorality and accused her of going to + meet other men. Even her husband began to question her + motive. Retrospectively the patient herself said that she + now felt she was losing her mind and did not wish to talk + to any one. At the time she told her husband that she felt + confused and as if she were guilty of something and being + condemned. Repeatedly she said she knew she was going to + get the family into a lot of trouble. Once she spoke of + suicide, and for a while felt as if she were dying. Finally + she became excited and shouted so much that she was taken + to the _Observation Pavilion_, where she was described as + being restless and noisy, thinking that she was to be + burned up and that she had been in a fire and was afraid to + go back. + + _On admission_ she looked weary and seemed drowsy. + Questions had to be repeated impressively before replies + could be obtained, when she would rouse herself out of this + drowsy state. She seemed placid and apathetic. She said + that nothing was the matter, but soon admitted that she had + not been well, first saying that her trouble was physical + and then agreeing that it had been mental. When asked + whether she was happy or sad, she said “happy,” but gave + objectively no evidence of elation. Her orientation was + defective. She spoke of being in New York and on + Blackwell’s Island, but could not describe what sort of + place she was in, saying merely that it was “a good place,” + or “a nice country place,” again “a good city.” Once when + immediately after her name L. had been spoken and she was + asked what the place was, she said “The L.” She knew that + she had arrived in the hospital that day but said that she + had come from Cleveland, and to further questions, that she + had come by train, but she could not tell how she reached + the Island. She claimed not to know what the month was and + guessed that the season was either spring or autumn + (August). She gave the year as 1917, called the doctor “a + mentalist,” and the stenographer “a tapper,” or “a mental + tapper.” She twice said she was single. When asked directly + who took care of her, said “Mr. Marconi,” who she claimed + at another time had brought her to the hospital. To the + question, who is he? she replied, “Wireless,” and could not + be made to explain further. That night she urinated in her + bed, and later lay quite limp, again held her legs very + tense. + + For five days she remained lying quietly in bed for the + most part, although once she called out “Come in, I am + here,” “Jimmie, Jimmie” (husband’s name). Several times she + threw her bed clothes off. Otherwise she made no attempt to + speak and took insufficient food unless spoon-fed. At one + examination she looked up rather dreamily but did not + answer. When shaken she breathed more quickly and seemed + about to cry but made no effort to speak. When left to + herself she closed her eyes and did not stir when told she + could go back to the ward. She was then lifted out of her + chair and took a step or two and stopped. Such urging had + to be repeated, as she would continue to remain standing, + looking about dreamily, although finally when taken hold of + she whimpered. When she got to the dining-table she put her + hand in the soup and then looked at it. So far there is + nothing in this case atypical of what we would call a + partial stupor. The cardinal symptoms of apathy, + inactivity, with a thinking disorder, are all present and + dominate the clinical picture. There is, further, the + history of a delusion of death during the onset of the + psychosis. Had her condition remained like this, there + would be no difficulty in classifying the case, but other + symptoms appeared. + + Five days after admission she was restless, somewhat + distressed, and announced that she wanted to talk to the + physician. When examined, the distress, with some + whimpering, continued. She asked the doctor not to be harsh + to her, frequently said there was something wrong and began + to cry. A normal interest appeared only once, when she + spontaneously said she wanted to see her relatives. A most + interesting feature, however, was a certain perplexity that + now appeared. She spoke of this directly: “I do not know + what it is all about. I know you are a doctor, that is all. + I don’t know whether I passed out and came back again or + what--I don’t know what to make of it.” She also felt + confused about her marriage--“There is where all the mixup + is. I was married when I was 16.” She was reminded that she + had said she was single, and replied “I am single.” Then + where is your husband? she was asked. “He must be dead.” + She recalled the examination on admission and remembered + some of the questions that she was asked then, also knew + that she had been at the Observation Pavilion and that she + had reached this hospital by boat. On the other hand she + still claimed that the year was 1917, and in connection + with the delusion of having died was quite unclear as to + the time. She said that it seemed as if she had died many + years ago and that she had come to the hospital years ago. + She also spoke of having died at a summer resort the year + before. When asked for her age, she said that she must be + very old, but on the other hand claimed that she was + supposed to die and to come to the hospital when she was 26 + (two years more than her actual age). + + Her psychosis continued from then on for about ten weeks. + She soon began to feed herself, but otherwise for most of + this period remained quietly in bed, looking about a good + deal, although showing no particular mood reaction until + questioned, when she was apt to make repeated statements + about her perplexity--that she did not know what it was all + about, every one had mixed her up, everything was so + strange, “my head is mixed up, I am trying to straighten + things up.” She frequently when interviewed became + lachrymose and often with her subjective confusion there + was considerable anxiety. Another unusual phenomenon for a + stupor patient was that she was frightened at a thunder + storm. On the whole, however, her apathy and indifference + were quite marked. For instance, during the latest phase of + her psychosis, when the nurses would sometimes make her + dance with them, she did so but without showing any + interest and not until immediately before her recovery did + she begin to speak spontaneously to any extent whatever. A + marked difference from the ordinary stupor was that this + apathy was invariably broken into when she was questioned + and ideas came to her mind, the nature of which seemed to + be essentially connected with her perplexity. + + Not only did ideas appear more frequently than one meets + them in stupor cases, but they were present in greater + variety. The dominant stupor death idea was, it is true, + almost constantly present, but it did not come to the + direct and unequivocal expression which we are accustomed + to see in typical stupor. She did not say “I am dead,” or + “I was dead,” but it was always “It seems as if I were + dead,” or “I think I must have died,” or some such dubious + statement. Other ideas were that her mother was dead and + had been put into a box. She frequently gave her maiden + name and said that she lived in Cleveland with her mother + and that this was Cleveland. At times she thought she was + engaged and was going to be married to her husband shortly. + Again there were notions that her husband had married + somebody else or that some harm was going to come to him. + Sometimes she thought that her mother’s name was her own, + that is, Mrs. L. The hospital once seemed like a convent to + her. + + Her subjective and objective confusion seemed quite + definitely to be connected with the insecurity and + changeability of these ideas. It appeared as if insight and + delusion were struggling for mastery in her mind, so that + reality and fancy were alternately, even simultaneously, + possessing her, and that this gave her the feeling of + perplexity from which she suffered. Once when she remarked + “It seems as if I had been dead all the time,” she was + questioned more about this and replied, “Well, sometimes I + thought I was dead, at other times it seemed as if I + wasn’t.” In answer to a direct question about her feeling + of confusion she said “I don’t know. I know I have lots of + good friends, they all want to help me and it seems as if + everything got mixed up between the L.’s (her married name) + and the G.’s (her maiden name).” This was apparently an + elaboration of the wavering ideas she had about her + singleness or her married state. Once after referring to + her husband as her sweetheart whom she was to marry, and + immediately thinking that perhaps he had married somebody + else, she added, with a sigh, “The more this goes on, the + more mixup.” In short, any question, even on some + apparently neutral topic, seemed to start up conflicting + ideas in her mind, the inconsistency of which she + recognized without being able to control their appearance. + Hence, whenever she was spoken to, she became perplexed and + distressed. + + Her orientation gradually improved so that, although it + remained vague, it was no longer glaringly inaccurate. Then + quite suddenly she one day came to a nurse and asked how + long she had been in the hospital. When told, she remarked + that it seemed as if she had spent the whole winter there. + She was examined at once and found to be quite clear and at + first in good control of her faculties. She remembered a + good many of her ideas, in fact was able to elaborate a + little from memory on what had already been reported from + her utterances during the psychosis. The recovery was not + immediately complete, however, for at this examination, + when told that she had constantly given her maiden name, + she became distressed and said the physician was trying to + mix her up and was reluctant for this reason to discuss her + ideas. This soon passed, however, and within a few days + she was quite normal and had remained so for some months + after her discharge from the hospital, when last seen. In + fact, according to the husband, she was in better mental + and physical health following the psychosis than she had + been for years. + +Essentially, then, this case shows what was at first a typical partial +stupor, but soon became complicated by a tendency for questioning to +provoke rather a free flow of ideas and a distressed perplexity. This +symptom of perplexity soon grew to dominate the clinical picture, so +that the psychosis was really a perplexity ushered in by a brief stupor +reaction with a background of stupor symptoms running through it. The +second case shows similar tendencies but different from the one whose +history has just been cited in that the perplexity was never complained +of by the patient herself and that her emotional reactions were more +marked and varied. + + + CASE 17.--_Celia C._ Age: 18. Admitted to the Psychiatric + Institute May 2, 1914. + + _F. H._ Four years after this attack her mother was a + patient in the hospital with an atypical manic-depressive + psychosis from which she apparently recovered. + + _P. H._ The patient herself was described by superficial + observers as being bright, sociable, well-informed and very + ambitious. + + When 18 years of age she was working very hard preparing + for some examinations, and worried lest she should fail in + them. Some years later the patient accounted for her + psychosis by saying she had a quarrel with her sister, + immediately after which she began to feel depressed. The + anamnesis states that she was slow, complained of not being + able to think and feeling as if she had no brain. She was + sent to a general hospital, where she was apprehensive, + wanted her mother to stay with her and one night called out + “Mother.” + + The case being recognized after a few days as a psychosis, + she was sent to the _Observation Pavilion_, where she was + described as jumping about in bed in a jerky, purposeless + manner, resistive when anything was done for her, and mute. + Her sister reported that when she visited her the patient + said “Go away, I am dead.” + + _On admission_ she looked dazed, stared vacantly and had a + tendency to draw the sheet over her. When put on her feet + she let herself fall limply. At times she became agitated, + sobbed and cried loudly, especially when attempts were made + to examine her physically, or, when she was asked + questions, she scarcely spoke. + + Her psychosis lasted but a little more than three months + under observation and was characterized by the following + symptoms: She was usually in bed, staring blankly or + appearing otherwise quite indifferent and apathetic, but + not infrequently, especially during the first few weeks, + she was quite restless, resistive, whined and suddenly + appeared startled or distressed with no occasion for this + reaction in the environment. Rarely she was suddenly + assaultive. When attempts were made to examine her, she was + frequently mute or would repeat the question with a rising + inflection, not getting anywhere, or would say, “What shall + I say,” or “I, I----” never finishing her sentence. After + orientation questions she might say “This is--this is--this + is----” all this, together with a rather perplexed + appearance, gave the impression of considerable + bewilderment, but at no time did she complain of + autopsychic perplexity. It was difficult to judge of her + orientation on account of her failure to answer questions, + but it soon appeared that she knew the names of the nurses, + for she sometimes called them spontaneously by name. She + always ate reluctantly. + + During these examinations, however, other symptoms often + appeared. When she was talked to, she was apt to indulge in + depressive statements and show considerable distress. Such + remarks were: “I must confess my guilt,” “I am a bad girl + and I have to face my guilt,” or “I have sinned,” or, + standing up with a dramatic air, “I must stand up and tell + the truth.” Once she said, “It is too late to live now.” + She spoke of having lied and usually would not say what + about, but once on questioning replied “I said I would not + tell what happened here.” She was asked, What do you mean? + and answered “I took my oath not to tell anything.” Pressed + further she said that the nurses poisoned her. Another time + she said she was in prison. To her aunt who visited her she + said, “I am a prostitute,” and once she remarked to the + doctor, “I have killed my honor,” and on another occasion + in the middle of the night she called out, “Chinatown + Charlie, come here.” She thought the doctor was her + brother. + + Most of these statements were associated with painful + emotion, but there were a few occasions when an element of + elation cropped out. Thus on one occasion she laughed, + another time gripped the doctor’s pad and tried to read it. + When the nurse laughed, she made a funny grimace at her and + said “Why do you laugh?” Again she once sang two songs, but + after the first verse got stuck and kept repeating one + word. + + At the end of three months she improved rather rapidly and + was in a condition for discharge as “recovered” a month + later. Retrospectively she said that she recalled feeling + guilty, thinking that her mother was dead, having been + killed by the patient as a result of worrying over the + latter’s failure in her examinations and refusal to eat. + She remembered, too, that at times she thought the building + was burning. Some things like “Chinatown Charlie” she + denied remembering, although she had a good recollection + for the external facts throughout the psychosis. Her + insight was superficially good, but she was reluctant to + discuss her psychosis, in fact claimed that she had been + made more of a lunatic by coming to the hospital than she + was on admission. + + Some five years later she had another somewhat similar + attack, again following a quarrel, this time with a fellow + employee. In this second psychosis, however, manic elements + were much more prominent. + +Here again, then, we have the symptoms of apparent apathy, inactivity, +and similar ideas of death, but the thinking disorder was possibly not +very profound, inasmuch as she had a good memory for external events. +Her ideas, too, are much more florid than those which we customarily +meet with in stupor cases, but the most marked peculiarity was that +this “stupor” was liable to constant interruption, either spontaneously +or as a result of questioning, which always produced a mood reaction. +She was apathetic only so long as she was left alone. In other words, +whenever an effort was made to test what seemed to be apathy, the +evidences of it disappeared. + +The third case to be considered is somewhat like that of the first, Anna +L. (Case 16), in that with the inactivity and apathy there was a +coincident subjective perplexity. The apathy, however, was less marked +than in the case of Annie L. + + + CASE 18.--_Catherine M._ Age: 24. Admitted to the + Psychiatric Institute November 10, 1913. + + _F. H._ Information as to the family is confined to the two + parents. The mother, who was frequently seen, seemed to be + a natural, sensible woman. The father, on the other hand, + had been alcoholic all his life, had had two convulsions + while drinking, and had little respect from any member of + the family, including the patient. + + _P. H._ The patient was said always to have been healthy, + from a physical standpoint, although never robust. She got + on well at school, and then worked first as a stock girl + and later as clerk in a department store, where her work + was efficient and she advanced steadily. As a child she + played freely with other girls but little with boys. As she + grew older she moved about socially a little more, made the + acquaintance of men as well as of girls, but never cared + much for the former and had no love affairs until she met + her husband. She was never demonstrative but always rather + quiet and modest. Occasionally she spoke of thinking that + people talked about her, but the informant doubted if she + brooded over this, because she was not of a worrying + disposition. Considering the ideas which appeared in her + psychosis, it is striking that in her normal life she was + rather antagonistic towards her father on account of his + alcoholism and the crudity of his speech and manners. + + When she met her husband she liked him from the first, + although she at no time became really demonstrative. They + were engaged for a year, during which time she agreed to a + postponement of three months for the marriage, which was + suggested by her mother. For some time before this event + she was working harder than usual and seemed a bit worn + out. She ceased working a month before marriage and + improved physically, although she became rather nervous, + that is, she was more easily startled, an accentuation of + what had been a characteristic for some years. Her husband + stated that at this time she became fearful of the + approaching marriage relations and asked him to be kind to + her in this respect. She was married a year before + admission. For two and a half months she refused + intercourse and visited her mother’s home a great deal. She + finally submitted. She was quite frigid but became pregnant + at once. Her abnormality then became apparent. She kept the + fact of her pregnancy to herself for several months and + then when she told her mother wanted to have an abortion + performed. Neurotic symptoms appeared. She became sensitive + with her husband, correcting his grammar, and cried easily. + She also began to be anxious about the approaching + childbirth, and with this became more religious. + + For the first few days after the delivery, she was fussy + with the nurse so that two in succession had to be + discharged. On the fifth day she woke up and seeing a nurse + lying on the couch beside her bed thought the latter was + colored. On the seventh day she had a dream in which she + thought she “nearly died in childbirth.” Then she began to + talk of dying for her baby or of having two babies, of + dying herself and rising again after Easter Sunday. She + became antagonistic to her husband and with this excited + and confused so that she was taken to the Observation + Pavilion. + + On _admission_ she looked pale and exhausted, had a slight + temporary fever and a coated tongue. Her orientation was + usually vague but sometimes she gave fair answers. Her + verbal productions were rather fragmentary and with the + exception of some repetitions there did not seem to be any + special topics which dominated her train of thought. + + For some days the great weakness and the slight fever + continued, and then, as it gradually cleared up, there came + a change in her mental condition that settled into the + state which characterized the rest of her psychosis. She + talked less and was often quite inactive, frequently lying + with her eyes closed for long periods, or sat or stood + about. Such movements as she made were slow and languid. + Her expression was either blank, absorbed, or gave the + appearance of peculiar appealing perplexity. This last was + not infrequently associated with a rather sheepish smile. + She was never resistive and always ate and slept well. With + the exception of a few times she did not soil herself. The + most interesting feature of her mood reaction was that in a + general setting of a slight perplexity there appeared at + times and evidently associated with definite ideas, changes + in her emotional state. Sometimes this was a matter of + distress or of mild ecstasy, sometimes she became markedly + blocked. There was at no time any frank elation, but often + an appropriate smile, that is, appropriate to the situation + and to the thought to which she was giving expression at + the time. Then, rarely, there were sudden bursts of + peculiar conduct, such as throwing herself on the floor or + running down the hall. When questioned as to her motive for + these acts, she would flush, look perplexed and apparently + be unable to explain them. + + Her verbal productions dealt with a rather limited range of + topics which can be briefly summarized. As in the other + cases, the reader will notice that the bulk of these ideas + are of a kind not usually prominent in the typical stupor + cases. Many of her thoughts seemed centered around her + husband. She always knew him when he visited her, but in + her thoughts there was a constant change as to his + personality. She persistently confused him with the + physicians, with her father, and with God, and one remark + is typical, “I thought he was God, priest, doctor, + lawyer--well, I wanted to go to Heaven; I thought he would + still be my husband; I always hoped that I would be home in + Heaven.” Not unnaturally with this confusion there were + doubts about her marriage. People said her marriage was + wrong and her husband bad. Frequently she thought he was + dead, or voices informed her that she was not married to + him, or that he was the devil in Hell. In this connection + she also said that people called her a whore, or it seemed + as if she were accused of not being married. + + As prominently as appeared the ideas of the invalidity or + impossibility of her marriage, to the same extent did her + father assume an important rôle for her. As a rule he + appeared in religious guise as God, but often he was the + doctor--“I knew my father at home and my father in Heaven; + which God do you mean? did you say God or father?” At times + she spoke of being in Heaven and that God seemed to be God, + doctor or priest. In this connection there were ideas of + being under the power of some one, God, devil or father. + + As is usually the case where strong interest is expressed + in the father, ideas of the mother being dead occurred, + although in the frankest form she reported them as dreams; + for instance, one night she woke up screaming, said that + she had dreamed that her mother was dead and her sister + dying. That, in the psychoanalytic sense, this represented + a removal of a rival, making union with her father easy, + appeared in the statement that her father was dead but that + she had dreamed he had come to life again for some one + else. When asked what she meant, the question had to be + repeated several times, then she said “My mother died, my + father and mother had a quarrel.” There is more than a + suggestion here of a difference in the significance of + death, in so far as it concerned the two parents. The + mother dies and remains dead, that is, she is gotten rid + of. The father dies but takes on a spiritual existence and + comes to life again, a frequent method in psychoses for + legitimizing the idea of union with the parent by + elimination of the grossly physical. + + There were strikingly few allusions to the plainly sexual. + She spoke of being married to the doctor, and even went so + far as to say that they belonged together in bed. On + another occasion she called him “darling.” Once she + reported that it was said that she was going to have babies + and babies and babies. These references were, however, + quite isolated, so that the erotic formed a very small part + of her productions. + + Delusions of death, we have seen, are the most constant + content of true stupors. In this case they were present but + distinctly in the background. She spoke quite frequently of + being in Heaven. She also talked of being crucified. Once + she said “I died but I came back again.” This last + utterance was rather significant in that frankly accepted + ideas of death were unusual; for instance, she would say + sometimes, “I think I am in Heaven, again not. It confuses + me, but I know I am in Heaven.” + + In general, then, her ideas were, on the whole, not at all + typical of stupor but much more like those met with in + other manic-depressive conditions. Correlated with this was + an unusual mood picture. Quietness and apparent apathy of + the patient were interrupted by little bursts of emotion, + and throughout the psychosis there was a coloring of + perplexity. Not only was this last objectively noticeable, + but she spoke very frequently of it and always in + connection with the inconsistency of the ideas in her mind + which puzzled her. For instance, in speaking to the doctor + she said “I think of you as Bill (her husband’s name) + sometimes--I get confused thinking of Bill as God, doctor, + lawyer, priest.” Again, referring to her husband, she made + these curious statements: “They seemed to speak of him as + being in the wrong--the right--it seems that the right + devil is the wrong one for me--they say he is not the right + one for me; they say he went wrong from the time we were + married.” Again, she said that she did not know who her + father was, and went on: “It puzzles me, this father + business, I knew my father at home and my father in + Heaven.” Again, “Which God do you mean? Did you say God or + father?” A hint as to how this subjective confusion made + the environment seem uncertain comes from the statement, + “You looked like the devil and yet you were God.” + + Distress and anxiety appeared not infrequently and always + appropriately. The distress was usually occasioned by an + idea of injury to others, as when she cried over the + fancied accusation of drowning her husband and mother; or + in connection with accusations of herself, such as when she + reported “They called me a whore.” As has been stated, + there was never any frank elation, but an element of + pleasurable expansive emotion was frequently present in + connection with her religious utterances. This came + particularly when she spoke of union with her father as + God. She seemed to swell with ecstatic emotion. It was + especially well marked once when she threw herself on the + floor and when asked what she was trying to do replied, “I + want to do what God wants me to do, drop dead or anything + at all.” Perhaps the most unusual affective reaction was a + blocking which occurred when certain topics appeared. This + is a phenomenon quite unusual for stupor, where speech + seems to stimulate and arouse the patient as a rule. One + got the impression that ideas tended to come into this + patient’s mind which were painful enough to disturb her + capacity for connected thought. A good example of this + reaction was when she was speaking of her father having + died and coming to life again. On being asked what she + meant, she became quite blocked and the question had to be + repeated several times, when finally the apparently + unrelated statements appeared: “I dreamed my mother + died--they had a quarrel.” Who had a quarrel? she was + asked, and replied “My mother and father.” Apparently her + thinking about her father coming to life for some one not + her mother stimulated deeply unconscious ideas concerning + the separation of her mother and father, and her taking the + mother’s place, and these ideas were sufficiently + revolutionary to upset her capacity of speech for the time + being. + + She recovered completely about six and a half months after + her admission. + +If we consider together the common features of these three cases, we see +that they resemble stupors only in the presence of inactivity and +apparent apathy. It is true that death appears in the ideational content +but not with that prominence, bordering on exclusiveness, which +characterizes such delusions in the true stupors. These three patients +give one the impression of being absorbed in thoughts that have many +variations. It seems as if they had difficulty in grasping the facts of +the environment, while feeling at the same time the vividness of the +changing internal thoughts, hence a confusion develops which is either +subjective, objective, or both. It is probably the introversion of +attention which gives rise to the apparent apathy, because normal +emotions emerge as part of our contact with reality around us. This lack +of contact with the environment leads also to inactivity. If one’s +attention and interest is turned inwards, there can be no evidence of +mental energy exhibited until the patient is roused to contact with the +people or things about him. It is noteworthy that in these cases +emotional expression emerged when the patients were stimulated to some +productiveness in speech. + +These conditions really constitute a different psychosis in the +manic-depressive group, essentially they are perplexity states such as +have recently been described by Hoch and Kirby.[7] Not infrequently we +see exhibitions of this tendency in what are otherwise typical stupors. +For example, Mary F. (Case 3) (the third case to be described in the +first chapter), showed for a few days after admission a condition when +she was essentially somewhat restless in a deliberate aimless way. At +the same time she looked dazed or dreamy. With this restlessness she +appeared at times “a little apprehensive.” Although she spoke slowly, +with initial difficulty she answered quite a number of questions. Her +larval perplexity was evidenced by the doubt expressed in a good many of +her utterances, such as, “Have I done something?” “Do people want +something?” “I have done damage to the city, didn’t I?” When asked what +she had done, she said, “I don’t know.” She asked the physician, “Are +you my brother?” and when questioned for her orientation said, “Is not +this a hospital?” The atmosphere of perplexity also colored the +information which she did recall correctly; for instance, when asked her +address, she said, “Didn’t I live at ----?” then giving the address +correctly. + +As stated in Chapter V dealing with the ideational content of stupor, +one has to look on the delusions of patients as symptoms subject to +analysis and classification just as truly as the variations in mood or +intellectual processes, in fact they should be subject to the same +correlation as are the mental anomalies which are usually studied, +particularly if we are to understand these psychoses as a whole. Let us, +therefore, consider the death ideas in the three cases studied in this +chapter. We find that, as in the ordinary stupors, there are delusions +of death, also of mutual death (with the father), but there is a +tendency to elaboration so that the death is only part of a larger +Œdipus drama, the rest of which is usually lacking in stupors. Here +it is present. So we have thoughts of the death of the mother or +husband, another rival, considerable preoccupation with Heaven, and also +erotic fancies. + +We find in manic-depressive insanity a tendency for more or less +specific ideational contents with different types of the psychoses.[8] +For example, there are religious and erotic fancies or ambitious schemes +dominating the thoughts of manic patients, fears of aggression and +injury met with in anxiety cases, and so on. In stupors, death seems to +be a state of non-existence with other meanings lacking or only hinted +at occasionally. When it tends to be elaborated, it leads over to +formulations suggesting personal attachments and emotional outlet, and +then we are apt to find interruptions of the pure stupor picture. For +example, Charlotte W. (Case 12), whose case has been described, thought +much about being in Heaven and ended with a hypomanic state. Atypical +symptoms appear just as constantly in these cases, as do the atypical +ideas. In other words, the thought content is definitely correlated with +the clinical picture. + +As the clinical pictures show the relationship of stupor to other +psychoses, so there is also a correlation with varying formulations of +the death fancy. We are now in a position to define more narrowly what +death means in stupor. It is an accepted fact, a Nirvana state. When +death means union with God or appears in other religious guise, manic +symptoms tend to develop. When it is unwelcome and appears as “being +killed,” we find anxiety symptoms. A patient can conceive of death +variously and have various clinical pictures. A knowledge of the +metamorphoses of ideas and their relationship to other symptoms enables +us to understand such cases, that, without this key, seem confused and +lawless jumbles of symptoms. Such theories tend to justify the view of +essential unity of the manic-depressive group. + +It would be instructive at this point to consider another case which +illustrates beautifully how a stupor reaction may crystallize out of +other manic-depressive states when attention has become focused on +personal death. This patient went through four phases while under +observation. First, while showing a perplexed expression but with fair +orientation, she gave utterance to erotic and expansive fancies. She was +restless, somewhat intractable and gave the impression of brooding over +her imaginations rather than luxuriating in them. In other words, her +condition seemed to be more that of absorbed than active mania. Second, +these same ideas, somewhat reduced, continued in an apathetic state +while impulsive symptoms developed: She began to shout like a huckster +to be taken to Heaven and made numerous affectless, suicidal attempts. +Third, came a true stupor and, fourth, a period of recovery when the +stupor symptoms all disappeared but insight into the falsity of her +ideas was lacking. + + + CASE 19.--_Celia H._ Age: 19. Admitted to the Psychiatric + Institute October 22, 1913. + + _F. H._ The father was living; he always drank, and + especially in later years contributed little to the support + of the family. The mother was living and said to be + normal, while a brother was coincidentally insane, with a + recoverable psychosis. + + _P. H._ The mother stated that the patient was bright at + school, enjoyed company and going out, had a droll wit, was + not at all seclusive, no dreamer, helped to support the + family and was efficient. She was very much attached to her + brother and once said that if anything should ever happen + to him she thought she would die. She also cared much for + her older sister, with whom she worked, and for her mother. + + Three months before the patient’s admission her brother + became depressed, mute, seemed worried, cried at times. He + was sent to the country. Two months before admission, when + the mother and the patient went to bring the brother to + town, and while they were at the station, he suddenly tried + to throw himself under a train but was restrained just in + time. The patient appeared intensely frightened, but did + not talk. In fact, she seemed somewhat bewildered and at + once became dull. “Her movement and manner were much as at + present.” + + When the patient was able later to give a retrospective + account of the onset, she claimed that for some months + before this incident she saw that her brother was losing + his mind. She worried about this as well as about her work, + and felt worn out. She said that when the brother tried to + throw himself under the train she was terrified and could + not speak or move, and that her mind got upset at once, “I + lost my memory.” The others forgot her and left her alone + on the platform. Strangers put her on another train and she + knew nothing until she arrived at home. + + The mother added that at the time when the incident with + the brother happened, the patient was menstruating and that + this ceased at once. + + At home she sat about inactive and did not seem even to + worry. Whenever any one asked her about her brother she + replied that he was dead. For two weeks before admission + she said she was rich, that she owned all the property + around. She also said she was married to Mattie S. In this + connection the mother says that a foolish neighborwoman, + the mother of Mattie S., told the patient since her + sickness, by way of encouragement, that she should marry + her son (the man mentioned). Finally, the patient also + expressed the idea that her mother was a stranger, that her + real mother was dead. + + At the _Observation Pavilion_ she was described as + wandering about in a perplexed manner, restless, resistive, + answering few questions and in a low tone. She said things + were “changed,” also that she was married to S. + + _Under Observation:_ 1. For about ten days the patient’s + condition may be described as follows: The most striking + feature was a certain restlessness with insistence on going + out, with complaints that this and that had been done to + her and with senseless struggling when interfered with. But + all the motions were slow, the whole restlessness aimless + and impulsive. Although the facial expression was somewhat + perplexed, it changed remarkably little, and whenever asked + whether she felt worried or anxious she denied it, and, + indeed, there was only a suggestion of perplexity in her + face. + + The ideas which she expressed during this time referred to + a few topics only, namely, marriage, wealth, and State + prison. The remarkable fact was that all the ideas about + marriage and wealth were spoken of, often immediately, + again after some interval, now in the positive and again in + the negative sense. Thus she said she was “Mrs. S.,” again + “You kept me from marrying Mattie S.,” or “I am not + supposed to be here--I am a married person,” but also “You + kept me from getting married.” Or, “Take off that black + dress, I am a bride,” again “You have taken my bridal crown + off my head,” “The steamboats (seen from the window) are + mine--I own the ships, the oceans, the land and + everything,” or again, she said she owned a kingdom, was + Sh.’s wife, a wealthy woman, had millions. Sometimes she + connected the millions with Sh. “Sh. has millions.” On the + other hand, she said: “I owned all this before I came. I + have nothing now,” or “You have taken the regal crown from + me,” “You have made a pauper of me,” “They did it again, + they took my millions away,” or “Let me out, they are + taking my millions.” + + Other ideas throughout this period were that this was a + State prison, that “bums” were around. On one occasion she + said “You can’t put down all these things and make me out a + lunatic.” At another time she pulled a patient’s hair and + then said without fun: “I fixed the leading lady of the + dump--she knows a lot, but she does not know enough to + keep her soup cool.” When questioned about this woman (who + at the time while cleaning had moved the furniture), she + said: “I don’t know where I am at.” + + The orientation during these days was not markedly + disordered, when one got down to it. Although she spoke of + State prison, it was always found she knew the name and the + location of the hospital, the names of people around her, + even the date approximately, though she was apt to say it + was February 19, 1492, or October 19, 1492, or when the + year was not given as 1492 she said it was “1900 or 1901, + or 1911 or 1912.” Frequently, however, it was hard to hold + her attention. + + Finally, it should be mentioned that she very often wet + herself in bed or when standing, even when standing in the + examining room. + + 2. The period following and lasting for two months may be + given in the form of abstracts of each note. + + _November 7:_ Yesterday quiet, though struggling. Says + without change of expression, “I saw four people killed--my + mother, my brother, a priest, and my dear sister--we were + all killed.” Again, “I don’t know where I am,” “I am an + orphan, my people died” (without affect). + + _November 20:_ More quiet recently, says little, but tries + to get out when brought to the examining room, but when not + prevented walks slowly about as before, says she wants to + go home. Looks peculiarly blank. + + _November 23:_ Has remained quiet, says she is Dr. M.’s + wife. But when told she is not married, she agrees. Her + attitude towards the doctor is not changed, but when the + nurses talk to him, she has tried to prevent it. + + _December 6:_ Has remained quietly in bed, gazing about. + Slow in motion. She has spoken of being Dr. M.’s wife, + again President Wilson’s wife, again “Vincent (brother) is + the ruler of the world.” + + At interview says little, seems abstracted, answers briefly + in low tone. (Does anything bother you?) “No.” (Are you + natural?) “Yes.” (Who are you?) “C. H.” (correct). (You + said you were the President’s wife?) “No.” (Are you + married?) “No.” (You talked about the kingdom?) “I own the + kingdom” (affectlessly). (Where is Vincent?) “Here.” (Have + you heard him?) “Yes.” (What did he say?) “Nothing.” (Is + he all right?) “Yes.” (Where is your mother?) “Home.” (Why + don’t you go home?) “I can’t.” (Why not?) “I can’t.” (Why + not?) “The family tree is broken, the Cardinal.” (What + about him?) “Nothing.” (Retrospectively she said later she + thought her brother was a cardinal.) + + _December 8:_ When her mother visited her she said “It is + about time you come--I thought you were dead.” Has walked + down the hall “looking” for her dead cousin. When asked if + she wanted to see her brother, said, “Ain’t he dead?” + + _December 12:_ Cries out in an affectless tone like a + huckster, “Father MacN., take me to Heaven,” repeating this + over and over. + + _December 15:_ Quiet as a rule, then for a time at the + door, pulling at it and with whining voice but affectlessly + saying “Give me the key--I want to go to the river--you + can’t keep me from Heaven--it is either Heaven or the + river, give me the keys, give me the keys, open the door,” + “The niggers are taking possession.” To the physician to + whom she had claimed to be married, often repeats “You + don’t belong to me, I don’t belong to you.” (What about the + niggers?) “A band of niggers, that is all they are.” (Are + the nurses niggers?) “That is all they are.” Asked about + her people, she says “They are in Heaven.” (Where are you?) + “I am in Heaven” (without change of expression). Again, + when asked where her people are, says “At home.” Then she + went willingly back to bed and was quiet. In the afternoon + she again went to the door and tried to get out. When + questioned, she said “I don’t want to be an animal,” + “Everybody is making an animal of me” (pointing to an + animal picture). Then again, while trying the door, repeats + in the same affectless manner that she wants to go “to the + river,” “to the bottom of the river,” “to Heaven to see my + mother.” This last was said in a whining tone, with some + tears. She kept turning the knob, tried to get the keys, + and struggled impulsively when prevented. + + _December 23:_ Though quiet on the whole, when a visitor + came yesterday, she ran after this woman saying “I want my + generations,” and clung to her, and to-day at intervals + keeps talking about wanting to see her generations but is + often quiet. (Retrospectively she said she wanted to see + all her ancestors from the beginning of time.) + + _December 27:_ Of late often talks affectlessly about + wanting to die or wanting to go to Heaven, struggling + impulsively to get medicine away from the nurses, asking + for poison, trying to drink her own urine, or even the + fluid in the bed pan after she had been given an enema, all + evidently with suicidal intent. + + _December 28:_ Still constant, impulsive and apparently + affectless attempts at suicide, tries to get medicine away + from nurses, to get the fire extinguisher bottles, a bottle + of ink, etc., struggling when prevented. + + But when examined quiet, even smiles at a joke. When + questioned, denies feeling either worried or depressed. She + said she wanted to go home. She gave poor attention to the + questions. Later she threw a wet sheet over a patient and + laughed (this is rare). Later she slapped another patient. + Again she began to talk about wishing to go to the grave. + Calls Dr. M. “Uncle John.” + + _December 30:_ Talks either about wanting to die, or + wanting to go to Heaven, or wanting to go to Ireland, all + this as usual in an affectless way. Calls Dr. M. “Uncle + John.” Keeps shouting “Take me to Ireland.” + + _January 9, 1914:_ Often quiet in bed, again goes to door, + talks about wanting to go “to Heaven” or “to Ireland.” On + the whole, says little. + + It seems, then, that the transition was not abrupt, that + many traits of the first period remained, but that she was + on the whole much quieter, with the exception of some + spells when she insisted on going out or killing herself. + At such times she showed an affectless, impulsive + excitement. Whether there was an element of perplexity then + is not clear from the notes. The topics of which she spoke + also changed. The idea of wealth was rarely expressed, also + the idea of marriage was much in the background, but + prominent ideas were those of death, Heaven, killing + herself, going to Ireland--all of which she produced in an + affectless way. It should be added that she persistently + wet and soiled during this, as well as in the first period. + + 3. Then followed three months of greater inactivity. She + lay in bed gazing, moving very little, not even when her + meals were brought. She answered but little and + consistently wet and soiled. This state lasted from about + the middle of February until the beginning of April. + + 4. From this stuporous state she emerged during the next + four weeks, the awakening being associated with persistent + efforts to arouse her. She then was, for six or seven + weeks, nearly normal, so far as her mood went, but had a + tendency to cling to some of her ideas and was + overtalkative. Her memory for the earlier phases of the + psychosis was good, as she recalled not only many external + events but most of her false ideas. She said, however, that + her mind had been a blank for the third stage and she + remembered nothing of it. At the end of this time she + cleared up entirely and was discharged as “recovered.” She + continued well for some months, during which she was + occasionally examined. + +This case gives an excellent example of the relationship of stupor to +other manic-depressive reactions. She begins with an absorbed state, +showing elements of perplexity and mania. With this there are expansive +ideas but, also, statements about losing everything and being in prison, +which suggest abandonment of life. Next, with increasing apathy, she +begins to speak of death and soon makes impulsive suicidal attempts. +Evidently her mind was becoming more and more focused on death and with +this there was an appropriate emotional change. She was either apathetic +or the affect exhibited itself in pure impulsiveness. Then comes the +stupor, when all ideas disappear and mentation is reduced or absent. +When the stupor lifts, the original ideas appear not only in memory but +occasion a wavering insight. It is appropriate that she recalled all of +her psychosis fairly well with the exception of the pure stupor, which +she remembered only as a time when her mind was a blank. + +FOOTNOTES: + +[7] Hoch, August, and Kirby, George H.: “A Clinical Study of Psychoses +Characterized by Distressed Perplexity.” _Archives of Neurology and +Psychiatry_, April, 1919, Vol. I, pp. 415-458. + +[8] Hoch, August: “A Study of the Benign Psychoses.” _Johns Hopkins +Hospital Bulletin_, May, 1915, XXVI, 165. + +A book on “the psychology of manic-depressive insanity” will shortly +appear by the editor. + + + + +CHAPTER IX + +THE PHYSICAL MANIFESTATIONS OF STUPOR + + +We must now discuss the most difficult of all the aspects of the stupor +problem. The subject is so involved and the evidence so inconclusive +that observers will probably interpret the phenomena here reported +according to their individual preconceptions. What we have to say is +therefore published not so much to convince as to stimulate further +work. The problem is wider than that of the mere etiology of the stupors +we are considering. Their relationship to manic-depressive insanity is +so intimate that we must tentatively consider this affectless reaction +as belonging to that larger group. A discussion of the basic pathology +of manic-depressive insanity is outside the sphere of this book. The +author, therefore, thinks it advisable to state somewhat dogmatically +his view, as to the etiology of these affective reactions, merely as a +starting point for the argument concerning stupors specifically. + +It is our view that the manic-depressive psychoses may be, and probably +are, determined remotely but fundamentally by an inherent neuropsychic +defect, but this physical and constitutional blemish is non-specific. +The actual psychosis is determined by functional, that is, +psychological factors. A predisposed individual exposed to a certain +psychic stress develops a manic-depressive psychosis. Naturally any +physical disease reduces the capacity for normal response to mental +difficulties; hence physical illness may facilitate the production of a +psychosis. But this intercurrent factor is also non-specific. + +Such is our view of the etiology of manic-depressive insanity as a +whole. When we approach the study of benign stupors, however, difficult +problems appear. As will be discussed in a later chapter on the +literature, reactions resembling benign stupors occur as a result of +toxins, particularly following acute rheumatism. Recently the medical +profession has been called on to treat many cases of encephalitis +lethargica where similar symptoms are observed. If the resemblance +amounted to identity, we would have to admit that a specific toxin may +produce a specific mental reaction which we have concluded on other +grounds to be psychogenic. As a matter of fact, in two particulars these +reactions show relationship to organic delirium. Knauer reports that in +post-rheumatic stupors illusions are frequent--an ice bag thought to be +a cannon, or a child, etc.--and there are bizarre misinterpretations of +the physical condition, such as lying on glass splinters, animals +crawling on the body, and so on. Such illusions are, in our experience, +not found in stupor, and, on the other hand, are cardinal symptoms of +delirium. Further, Knauer reports that even at the height of +post-rheumatic stupor, external stimuli make some impression, in that a +thoughtful facial expression appears. In deep stupors, such as occurred +in our series, this response is not seen. The same phenomenon of +“rousing,” larval in Knauer’s cases, is often well marked in +encephalitis lethargica and is, of course, a pathognomonic symptom of +delirium. We might therefore think that these conditions are mixtures of +two organic tendencies, namely, delirium and coma. It is not impossible +that resemblances to benign stupor are due to functional elements +appearing in the reduced physical state as additions to the organic +symptoms. The prominence of pain might be taken as a likely cause for an +instinctive reaction of withdrawal, which would account for the +emotional palsy of these conditions on psychogenic grounds. [This +argument can be better understood when the chapter on Psychological +Explanation of Stupor has been read.] We therefore feel justified in +holding that the resemblance of the symptoms of certain plainly organic +reactions to those of benign stupor do not necessitate a splitting of +these stupors from the manic-depressive group. + +When we consider certain bodily manifestations of these typical stupors, +however, fresh difficulties are encountered. Unlike depressions, +elations and anxieties, certain physical symptoms appear with frequency, +even regularity. This would seem to indicate the presence of physical +disease. Inasmuch as the most constant of them is fever, the natural +conclusion would be that we are dealing with an infection which +produces a mental state called stupor. If we were not faced with an +obvious relationship to manic-depressive insanity, where such symptoms +are usually accidental and intercurrent, we would accept this +explanation, but this quandary necessitates further analysis. + +Let us first consider the fever. In 35 cases, on whom data of +temperature could be found from the records extant, 28 showed fever +usually running between 99° and 100°, often up to 101° or slightly over +this point. When these cases were analyzed, however, it was found that +27 were typical and 8 atypical, showing pictures resembling those +described in the last chapter. Of the latter only one had a rise of +temperature, while of the typical group only one was afebrile. +Therefore, since out of 27 typical cases 26 had the typical slight +fever, we must conclude it to be a highly specific symptom. Of these 28 +cases the incidence of the fever was as follows: 8 showed it only on +admission; in 7 it was highest on admission but continued at a low rate +throughout the rest of the psychosis; in 5 it extended without much +variation throughout the psychosis; in 4 it appeared intermittently, +while in 2 it was accentuated during periods when the mental symptoms +were most pronounced. We see, then, that there is a distinct tendency +for the fever to be associated with the onset of the disease. + +When we look for other data from which we might discover causes for the +fever, we find less than we would like. The records are of observations +made, some of them, twenty years ago. Although the mental examinations +were careful, the records of the physical symptoms either were not made +or were lost in many cases. Consequently our description must be +tentative and is published merely to stimulate further research as cases +come to the attention of psychiatrists. + +One looks, first, for other evidence of infection. Some of the cases +were thoroughly examined with modern methods and nothing whatever found. +Blood examinations were made in five cases; three of these had rather +high temperature with the following blood pictures: Charles O., 103°, +leucocytosis of 23,000, with 91.5% polymorphonuclears; Annie G. (Case +1), 103°, leucocytosis of 12,000 to 15,000, and 89% polymorphonuclears; +Caroline DeS. (Case 2), 104°, 15,000 leucocytes, no differential made, +Widal and diazo reaction negative. These three cases, then, had marked +febrile reactions and leucocytosis. It is quite possible that they had +infections which were not discovered. Of the other two Rosie K. (Case +11) had a temperature of 100° and 17,500 leucocytes associated with a +fetid diarrhea, an unquestioned infection, while Mary C. (Case 7), with +a temperature of only 100°, had no rise in number of total white cells +but 41% of lymphocytes. This last might be due to an internal secretion +or an involuntary nervous system anomaly. The possibility of the three +high temperatures with leucocytosis being due to intercurrent infections +must be considered. Charles O. had high fever only for ten days during +a psychosis of several months. Annie G.’s high fever was of about the +same duration. Caroline DeS. had short periods of marked pyrexia in the +first and seventh months of her long psychosis. Except for these +episodes, these three patients had the typical slight elevation of +temperature. Three cases out of thirty-five, in which high fever and +leucocytosis appeared episodically, are hardly enough to justify the +view that stupors are the result of a specific infection. We must +remember, too, that no focal neurological symptoms are ever observed, +which makes the possibility of a central nervous system infection highly +unlikely. + +An alternative view might be that the slight rise of fever is somehow +the result of stupor, not the cause of it. The editor consulted +Professor Charles R. Stockard, of Cornell Medical College, as to this +possibility. The following argument is the result of his suggestions: + +What we call a normal temperature is, of course, the result of a balance +maintained between heat production and heat loss. Either an increase in +the former or a decrease in the latter must produce fever. It is +possible that heat production may be increased in many stupors as a +result of the muscular rigidity. Some cases showed higher temperature +when this was more marked, but this was not sufficiently constant to +justify any conclusions being drawn. + +Heat loss occurs preponderantly as a result of radiation from the skin +and by sweating with consequent evaporation of the secretion. These +processes are functions of the skin and surface circulation. Are they +disturbed in our stupors? We find considerable evidence that they are. +Flushing or dermatographia occurred in six cases, cold or blue +extremities in four cases, greasy skin in four, marked sweating in +three, the hair fell out in two cases, while the skin was pathologically +dry in one case, in fact there were few patients who showed normal skin +function. Circulatory anomalies were also observed. The pulse was very +rapid in eleven cases, weak or irregular in two, and slow in one case. +All these symptoms are expressions of imbalance in the involuntary +nervous system, further evidence of which is found in the rapid +respiration of six cases and the shallow breathing of one patient. These +pulse and respiration findings are the more striking in that individuals +in stupor are, by the very nature of their disease, free from emotional +excitement. + +This imbalance could result from a poverty of circulating adrenalin +which is necessary for the activation of the sympathetic nerves. A cause +for low suprarenal function is to be found in the apathy of the stupor +case. As Cannon and his associates have so conclusively demonstrated, +any emotion which was open to investigation resulted in an increase of +adrenalin output. As our emotions are constantly operating during the +day--and often enough during sleep as well in connection with dreams--we +must presume that emotional stimulus is a normal excitant for the +production of adrenalin. It is therefore inconceivable that the blood +could receive its normal supply of adrenalin with an apathy of the +degree seen in stupor unless some purely hypothetically substitutive +excitant were found. + +We may therefore tentatively assume that the fever which marks the onset +and frequently the course of these benign stupors is the result of a +failure of the heat loss function, this being due to an imbalance in the +involuntary nervous system that is occasioned, in turn, by insufficient +circulating adrenalin, and the final cause for the poor suprarenal +function is to be traced to the most consistent symptom of the stupor, +namely, apathy. This hypothesis is welcome, not only because it would +account adequately for the fever, but it also tends to accentuate the +relationship with other forms of manic-depressive insanity, all of which +are marked fundamentally by a pathological emotion. Naturally enough, +one turns to the records again to see if the blood-pressure of these +patients was low, as would be expected with a poor adrenalin supply. +Unfortunately record was made of the blood-pressure in only two cases, +in both of which the reading was 110 m.m. Two such isolated observations +mean, of course, nothing whatever. It is possible that the drooling +which so many stupor cases show is not merely the result of the failure +of the swallowing reflex, but represents as well a compensation for +anhydrosis by excessive salivary secretion. + +Another symptom suggestive of involuntary nervous system or endocrine +disorder is the highly frequent suppression of the menstrual function. +At times this may occur as a sequel to mental shock, as it did in the +case of Celia H. (Case 19), who was menstruating when, frightened by the +suicidal attempt of her brother, the flow ceased abruptly. That purely +psychic factors can produce marked changes in such functions has been +demonstrated by Forel and other hypnotists time and again; presumably +the effect is produced by way of alteration in the endocrine or +involuntary nervous system influence. In such cases, however, we can +trace the menstrual suppression directly to an emotional cause. On the +other hand, most women in stupor fail to menstruate during the bulk of +the psychosis at a time when we believe emotions to be absent or greatly +reduced in their intensity. The recent work of Papanicolaou and +Stockard[9] offers a simple explanation for this phenomenon. They have +shown that in the guinea pig the œstrous cycle can be delayed by +starvation, while in weaker animals a period may be suppressed +completely. When one considers that even with the greatest care the +nutrition of tube-fed patients is bound to be poor, it would be only +natural to suppose that this malnutrition would cause such a disturbance +in the œstrous cycle and was evidenced objectively by a failure to +menstruate. Even in patients who are not tube-fed, under-nutrition is +to be expected and, as a matter of fact, is usually observed. The work +of Pawlow and Cannon has shown how essential psychic stimulus is for +gastric digestion. Any condition of apathy would therefore tend to +retard digestion and indirectly affect nutrition. + +Finally, under the heading of Physical Manifestations of Stupor, we must +consider epileptoid attacks, of which there was a history in two of our +cases, both of which have already been described in the first chapter of +this book. Anna G. (Case 1), in her second attack, was treated at +another hospital, and from the account which they sent it appears that +the stupor was immediately preceded by a seizure in which the whole body +jerked. This is, of course, rather thin evidence of the existence of a +definite convulsion, but in the case of Mary F. (Case 3) we have a +fuller description. During the two days when the stupor was incubating, +she had repeated seizures of the following nature. She sometimes said +that prior to the attacks it became dark before her eyes and that her +face felt funny or that she had a pain in the stomach which worked +toward her right shoulder. The attack would begin when sitting in a +chair, with the closing of her eyes, clenching her fists and pounding +the side of the chair. She would then get stiff and slide on to the +floor, where she would thrash her arms and legs about and move her head +to and fro. The warning of the pain working from the stomach to the +right shoulder is highly suggestive of an epileptic aura, although the +other symptoms mentioned so far could have been considered hysterical or +poorly described epileptic phenomena. The rest of the description +indicates an epileptic seizure more strongly. She frothed at the mouth +and once wet herself during an attack. They lasted only for a few +minutes and she would breathe heavily after them. At the end of one +attack she wiped the froth from her mouth with her handkerchief and gave +it to her aunt, saying, “Burn that, it is poison.” This is perhaps a +little less like epilepsy. It is plainly impossible for us to say with +any positiveness that either these were or were not genuine convulsions, +but it is nevertheless important to record them, because such phenomena +are observed fairly frequently in dementia præcox cases but are +practically unknown in manic-depressive insanity. This, then, would be +another example of the resemblance to dementia præcox in these stupors +which are unquestionably benign.[10] + +We see, then, in reviewing all the physical manifestations of the +benign stupors, that none occurred which cannot be explained as +secondary to the mental changes, and therefore, until such time as +physical symptoms are reported which cannot be so explained, we see no +reason for changing our view that the benign stupor is to be regarded as +one of the manic-depressive reactions. + + +FOOTNOTES: + +[9] Papanicolaou, G. N., and Stockard, C. R., “Effect of Under-feeding +on Ovulation and the Œstrous Rhythm in Guinea-pigs.” _Proceedings of +the Society of Experimental Biology and Medicine_, Vol. XVII, No. 7, +Apr. 21, 1920. + +[10] As a matter of fact, if the views of Clark and MacCurdy[B] be +accepted, some reason for these epileptic-like attacks may be imagined. +According to them, epilepsy is a disease characterized by a lack of the +natural instinctive interest in the environment which is expressed +chronically in the deterioration, and episodically in the attacks, the +most consistent feature of which is loss of consciousness. Now, in +stupor we have an analogous reaction where, although consciousness is +not disturbed in the sense in which it is in epilepsy, it is +nevertheless considerably affected, inasmuch as contact with the +environment is practically non-existent. The coincident thinking +disorder is quite similar, both in epileptic dementia and the torpor +following seizures and in these benign stupors. MacCurdy has suggested +tentatively that the epileptic convulsion may be secondary to a very +sudden loss of consciousness which removes a normal inhibition on the +muscles, liberating the muscular contractions which constitute the +convulsion. If this view were correct, it would not be hard to imagine +that during the onset of these stupors the tendency to part company with +the environment, which ordinarily comes on slowly, might occur with +epileptic suddenness and hence liberate convulsive movements. This is, +however, a pure speculation but not fruitless if it serves to draw +attention to the analogies existing between the stupor reaction and some +of the mental symptoms of epilepsy. These analogies are strong; aside +from the obvious clinical differences, the stupor and epileptic +reactions are dynamically unlike in that they are the product of +different temperaments and precipitated by different situations. + + +FOOTNOTES: + +[B] Clark, L. Pierce. “Is Essential Epilepsy a Life Reaction Disorder?” +_Am. Jour. of the Medical Sciences_, November, 1910, Vol. CLVIII, No. 5, +p. 703. This paper gives a summary of Dr. Clark’s theories. + +MacCurdy, John T., “A Clinical Study of Epileptic Deterioration.” +_Psychiatric Bulletin_, April, 1916. + + + + +CHAPTER X + +PSYCHOLOGICAL EXPLANATION OF THE STUPOR REACTION + + +In the previous chapter mention has been made of our view that +manic-depressive insanity is a disease fundamentally based on some +constitutional defect, presumably physical, but that its symptoms are +determined by psychological mechanisms. In accordance with this +hypothesis we seek, when studying the different forms of insanity +presented in this group, to differentiate between the different types of +mental mechanisms observed, and by this analysis to account for the +manifestations of the disease on purely psychological lines. If benign +stupors belong to this group, then we should be able to find some +specific psychology for this type of reaction. + +All speech and all conduct, except simple reflex behavior, are +presumably determined by ideas. When an individual is not aware of the +purpose governing his action, we assume, in psychological study, that an +unconscious motive is present, so that in either case the first step in +psychological understanding of any normal or abnormal condition is to +discover, if possible, what the ideas are that lead to the actions or +utterances observed. In the case of stupors the situation is fairly +simple, in that the ideational content is extremely limited. As has been +seen, it is confined to death and rebirth fancies, other ideas being +correlated with secondary symptoms, such as belong to mechanisms of +other manic-depressive psychoses. It is not necessary to repeat the +catalogue of the typical stupor ideas, as they have been given in an +earlier chapter. Our task is now to consider the significance of these +death and rebirth delusions and their meaning for the stupor reaction. + +Thoughts concerned with future and new activities require energy for +their completion in action and are therefore naturally accompanied by a +sense of effort which gives pleasure to an active mind. When the sum of +energy is reduced, one observes a reverse tendency called “regression.” +It is easier to go back over the way we know than to go forward, so the +weakened individual tends to direct his attention to earlier actions or +situations. To meet a new experience one must think logically and keep +his attention on things as they are, rather than imagine things as one +would like to have them. + +Progressive thinking is therefore adaptive, while regressive thinking is +fantastic in type, as well as concerned with the past--a past which in +fancy takes on the luster of the Golden Age. Sanity and insanity are, +roughly speaking, states where progressive or regressive thinking rule. +The essence of a functional psychosis is a flight from reality to a +retreat of easeful unreality. + +Carried to the extreme, regression leads one in type of thinking and in +ideas back to childhood and earliest infancy. The final goal is a state +of mental vacuity such as probably characterizes the infant at the time +of birth and during the first days of extra-uterine life. In this state +what interest there is, is directed entirely to the physical comfort of +the individual himself, and contact with the environment is so +undeveloped that efforts to obtain from it the primitive wants of warmth +and nutrition are confined to vague instinctive cries. Evolution to true +contact with the world around implies effort, the exercise of +self-control, and also self-sacrifice, since the child soon learns that +some kind of _quid pro quo_ must be given. Viewed from the adult +standpoint, the emptiness of this early mental state must seem like the +Nirvana of death. At least death is the only simple term we can use to +represent such a complete loss of our habitual mental functions. When +life is difficult, we naturally tend to seek death. Were it not for the +powerful instinct of self-preservation, suicide would probably be the +universal mode of solving our problems. As it is, we reach a compromise, +such as that of sleep, in which contact with reality is temporarily +abandoned. In so far as sleep is psychologically determined, it is a +regressive phenomenon. It is interesting that the most frequent +euphemism or metaphor for death is sleep. Sleep is a normal regression. +It does not always give the unstable individual sufficient relaxation +from the demands of adaptation and so pathological regressions take +place, one of which we believe stupor to be. It is important to note +that objectively the resemblance between sleep and stupor is striking. +So far as mental activity in either state can be discovered by the +observer, either the sleeper or the patient in stupor might be dead. +Briefly stated, then, our hypothesis of the psychological determination +of stupor is that the abnormal individual turns to it as a release from +mental anguish, just as the normal human being seeks relief in his bed +from physical and mental fatigue. When this desire for refuge takes the +shape of a formulated idea, there are delusions of death. + +The problem of sleep is, of course, bound up with the physiology of +rest, and as recuperation, in a physical sense, necessitates temporary +cessation of function, so in the mental sphere we see that relaxation is +necessary if our mental operations are to be carried on with continued +success. This is probably the teleological meaning of sleep in its +psychological aspects, for in it we abandon diurnal adaptive thinking +and retire to a world of fancy, very often solving our problems by +“sleeping over them.” The innate desire for rest and a fresh start is +almost as fundamental a human craving as is the tendency to seek release +in death. In fact the two are closely associated both in literature and +in daily speech, for in many phases we correlate death with new life. If +one is to visualize or incorporate the conception of new life in one +term, rebirth is the only one which will do it, just as death is the +only word which epitomizes the idea of complete cessation of effort. +Not unnaturally, therefore, we find in the mythology of our race, in our +dreams and in the speech of our insane patients, a frequent correlation +of these two ideas, whether it comes in the crude imagery of physical +rebirth or projected in fantasies of destruction and rebuilding of the +world. Many of our psychotic patients achieve in fancy that for which +the Persian poet yearned: + + “Ah Love! could you and I with Him conspire + To grasp this Sorry Scheme of Things entire, + Would we not shatter it to bits--and then + Re-mold it nearer to the Heart’s Desire!” + +A vision of a new world is a content occurring not infrequently in manic +states, but before the universe can be remolded it must be destroyed. +Before the individual can enjoy new life, a new birth, he must die, and +stupor often marks this death phase of a dominant rebirth fantasy. In +this connection it was not without significance to note that stupors +almost universally recover by way of attenuation of the stupor symptoms, +or in a hypomanic phase where there seems to be an abnormal supply of +energy. Antæus-like, they rise with fresh vigor from the Earth. They do +not pass into depressions or anxieties. + +Rebirth fancies unquestionably, then, contain constructive and +progressive elements, but, as has been stated above, any thinking which +implies a lapse of contact with the environment is, in so far as that +lapse is concerned, regressive, and in consequence rebirth fancies, as +dramatized by the stupor patients, are regressive, just as are the +delusions of death itself. + +It is obvious that an acceptance of death implies rather thorough mental +disintegration. Before that takes place there may be some mental +conflict. The instinct of self-preservation may prevent the individual +from welcoming the notion of dissolution, so that this latter idea, +though insistent, is not accepted but reacted to with anxiety; hence we +often meet with onsets of stupor characterized by emotional distress. It +has already been suggested that death may foreshadow another existence. +Often in the psychoses we meet with the idea of eternal union in death +with some loved one whom the vicissitudes and restrictions of this life +prevent from becoming an earthly partner. This fancy is frequently the +basis of elation. Similarly, new life in a religious sense as expressed +in the delusion of translation to Heaven, is a common occasion for +ecstasy. These formulations of the death idea may occur as tentative +solutions of the patient’s problems leading to temporary manic episodes +while the psychosis is incubating. It seems that stupor as such appears +only when death and nullity are accepted. + +The above are more or less a priori reasons for regarding the stupor as +a regressive reaction. We must now consider the clinical evidence to +support this view. In the first place, we always find that stupor occurs +in an individual who is unhappy and who has found no other solution +than regression for the predicament in which he is. There is nothing +specific in the cause of this unhappiness. At times the factors +producing it are mainly environmental; at others, the problem is +essentially of the patient’s own making. Of course almost any type of +functional psychosis may emerge from such a state of dissatisfaction, +but it is important to note that unlike manic states, for instance, +stupors invariably develop from a situation of unhappiness. Quite +frequently the choice of the stupor regression is determined by some +definitely environmental event which suggests death. This often comes as +the actual death of the patient’s father (in the case of a woman) or +employer, events which inflate the already existing, although perhaps +unconscious, desire for mutual death. Again, the precipitating factor +may be a situation which adds still another problem and makes the burden +of adaptation intolerable, forcing on him the desire for death. In these +cases the actual psychosis is sometimes ushered in dramatically with a +vision of some dead person (often a woman’s father) who beckons, or +there are dream-like experiences of burial, drowning, and so on. + +A few cases taken at random from our material exemplify these features +of the unhappiness in which the psychosis appears as a solution with its +development of the death fancy. + +Alice R., at the age of 25, was much troubled by worrying over her +financial difficulties and the shame of an illegitimate child. +Retrospectively she stated, “I was so disgusted I went to bed--I just +gave up hope.” Shortly before admission she said she was lost and +damned, and to the nurse in the Observation Pavilion she pleaded, “Don’t +let me murder myself and the baby.” + +Caroline DeS. (Case 2) for some time was worried over the engagement of +her favorite brother to a Protestant (herself a Catholic) and the +threatened change of his religion. At his engagement dinner she had a +sudden excitement, crying out, “I hate her--I love you--papa, don’t kill +me.” This excitement lasted for three weeks, during two of which she was +observed, when she spoke frequently of being killed and going to Heaven. +The conflict was frankly stated in the words, “I love my father but +don’t want to die.” Then for two weeks she had some fever, was tube-fed, +muttered about being killed or showed some elation, there being +apparently interrupted stuporous, manic and, possibly, anxiety episodes. +Finally she settled down to a year of deep stupor. + +Laura A. had for three months poor sleep with depression over her +failure in study. Another cause for worry was that her father was home +and out of work. She reached a point where she did not care what +happened but continued working. Ten days before admission she was not +feeling well. The next morning she woke up confused and frightened, +speedily became dazed, stunned, could not bring anything to her memory. +This rather sudden stupor onset was not accompanied by any false ideas, +at least none which the family remembered. + +Mary C. (Case 7) was an immigrant who felt lonely in the new country. +Two weeks before admission her uncle with whom she was living died. She +thought she had brought bad luck, complained of weakness and dizziness, +then suddenly felt mixed up, her “memory got bad,” and she thought she +was going to die. Next she was frightened, heard voices, thought there +was shooting and a fire. For a short time she was inactive and later +began shouting “Fire!” When taken to the Observation Pavilion, she was +dazed, uneasy, thought she was on a boat or shut up in a boat which had +gone down; all were drowned. Then came a mild stupor. + +Maggie H. (Case 14), while pregnant, fancied that her baby would be +deformed and that she would die in childbirth. Three weeks before +admission this event took place. For five days she worried about not +having enough milk, about her husband losing his job (he did lose it) +and thought her head was getting queer. On the fifth day she cried, said +she was going to die, that there was poison in the food, that her +husband was untrue to her. She became mute but continued to attend to +her baby. She saw dead bodies lying around, and by the time she was +taken to the Observation Pavilion was in a marked stupor. + +Turning now to the symptoms of the stupor proper, we note, first, the +effects of the loss of energy which regression implies. The inactivity +and apathy which these patients show is too obviously evidence of this +to require further comment. Another proof of the withdrawal of the +libido or interest is found in the thinking disorder. Directed, accurate +thinking requires effort, as we all know from the experience of our +laborious mistakes when fatigued. So in stupor there is an inability to +perform simple arithmetical problems, poor orientation is observed, and +so on. Similarly what we remember seems to be that which we associate +with the impressions received by an active consciousness. Actual events +persist in memory better than those of fancy, in proof of which one +thinks at once of the vanishing of dreams on waking, with its +reëstablishment of extroverted consciousness. This registration of +impressions requires interest and active attention. Without interest +there is no attention and no registration. The patient in stupor +presents just the memory defect which we would expect. Indifference to +his environment leads to a poor memory of external events, while on +recovery there may be such a divorce between consciousness of normal and +abnormal states that the past delusions are wiped from the record of +conscious memory. Withdrawal of energy then produces not only inactivity +and apathy but grave defects in intellectual capacity. + +The natural flow of interest in regression is to earlier types of +ambition and activity. This is betrayed not merely by the thought +content dealing with the youth and childhood of the patient, but also is +manifested in behavior. Excluding involution melancholia there is +probably no psychosis in which the patients exhibit such infantile +reactions as in stupor. Except for the stature and obvious age of these +patients, one could easily imagine that he was dealing with a spoiled +and fractious infant. One thinks at once of the negativism which is so +like that of a perverse child and of the unconventional, personal habits +to which these patients cling so stubbornly. Masturbation, for instance, +is quite frequent, while willful wetting and soiling is still more +common. We sometimes meet with childishness, both in vocabulary and mode +of expression. In one case there was evidently a delusion of a return to +actual childhood, for she kept insisting that she was “in papa’s house.” + +The frequency with which the delusion of mutual death occurs in stupor +is another evidence of its regressive psychology. The partner in the +spiritual marriage is rarely, if ever, the natural object of adult +affection, but rather a parent or other relative to whose memory the +patient has unconsciously clung for many years, reawakening in the +psychosis an ambition of childhood for an exclusive possession that +reaches its fulfillment in this delusion. Closely allied with this is +another delusion, that of being actually dead, which the patients +sometimes express in action, even when not in words. The anesthesia to +pin pricks, the immobility and the refusal to recognize the existence of +the world around, in patients who give evidence of some intellectual +operations still persisting, are probably all part of a feigned death, +with the delusion expressing itself in corpse-like behavior. + +Finally we must consider the meaning of the deep stupor where no +mentation of any kind can be proven and where none but vegetative +functions seem to be operating. This state is either one of organic +coma, in which case it marks the appearance of a physical factor not +evidenced in the milder stages, or else it is the acme of this +regression by withdrawal of interest. As has been stated, back of the +period of primitive childish ideas there lies a hypothetical state of +mental nothingness. If we accept the principle of regression we find +historically an analogue to what is apparently the mental state of deep +stupor in the earliest phases of infancy. This view receives +justification from the study of the phenomenon of variations in +symptoms. Mental faculties at birth are larval, and if such condition be +artificially produced mental activity must be potentially present (as it +would not be if we were dealing with coma). In Chapter IV phenomena of +interruption of stupor symptoms were detailed. One case that was +mentioned is now of particular importance as demonstrating that an +appropriate stimulus may dispel the vacuity of complete stupor by +raising mental functions to a point where delusions are entertained. +This patient retrospectively recalled only certain periods of her +deepest stupor, occasions when she was visited by her mother. At these +times, as she claimed, she thought she was to be electrocuted and told +her mother so, adding, “Then it would drop out of my mind again.” +Otherwise her memory for this state was a complete blank. Here we see a +normal stimulus producing not normality but something on the way towards +it, that is, a condition less profound than the state out of which the +patient was temporarily lifted. + +This case exemplifies the principle of levels in the stupor reaction +which we have found to be of great value in our study. These levels are +correlated with degrees of regression, as a review of the symptoms +discussed above may show. In the first place, the dissatisfaction with +life, the first phase of regression, leads to the quietness--the +inactivity and apathy, which are the most fundamental symptoms of the +stupor reaction as a whole. Initiative is lost and with this comes a +tendency for the acceptance of other people’s ideas. That is the +probable basis for the suggestiveness which we concluded was a prominent +factor in catalepsy. Indifference and stolidity may exist with those +milder degrees of regression which do not conflict with one’s critical +sense, and hence may be present without any false ideas. The next stage +in regression is that where the idea of death appears. Although not +accepted placidly by the subject, its non-acceptance is demonstrated by +the idea being projected--by its appearance as a belief that the patient +will be killed. This notion of death coming from without has again two +phases, one with anxiety where normality is so far retained that the +patient’s instinct of self-preservation produces fear, and a second +phase where this instinct lapses and the patient so far accepts the +idea of being killed as to speak of it with indifference. The next step +in regression is marked by the spoiled-child conduct, interest being so +self-centered as to lead to autoerotic habits and the perverse reactions +which we call negativism. When death is accepted but mental function has +not ceased, the latter is confined to a dramatization of death in +physical symptoms or to such speech and movements as indicate a belief +that the patient is dead, under the water, or in some such unreal +situation. Finally, when all evidence of mentation in any form is +lacking, we see clinically the condition which we know as deep stupor +and which we must regard psychologically as the profoundest regression +known to psychopathology, a condition almost as close to physiological +unconsciousness as that of the epileptic. + +Naturally we do not see individual cases in which all these stages +appear successively, each sharply defined from its predecessor. To +expect this would be as reasonable as to look for a man whose behavior +was determined wholly by his most recent experience. Any psychologist +knows that every human being behaves in accordance with influences whose +history is recent or represents the habit of a lifetime. At any given +minute our behavior is not simply determined by the immediate situation, +but is the product of many stages in our development. Quite similarly we +should not expect in the psychoses to find evidences of regression to a +given period of the individual’s life appearing exclusively, but rather +we should look for reactions at any given time being determined +preponderantly by the type of mentation characteristic for a given stage +of his development. As a matter of fact, we see in psychoses, +particularly in stupor, more sharply defined regressions to different +levels than we ever see in normal life. + +Our psychological hypothesis would be incomplete and probably unsound if +it could not offer as valid explanations for the atypical features in +our stupor reactions as for the typical. The unusual features which one +meets in the benign stupors are ideas or mood reactions occurring +apparently as interruptions to the settled quietude or in more +protracted mild mood reactions, such as vague distress, depression or +incomplete manic symptoms, which have been described in the chapter on +affect. The interruptions are easily explained by the theory of +regression. If stupor represents a complete return to the state of +nothingness, then the descent to the Nirvana or the re-ascent from it +should be characterized by the type of thinking with the appropriate +mood which belongs to less primitive stages of development. A review of +our material seems to indicate that there is a definite relationship +between the type of onset and the character of the succeeding stupor. +For instance, in the cases so far quoted in this book, the onsets +characterized by mere worry and unhappiness and gradual withdrawal of +interest had all of them typical clinical pictures. On the other hand, +of those who began with reactions of definite excitement, anxiety or +psychotic depression, there were interruptions which looked like +miniature manic-depressive psychoses in all but one case. This would +lead one to think that these patients retraced their steps on recovery +or with every lifting of the stupor process, moved slightly upward on +the same path on which they had traveled in the first regression. The +case of Charlotte W. (Case 12), which is fully discussed in the chapter +on Ideational Content, offers excellent examples of these principles. + +The next atypical feature is the phenomenon of reduction or dissociation +of affect, the frequency of which is mentioned in Chapter V. As the law +of stupor is apathy, normal emotions should be reduced to indifference +and no abnormal moods, such as elation, anxiety or depression, should +occur. What often happens is that these psychotic affects appear but +incompletely, often in dissociated manifestations. This looks like a +combination of two psychotic tendencies, the stupor reduction process +which inhibits emotional response and the tendency to develop abnormal +affects which characterize other manic-depressive psychoses. There is no +general psychological law which makes this view unlikely. One cannot be +anxious and happy at the same instant, although one can alternate in his +feelings; but one can fail to react adequately to a given stimulus when +inhibited by general indifference. In fact it is because apathy is, +properly speaking, not a mood but an absence of it, that it can be +combined with a true affect. It is possible, therefore, to have a +combination of stupor and another manic-depressive reaction, while the +others cannot combine but only alternate.[11] + +Finally we must discuss the psychological meaning of cases, such as +those described in Chapter VIII, where we concluded that there were +psychoses resembling stupors superficially. It seemed likely that these +patients were absorbed in their own thoughts, rather than being in a +condition of mental vacuity. It is not difficult to explain the +objective resemblance. All evidence of emotion (apart from subjective +feeling tone which the subject may or may not report) is an expression +of contact with the outer world. There must be externalization of +attention to environment before a mood becomes evident. A moment’s +reflection will show this to be true, for no further proof is needed +than the phenomena of dreaming. The attention being given wholly to +fantasies, the subject lies motionless, mute and placid, although +passing through varied autistic experiences. Only when the dream becomes +too vivid, disturbs sleep and re-directs attention to the +environment--only then is emotion objectively betrayed. There is an +appearance of apathy and mental vacuity which the dreamer can soon +declare to be false. He was feeling and thinking intensely. In any +condition, therefore, such as that of perplexity or of an absorbed manic +state, the patient may be objectively in the same condition as a typical +stupor. The histories of the two psychoses differentiate the two +reactions which may be indistinguishable at one interview. The keynote +of one reaction is _indifference_, while that of absorption is +_distraction_, a perversion of attention to an inner, unreal world. + +In summary we may recapitulate our hypotheses. Stupor represents, +psychologically speaking, the simplest and completest regression. +Adaptation to the actual environment being abandoned, attention reverts +to earlier interests, giving symptoms of other manic-depressive +reactions in the onset or interruptions, and finally dwindles to +complete indifference. The disappearance of affective impulse leads to +objective apathy and inactivity, while the intellectual functions fail +for lack of emotional power to keep them going. The complicated mental +machine lies idle for lack of steam or electricity. The typical +ideational content and many of the symptoms of stupor are to be +explained as expressions of death, for a regression to a Nirvana-like +state can be most easily formulated in such a delusion. Other clinical +conditions may temporarily and superficially resemble stupor on account +of the attention being misdirected and applied to unproductive +imaginations. To employ our metaphor again, in these false stupors the +current is switched to another, invisible machine but not cut off as in +true stupor. + + +FOOTNOTES: + +[11] The reader will note that this view is opposed to that of +Kraepelin, who has written largely on so-called “_mixed conditions_” in +manic-depressive insanity. We believe that careful clinical studies +confirm our opinion and that his classification is based on less +thorough observation and analysis. This subject will be discussed at +greater length in a forthcoming book on “The Psychology of Morbid and +Normal Emotions,” by Dr. MacCurdy. + + + + +CHAPTER XI + +MALIGNANT STUPORS + + +As we have seen, the benign stupors are characterized by apathy, +inactivity, mutism, a thinking disorder, catalepsy and negativism. All +these symptoms are also found in the stupors occurring in dementia +præcox. In fact this symptom complex has usually been regarded as +occurring only in a malignant setting. There can be no question about +the resemblance of benign to dementia præcox stupors. Even such symptoms +as poverty and dissociation of affect, usually regarded as pathognomonic +of dementia præcox, have been described in the foregoing chapters. +Either recovery in our cases was accidental or there is a distinct +clinical group with a good prognosis. If the latter be true, the +symptoms must follow definite laws; if they did not, we would have to +abandon our principles of psychiatric classification. Naturally, then, +we seek to find the differences between the cases that recover and those +that do not. There is never any difficulty in diagnosis where a stupor +appears as an incident in the course of a recognized case of catatonic +dementia præcox. We shall therefore consider only such clinical pictures +as resemble those described in this book, in that the symptoms on +admission to a hospital or shortly after are those of stupor. It should +be our ambition to make a positive diagnosis before failure to recover +in a reasonable time leads to a conclusion of chronicity. + +It is probably safe to assume, on the basis of as large a series as +ours, that the symptoms of stupor _per se_ imply no bad prognosis. +Further, it has been noted that a relatively pure type of reaction is +seen, the symptoms appearing with tolerable consistency. In analyzing +the histories of dementia præcox patients, therefore, one looks for +inconsistencies among, or additions to, the stupor symptoms. We may say +at the outset that we have been able to find no case of malignant stupor +that showed what we regard as a typical benign stupor reaction, and it +is questionable whether partial stupor as we have described it, ever +occurs with a bad prognosis. Usually the discrepant symptoms in the +dementia præcox cases are sufficiently marked to enable one to make a +positive diagnosis quite soon after the case comes under observation. + +The law of benign stupor is a limitation of energy, emotion and +ideational content. In dementia præcox we have a re-direction of +attention and interest to primitive fantastic thoughts and a consequent +perversion of energy and emotion. In many malignant stupors one can +detect evidence of this second type of reaction in symptoms that are +anomalous for stupor. For instance, one meets with frequent silly and +inexplicable giggling. Then, too, smiling, tears or outbursts of rage, +the occasions for which are not manifest, are much more frequent than in +typical stupor. Similarly, delusional ideas (not concerned with death at +all) may appear or the patient may indulge in speech that is quite +scattered, not merely fragmentary. Two cases may be cited briefly to +illustrate these dementia præcox symptoms superadded to those of stupor. + + + CASE 20.--_Winifred O’M._ Age: 19. Single. Admitted to the + Psychiatric Institute May 6, 1911. + + _F. H._ The occurrence of other nervous or mental disease + in the family was denied. + + _P. H._ The patient seems to have been rather shy and + goody-goody in disposition. According to her mother this + seclusiveness did not begin to be markedly noticeable until + the winter before her psychosis, when there was some + trouble about getting work. She had previously been to a + business school. Then she held a position as stenographer + temporarily. When this job was over she had a number of + positions that did not last long and was once idle for two + months. In February (three months before admission) her + father was out of work, which added to her worry. + + _Onset of Psychosis:_ Nine days before admission a young + man died in the house where they lived. The next day her + mother insisted on the patient and her sister going to the + funeral. On coming home the patient complained of being + afraid and having a funny feeling. She woke up at 2:30 that + night and lit all the gas, for which she could give no + explanation. The day following, or a week before admission, + she was slow, confused, could not get her clothes together. + The next day she was restless and worried, giving a + superficial explanation for the latter. She played the + piano a great deal. The following day she was fidgety and + cried. At 4 p.m. she was put to bed and appeared to fall + asleep. At midnight when a priest called she said to him + privately that she was all over the world, that she went to + the 12th floor of the Metropolitan Building, that she sat + down and took the man’s money, $7, and came right away. She + recognized the priest. Three days before admission she + wanted to stay in bed, kept her eyes closed. When spoken to + she would smile but did not open her eyes. She did not pass + her urine all day. Her mother then gave her some medicine + which the doctor had left. The patient immediately had a + peculiar attack in which she heaved her breast, drew her + head back, clenched her fists and worked her feet. Saliva + escaped from the side of her mouth. This attack lasted some + three to five minutes. + + Her mother then called an ambulance and she was taken to + the _Observation Pavilion_. She thought that the ambulance + doctor was an uncle, a soldier in the Philippines, of whom + she was very fond. There she remained in bed, with all her + muscles relaxed, her mouth constantly open, saying nothing + and indeed resisting efforts which were made to get her to + open her eyes. + + _Under Observation:_ She sat or lay down with her eyes + closed and usually limp, although occasionally resistive. + There was practically no reaction to pin pricks. Sometimes + she opened her mouth as if to speak but rarely did so + except in a very low tone and after repeated questioning. + Her answers were rarely relevant. To the usual orientation + questions she gave no answers that would indicate that she + knew where she was. Sometimes she said “Jimmy” when asked + her name, and replied to another question, “Jimmy big smile + on.” Once she said, “I don’t know myself--what I am talking + for--what I am doing.” In general her speech seemed to + indicate that her thought was directed entirely inward and + that she paid no attention whatever to the questions. In + most benign cases such a condition is accompanied by + perplexity or a dreamy, dazed expression. This the patient + had not. On the other hand, she was sometimes definitely + scattered. For example, when asked, How do you feel? she + replied, “Large all name.” Again to the command, Tell me + your trouble, her answer was, “I couldn’t tell my mother + last night and I can’t tell her this night and I can’t tell + my _proud_.” She referred in a fragmentary way to being + crazy and to having been dead. She admitted hearing voices + but may not have understood the question. + + A week after admission, when visited by her mother, the + latter asked her to kiss her. The patient opened her mouth + widely and put out her tongue. This is a type of response + which we have never seen in our benign cases. + + Two days later repeated questioning made it evident that + the patient knew more about her environment than would be + expected, judging from her other symptoms. She gave the + month correctly knew that she was in a hospital and told of + having recently been visited by her father. At the same + interview she spoke of masturbation, of wanting to marry + her uncle, and of having been in bed with her father. The + last she referred to as a “fall.” Such frank incest ideas + are never found in benign psychosis in our experience. + Other dementia præcox ideas appeared quite soon, for within + three days, when she was talking slightly more freely, she + spoke of having often imagined she was having sexual + experiences as a result of the influence of a man who lived + upstairs, and that even when sitting with her family at the + table she felt sexual sensations. + + Her condition then remained essentially the same for some + time. Then about six weeks after admission she became + somewhat less resistive, was frequently seen sitting up in + bed, moving her lips considerably (without speech) and + regarding the surroundings with a bright interested + expression and occasionally smiles. About this time she + began exposing herself and chewing her finger nails. + + Four months after admission she was noted as being very + resistive and negativistic, allowing saliva to accumulate + in her mouth and making no attempt to keep the flies off + her. At the same time she would keep in her mouth food that + had been put there without chewing it. + + Two months later she seemed to laugh occasionally when + other patients did so, but at the same time she showed a + cataleptic tendency and was quite mute. + + Six months after admission she began to feed herself but + rather sloppily. When one would speak to her, she would + occasionally smile, but if shaken she would weep silently. + About this time she began to do a little work in the ward, + pushing a floor polisher. + + For the next couple of months her condition was about the + same. She would stand around the ward, doing a little work + if urged, might even dance if forced to. She was + consistently mute. She was dirty but often decorated + herself. Rarely she was assaultive. + + Then ten months after admission she one day suddenly + became talkative, distractible and emotional, laughing and + crying. There was with this, however, no open elation. Her + talk was obscene, at times flighty, at times definitely + scattered. All her habits were filthy. + + This pseudomanic episode lasted for a couple of months, and + then she settled down to a fairly consistent deterioration + with indifference, silly laughter, occasional + assaultiveness, destructiveness and untidiness. + + Nearly two years after admission she had another period of + excitement lasting about a couple of months. Shortly after + this she began to fail physically, and in November, 1913, + two years and five months after her admission, she died of + pulmonary tuberculosis. + +In summary, then, we see that this patient exhibited symptoms of +dementia præcox from the outset of her stupor, with scattering, genital +sensations and incest ideas. The stupor symptoms gradually gave way to +the typical indifference, negativism, obscenity, filthiness and +inexplicable conduct of dementia præcox. At the beginning, however, the +condition was superficially similar to that of a benign stupor, it being +only on careful observation that other symptoms were noted. + + + CASE 21.--_Rose S._ Age: 23. Admitted to the Psychiatric + Institute April 5, 1905. + + _F. H._ The mother was living, the father dead. Otherwise + no pertinent information was secured. + + _P. H._ The patient was said always to have been somewhat + seclusive, mingling little with other people; this tendency + was so strong that she would leave the room when visitors + came. She always slept a great deal. It was stated that she + was able to do heavy housework quite well, but never + learned cooking. + + At 16 she hired out as a servant for a year and a half, and + then did laundry work. When 18 she had an illegitimate + child by a co-worker. + + _History of Psychosis:_ About a year before admission the + patient’s sister was burned to death. When the patient + heard of this she said that something had come up in her + throat. Henceforth she often complained of a lump in her + throat, and often bit her nails. Two months before + admission she suddenly left the laundry, again spoke of the + lump in her throat, and claimed to have seen the dead + sister. Two weeks later when the family had an anniversary + mass for the sister the patient appeared sad, but the + following day laughed, said she had seen her “sister + beckoning her to come.” She also thought she saw her + picture “and Heaven was behind it.” She also talked of + “dead relatives and friends.” A reaction of levity in + connection with a sister’s death is highly suggestive of a + malignant psychosis. + + Two weeks before admission her mother found her in a + stupor, immovable, with her eyes closed. In 24 hours she + woke up, began to sing “Rest for the Weary,” prayed, then + was stuporous again for six hours. When she came out of + this, she said she was “going to die,” God had told her so + and talked of her own funeral arrangements. She again went + into a stupor, in which she was sent to the Observation + Pavilion. + + At the _Observation Pavilion_ she was described as happy, + laughing, singing, saying she felt happy, but adding, “I + like to be sad too, I am going to Heaven Easter Sunday.” + She claimed that her sister frequently stood in front of + her, and that she knew she wanted her to go with her. + + _Under Observation:_ For about three weeks the patient + showed a variable stupor. She would lie with a mask-like + face inaccessible, cataleptic, drooling saliva, often with + her mouth open. When taken up, she was usually perfectly + flaccid, but once she let herself slide on the floor after + she had stood immobile at the window. Sometimes there was + marked resistance to passive motions, especially when + attempts were made to open her mouth or eyes, or on one + occasion when the examiner tried to open her hand in which + she held her handkerchief. Yet when one persisted in urging + her to respond there frequently could be elicited more or + less marked reactions. Thus repeatedly she could be made to + obey some commands, as showing the tongue, etc., even when + she would not answer. Once when her eyes were opened, tears + rolled down her cheeks--again, she usually reacted to pin + pricks by slight flushing, once she said, “Stop! it + hurts.” Again, she said, “Leave me alone, I want to sleep.” + + So far the description of this reaction is that of a benign + stupor. There were, however, other symptoms. In the first + place, she could sometimes be made to open her eyes and + write, although she would not speak. In spite of the + penmanship being careless, there were no mistakes. This + exhibition of an unhabitual and more difficult intellectual + effort when the patient was mute is suggestive of an + inconsistency. So was her habit of sometimes singing a + hymn, “Rest for the Weary,” when no other sign of mental + life was given. But, more important than these, she could + not infrequently be induced to answer questions and at such + times she spoke promptly and with natural affective + response. + + A number of her replies were of the type to be expected in + a benign stupor. In the first place, she spoke of her + condition as “going off to sleep” and also as “death,” “I + was dead all day.” “I died three times yesterday,” or she + merely described it by saying “I go off into states when I + lie with my mouth open and eyes closed, and cannot speak or + open my eyes.” When asked how she got into this condition, + she said “My sister died and I think it was on my mind.” + Again she said she became sad at the anniversary mass of + the sister and had been sad ever since. On the other hand, + she also stated that when she came home from the mass she + first was silly and danced. Spontaneously she spoke of + having frequently had visions of her dead sister; once she + saw her with wings. In explanation of her singing “Rest for + the Weary,” she said it was the hymn sung at her father’s + funeral. An anomalous feature had to do with her + description of her feelings. She claimed to have no memory + of her stupor periods and yet said of them: “I feel + peaceful-like,” or “I feel awfully happy and sad together,” + or “I am sad and contented--I like it that way.” + + A striking symptom was that, when a sensory examination was + made during the first few days during one of the periods + when she responded well, she showed glove and stocking + anesthesia, also anesthesia of neck and left breast. + + But in addition to the above statements the patient also + began to make others of a definite dementia præcox type. + About ten days after admission she said, “What any one says + goes right through my brain,” or she talked of being + hypnotized. “The typewriting machine turned my eyes--three + or four girls turned my eyes--they look at me and get their + chance, their left eye--turning me into images. I want to + be the way I was born--turn my body! look how their bodies + are turned before they die,” or “Take it if you get it--he + got the name out--I was over there to death--himself to + death--of, you know--you played out--she is played out.” + ... This while she snickered between the sentences. As + early as four weeks after admission she had begun to giggle + or laugh, often in an empty fashion, and a transition from + the more constrained stuporous state, with interruptions of + laughter, to an indifferent silly, muttering to herself was + gradual. + + In 1909 she was described as not talking, standing around, + showing no interest in anything, muttering. The only + response obtained was “I don’t know.” In December, 1911, + she was transferred to another hospital as a case of + deteriorated dementia præcox. + +_To Recapitulate:_ We have here a young woman who for a year had +indefinite mental symptoms and suddenly developed a stupor. This was +atypical in that she sang and wrote when otherwise apparently deeply +stuporous. When persuaded to talk, her utterances, even as early as ten +days after admission, were of a malignant type and with such statements +she giggled. This last is apparently a highly important sign. Quite +frequently in our cases the first signal of a dementia præcox reaction +has been giggling in a setting of what was apparently a typical benign +stupor. + +As has frequently been stated, symptoms of benign stupor are closely +interrelated. Consequently the reaction is, when benign, a consistent +one. We do not find free speech with profound apathy and inactivity, +nor do we expect to meet with unimpaired intellectual functions when +other evidences of deep stupor are present. The inconsistency of mental +operations which characterize dementia præcox, however--the “splitting” +tendency which Bleuler has emphasized in his term “schizophrenia”--is +just that added factor which may produce disproportionate developments +of the various stupor symptoms in the dementia præcox type of that +reaction. Examples of this have been given in the two cases just quoted. +The history of the following patient shows this tendency more +prominently. + + + CASE 22.--_Nellie H._ Age: 20. Admitted to the Psychiatric + Institute June 11, 1907. + + _F. H._ The father had repeated depressions; he died of + typhus fever. The mother was living. + + _P. H._ The brother of the patient stated that she was like + other girls, and very good at school. At 16 she became + quieter, less energetic. She came to America at 17. After + arriving here she has seemed low spirited, cranky and + faultfinding. She often complained of indefinite stomach + trouble and headaches; when at home she often had a cloth + around her head. The informant recalled that she said, “I + wish I could get sick for a long time and get either cured + or die.” However, she worked. For one and a half years + prior to admission her “crankiness” is said to have become + much worse. She complained continually of being tired; + quarreled much with her mother; said she did not have + enough to eat. It is also stated that she was constantly + afraid of losing her job. + + _History of Psychosis:_ For six months before admission she + said frequently that her boss was giving her hints that he + liked her. (She did not know him socially at all.) Six days + before admission she came home, saying the boss had told + her he had no more work for her. Nevertheless, she went + back next day and was again sent home. At home she sat + gazing. Next day again wanted to go and see the boss, but + was prevented. At times she tried to get out of the window; + again sat gazing, repeating to herself “Always be true.” + She said she was in love with the boss. When the doctor + gave her medicine she thought it was poison. Finally she + began to be talkative and elated. At the _Observation + Pavilion_ she became very quiet. + + _Under Observation:_ She lay in bed indifferent, not + eating, unless spoon-fed, when she would swallow. She + soiled herself. She answered no questions as a rule, and + only on one occasion, when urged considerably, said in + answer to questions that this was a hospital, so that she + evidently had more grasp on the nature of her environment + than her behavior indicated. To her brother who called on + her during the first ten days she said she could not find + her lover here (an idea inconsistent with the benign stupor + picture). + + Then she became more markedly stuporous, drooling saliva, + very stiff, often lying with head half raised, gazing + stolidly, never answering, soiling. Later, after a month, + this was less consistent. She now and then went to the + closet, sometimes she smiled, ate some fruit brought to + her, spoke a little. Repeatedly when people came she clung + to them, wanted to go home, again was seen to weep + silently. On another occasion she suddenly threw the dishes + on the floor with an angry mood, without there being any + obvious provocation. Again she got quite angry when urged + to eat her breakfast, and on that occasion pulled out some + of her own hair. Usually she had to be fed, was stiff, + sitting with closed fists, not reacting as a rule in any + other way, wholly inaccessible and has been that way for + years. The stupor merged into a catatonic state merely by + the development of the inconsistency in her affective + reactions. + +We see then that inconsistencies among the stupor symptoms themselves +and the intrusion of definitely dementia præcox symptoms differentiate +the malignant from the benign reactions. As a matter of fact, we find, +as a rule, that careful examination of the onset reveals further +atypical features, suggestions or definite evidences of a dementia +præcox reaction before the stupor itself appears. One common occurrence +is a slow deterioration of character and energy that proceeds for months +or years before flagrantly psychotic symptoms appear. + +Then when delusions or hallucinations are eventually spoken of by the +patient, an appropriate or adequate reaction is lacking. In a benign +psychosis false ideas do not appear with an equable mood unless the +stupor reaction has already begun. + +More important than this, although in benign stupors there may be a +reduction or an insufficient affect, it is never inappropriate. This +pathognomonic symptom of dementia præcox frequently occurs in the onset +to malignant stupors. In fact we often find in reviewing such cases that +a plain dementia præcox reaction has been in evidence, that a diagnosis +has not been made simply because the stupor picture blotted out this +earlier psychosis before an opinion was formed. Frequently these early +symptoms are reported in the anamnesis and not actually observed by the +physician. + +Three cases may be cited as examples of dementia præcox onsets. It will +be noted that the ensuing stupors were, like those already quoted, +atypical. + + + CASE 23.--_Catherine H._ Age: 21. Admitted to the + Psychiatric Institute October 10, 1904. + + _F. H._ The mother’s brother had two attacks of delirium + tremens. The mother died when the patient was eleven years + old; she is said to have been normal. The father was + living. + + _P. H._ The patient was always a nervous child, had very + bad dreams, but she was smart at school up to ten or + eleven, and played with other girls. Then she began to work + less well, got thin, more nervous, complained of headaches. + It was about that time that her mother died. (The reaction + to the death was said not to have been different from that + of her sister.) She was kept at home and was quiet.... “You + could see something was working on her.” She began to + menstruate at 14, and it was claimed that she then wakened + up a little. It was further stated that she was always + “stuck up” about her clothes. + + At 16 she went to work in a factory, but her sister thought + the work was too much for her, so she was taken home. + Thereafter she lived alone with her father, doing his + housework, her sister having married about that time. At 17 + her hair began to come out excessively, so that she had to + cut it, and when it grew again it was gray. She became very + sensitive about this, even refused to take positions + because she thought people would remark about it. + + For two years before admission she evidently was different. + Although she did her father’s housework well enough, she + turned against her sister and refused to speak to her + because, she alleged, the sister had not come to help her + in her housework. Another pronounced manifestation during + that time was her frequent talk about her bowels. She + complained of constipation, creepy, crawling sensations in + the stomach which she thought was a “tapeworm.” She got + pamphlets and took patent medicines. She was taken to a + physician nine months before admission, who operated on her + for piles. While still in the hospital she asked her father + to take her home to die (although there was no reason for + such a request). Again she said the gauze had been left in + the rectum too long and that the rectum was full of wind. + Later she said the rectum was closing up. After this, the + sister stated, she was extremely nervous if she passed a + day without a movement of the bowels. She was quiet + henceforth, went out less and said little, claiming it was + better for her head if she said little. She often sat, head + in hand, in the hall. All through the summer she frequently + remarked, “I am a good girl.” Four months before admission + during a period of five weeks she would let her bowels move + when standing up. This was relieved by enemas. The father + states that she was cranky to him, that sometimes when he + merely asked a question she would say, “You hurt my + feelings,” and once, “You break my heart.” Occasionally she + seemed to worry about the money spent for her on doctors + and medicine. + + About two months before admission she said everybody was + looking at her. Ten days before admission she said, “I have + been sick all this time and thought I was going to die. Now + I think Tom (her brother) is going to die.” She became + fearful of being left alone. Finally she went to the + priest, who told her to go home. Then she prayed, leaving + the candles burning in the room. That night she was found + kneeling before a church in her nightgown. Again she threw + a lot of articles into the yard, saying a curse had been + put on her by her father, and she did not wish to give him + anything. When she was taken to the Observation Pavilion + she said, “I am a good girl--my mother is dead--it is all + my father’s fault.” + + At the _Observation Pavilion_ she put her arm under a hot + water faucet “to save the world,” prayed and laughed--again + sank back and appeared as if asleep. She said, “I hear + angels telling me how to pray when I lose my + thoughts--sisters and nuns are all around me here, to save + and purify the world now and forever, and at the hour of + our death.” + + _Under Observation:_ On admission the patient kept her eyes + closed, sang hymns in measured tones, or prayed, or showed + a certain ecstasy in her face while her lips quivered and + tears ran down her cheeks. On the whole, she answered few + questions. When asked how she felt, she said she was happy. + (Why do you cry?) “I was crying when I asked God to save + souls.” (Are you afraid?) “Not now, I have been afraid of + everything on Earth ever since my mother died.” (What do + you mean?) “No one would look at me or talk to me--they + said I was a bad girl, but I was pure.” Again she said, + “They laughed about me, talked about me--and they drew up a + play about me--Devil’s Island.” Or she spoke about having + had stomach trouble, bowel trouble, teeth trouble, eye + trouble, compound, complicated trouble. (What do you mean?) + “Father scolding all the time, he sent me to get bug + medicine (true). God gives that medicine to the one that + started all the trouble--Devil’s Island.” + + She soiled her bed and was asked why she did it. She said + “I have been transformed into a baby, the Lord said I was + too pure to be a woman--I had to become a baby to save the + world.” Or when asked her name she called herself “Baby + Chadwick of the whole world--divine Irish Catholic + World--Amen,” or again “I am the Roman Catholic Irish + Divine Baby.” + + Although she was not essentially disoriented she called the + place “mid-heaven,” or “a holy house, sort of a hospital.” + She also said, “In two years more there will be a new world + and it will be more happy and holy.” + + The day after entrance the patient, though in part as + described, had a spell when she kept her eyes closed and + was rigid. Spells like these returned. (About a month after + admission she became completely stuporous.) She prayed at + times, at other times was constrained, or kept her eyes + closed. Her orientation throughout was good. The content of + her psychosis, in addition to the praying attitude, had a + more or less vague religious coloring. Thus she called the + hospital the “House of God.” Again, when on one occasion + she had jumped at the window guard and was asked “why?” she + said “holy communion.” Again she said she was “Mary, Virgin + Mother.” But this religious trend was intermingled with + remarkable elements of another sort. Thus when in order to + study her knowledge of the events after admission, she was + asked what she had done when she was brought into the ward, + she said, “I went into the sanctuary where my bowels moved + and water passed from me.” (Why do you call it sanctuary?) + “Because Jesus did the same thing I did.” + + Possibly vague sexual allusions are also contained in the + following: She said one day to the doctor, “Everything went + wrong last night, good, pure, true and holy doctor, I led + you astray and you were dying last night, may the Almighty + God forgive me, I ought to have died, but I fought it out, + for, if I had died, my mother’s soul would not have been + saved in Heaven and from the flames of Hell.” Again, “I + will not look at you again, good, pure, holy doctor of the + world.” (Why?) “I am afraid I will lead you astray.” And + also: “I led James. Peter astray too.” It should be added + that she sometimes masturbated rather shamelessly. + + She said she heard her mother’s voice. (What did she say?) + “Something in the sky for me, angels call for me.” (What do + the angels say?) “The name of my good mother in Heaven.” + Again she said she had heard her mother the night she came + here. (What did she say?) “It was like a voice--feed the + calf--that means me, I suppose.” + + Then after a month the stupor became more continuous. She + lay totally inactive for the most part, had to be fed, + soiled herself, drooled saliva, was at times cataleptic, + often rigid. Her limbs became cyanotic. A few times tears + were seen. On other occasions she whispered “peace,” or + “peace for hazing,” or “pray--peace,” or “I like to be + good.” Usually no responses could be obtained. + + After some months she was at times seen laughing. This + gradually passed into a state of total disinterestedness + and inaccessibility. She could finally be made to polish + the floor in an automatic fashion, but never spoke, and + five years after admission she was transferred to another + hospital, where she died (eleven years after admission to + the ward of the Institute) without any change in her mental + condition having taken place. + + + CASE 24.--_Adele M._ Age: 22. Admitted to the Psychiatric + Institute November 11, 1904. + + _P. H._ The father stated that the patient was always + “cranky,” had outbursts of temper, even when a small child + and was quarrelsome; also said that she was “seclusive,” + had few friends, was averse to meeting people, never had a + beau. She was taken out of school at 14 because she was not + promoted on two successive occasions from the same class. + Then she was put to work, but she was usually discharged + for incompetency. + + _Onset of Psychosis:_ Three years before admission it was + noted that she laughed occasionally without cause. She was + idle. This laughing, and also crying, was sometimes more + frequent, again less noticeable. + + Six months before admission she began to say she wanted to + leave home, but made no move to do so. Then she began to + speak of bad odors, made some remarks about the neighbors + talking about her--saying she should kill herself; again + she said the family would be brought to death, or the + mother was falling to pieces, the father looked sick. She + also said her head was swelling and was getting thick. + Finally she wanted to hire a furnished room and kill + herself and asked if 75 cents which she had was enough to + do it with. + + Two weeks before admission she left home, wandered about + all night, was picked up by the Salvation Army, and + returned to her home. She said she wanted to die. + + At the _Observation Pavilion_ she stated that her mother + was falling to pieces and her father sick. She also said + she wanted to die. + + _Under Observation:_ The patient was at first petulant, + saying “I don’t want to stay here,” turning her face away + from the doctor, generally uninterested. Though it could be + established that she was quite oriented, often her answers + were “I don’t know,” or she did not answer. But she was + also seen crying at times, and she was apt to bite her + finger nails. She had to be tube-fed. Gradually these + tendencies increased so that she lay in her bed with head + covered, saying in a peevish tone, when spoken to, “Oh, let + me alone.” And for years she was mute, lying with her head + covered, tube-fed. When reëxamined in 1914 (ten years + later), she was found lying in bed with an empty smile. + There was paper stuffed in her ears. When approached, she + turned her head away and would not talk. + + + CASE 25.--_Catherine W._ Age: 42. Admitted to the + Psychiatric Institute November 11, 1904. + + _F. H._ The father died at 75, the mother at 44. Two + sisters died of tuberculosis. A brother wanted to marry but + was opposed by the father; he set fire to the house of the + girl and then drowned himself. + + _P. H._ The patient came to this country when 20, and + worked for some years as a servant. Then she married after + a short acquaintance. The husband, according to his own + statement, drank, and there was friction from the first. + She left him a few weeks after marriage, and a few months + later he went to Ireland; she also went some time later but + did not go to see him. Then they lived together again. They + had four children, but had had no intercourse for nine + years. + + _Development of Psychosis:_ Eight years before admission + the patient became nervous, slept badly, but got better. It + was claimed that for six years she had been quieter and + more sullen than before. Three years before admission the + patient had to take a place as janitress, since she needed + the money. From the first she had trouble with the tenants + and accused everybody of being in league against her. Some + six or eight weeks after she had taken the position, she + developed what was called typhoid fever, and some time + later the daughter came down with the same disease. After + the typhoid she was more antagonistic towards her husband, + accused him of infidelity, repeatedly locked him out of the + house, but continued to do her housework. About six months + after this illness she left her home, but returned in a + week. She had vague ideas thereafter that the priests were + saying things against the family, and she often quarreled + with the tenants. For a year she had done no work but sat + about. Ten days before admission she stopped eating. + + _Under Observation:_ The patient was mute, stolid, gazing + straight ahead, sometimes cataleptic. She had to be + tube-fed, was usually very resistive to any passive + motions; quite often she retained her urine, but she did + not hold her saliva. Yet there was some quick responses at + least in the beginning. At such times it was found that she + was oriented, but nothing could ever be obtained about her + feelings, etc., except that she once said, when asked + whether she was worried, that she “felt weak,” had “nothing + to worry about.” Occasionally she was seen to cry silently; + at times she would breathe faster when questioned, or + flush; once she took hold of the doctor’s hand when he + questioned her, and cried, but made no reply. On another + occasion she was affectionate to her son, kissed him, + although she paid no attention to her daughter who + accompanied the son. Later she said to the nurses, “He is + the best son that ever lived.” But more and more she became + disinterested, totally inaccessible, resistive, had to be + tube-fed. In this condition she remained for five and a + half years. At the end of that time she died of tubercular + pneumonia. + + + + +CHAPTER XII + +DIAGNOSIS OF STUPOR + + +In any functional psychosis an offhand diagnosis is dangerous. When one +deals with such a condition as stupor, however, the problem is exacting, +for, although “stupor” may be seen at a glance, what is seen is really +only a symptom or a few symptoms. “Stupor,” then, is more of a +descriptive than a diagnostic term. The real problem is to determine the +psychiatric group into which the case should be placed. This is a +difficult task, for the differential diagnosis rests on the observation +and utilization of minute and unobtrusive details. A correct +interpretation can be only reached by obtaining a complete history of +the onset and observing the behavior and speech of the patient for a +long period, usually of weeks, sometimes of months. With these +precautionary words in mind, it may be well to summarize briefly the +diagnostic problems in connection with benign stupor. + +In the first place one naturally considers the differentiation from +conditions of organic stupor or coma. Since psychotic stupors never +develop without some signs of mental abnormality, the history is usually +a sufficient basis for final judgment. In case no anamnesis is +obtainable the functional nature of the trouble may be recognized by the +absence of those physical signs which characterize the organic stupors. +One sees no violent changes in respiration, pulse or blood-pressure, +such as are present in the intoxication comas of diabetes or nephritis. +There is no characteristic odor to the breath, and the urine is +relatively normal. The unconsciousness of trauma or apoplexy is +accompanied by focal neurological signs. Even in aerial concussion (so +frequently seen in the war) where no one part of the brain is +demonstrably affected more than another, there are neurological +evidences of what one might call “physiological” unconsciousness. The +eyes roll independently, the pupils fail to react to light. On the other +hand, there are definite symptoms characteristic of the functional +state. Mental activity is evidenced by a muscular resistiveness or +retention of urine. Even in states of complete relaxation the eyes move +in unison, the pupils react to light, and almost universally the corneal +reflex is present. The patient appears in a deep sleep rather than +actually unconscious. + +The post-epileptic sleep may resemble a stupor strongly. But this +condition is temporary and the situation and appearance of the patient +betrays the fact that he has just had a convulsion. Rarely, protracted +stuporous states occur in epilepsy which closely resemble the conditions +described in this book. In fact it is probable the true stupors may +occur in epilepsy just as in dementia præcox or manic-depressive +insanity. + +There is usually little difficulty in the discrimination of hysterical +stupor. Occasionally it shows, superficially, a similarity to the +manic-depressive type. Fundamentally, there is a wide divergence between +the two processes, in that in the hysterical form a dissociation of +consciousness takes place, the patient living in a reminiscent, +imaginary or artificially suggested environment, while in a true stupor +there is a withdrawal of interest as a whole and a consequent diffuse +reduction of all mental processes. This difference is sooner or later +manifested by the appearance in the hysteric of conduct or speech +embodying definite and elaborated ideas. + +As has been stated fully in the last chapter (to which the reader is +referred), the stupor of dementia præcox is to be differentiated from +that of manic-depressive insanity by the inconsistency of the symptoms +in the former and the appearance of dementia præcox features during the +stupor, such as inappropriate affect, giggling, or scattering. Further, +the nature of the disorder is usually manifest before the onset of the +stupor as such. + +Sometimes very puzzling cases occur in more advanced years when it is +difficult to say whether one is dealing with involution melancholia or +stupor. Such patients show inactivity, considerable apathy and wetting +and soiling, and with these a whining hypochondria, negativism, and +often a rather mawkish sentimental death content without the dramatic +anxiety which usually characterizes the involution state. In these cases +the diagnosis is bound to be a matter of taste. In our opinion it is +probably better to regard these as clinically impure types. They may be +looked on as, fundamentally, involution melancholias (the course of the +disease is protracted, if not chronic) in whom the regressive process +characteristic of stupor is present as well as that of involution. + +Great difficulties are also met with in the manic-depressive group +proper. So often a stupor begins with the same indefinite kind of upset +as does another psychosis that the development may furnish no clew. Any +condition where there is inactivity, scanty verbal productivity and poor +intellectual performance resembles stupor. This triad of symptoms occurs +in retarded depressions, in absorbed manic states and in perplexities. +Negativism and catalepsy are never well developed except in stupor. So +if these symptoms be present the diagnosis is simplified. But they are +often absent from a typical stupor. Let us consider these three groups +separately. + +The most important difference between stupor and depression lies in the +affect. Although inactive and sometimes appearing dull the depressive +individual is not apathetic but is suffering acutely. He feels himself +wicked, paralyzed by hopelessness, and finds proof of his damnation in +the apparent change of the world to his eyes and in the slowness of his +mind. But he is acutely aware of these torments. The stupor patient, on +the other hand, does not care. He is neither sad nor happy nor anxious. +This contrast is revealed not only by the patients’ utterances but by +their expressions. The stuporous face is empty, that of the other lined +with melancholy. The intellectual defect, too, is different. In retarded +depression the patient is morbidly aware of difficulty and slowness, but +on urging often performs tests surprisingly well. In the stupor, +however, one is faced with an unquestionable defect, a sheer +intellectual incapacity. + +In Chapter VIII the differential diagnosis between perplexity and stupor +has already been touched upon. Here again the affect is a point of +contrast. The patient has not too little emotion but too much. The +feeling of intangible, puzzling ideas and of an insecure environment +causes the subject distress, of which complaint is made and which can be +witnessed in the furrowed brow and constrained expression. There is +also, as we have seen, a rich ideational content in these cases, if one +can get at it. The mind is not a blank, as in the stupor, or concerned +only with delusions of death. + +Finally, there are the absorbed manic states. These are the most +difficult, inasmuch as the patient is often so withdrawn and so +introverted that at any given interview there may be no objective +evidence of mood or ideas. Here the development of the psychosis is +often an aid to diagnosis. The patient passes through phases of +hypomania to great exultation, the flight becomes less intelligible, +with this the activity diminishes until finally expression in any form +disappears. If this sequence has not been observed, continued +observation tells the tale. The patient still has his ideas and may be +seen smiling contentedly over them (not vacuously as does the +schizophrenic) or he may break into some prank or begin to sing. Any +protracted familiarity with the case leads to a conviction that the +patient’s mind is not a blank, but that his attention is merely directed +exclusively inward. Then, too, when his ideas are discovered, it is +found that they are not exclusively occupied with the topic of death. + + + + +CHAPTER XIII + +TREATMENT OF STUPOR + + +In dealing with cases of benign stupor the first duty of physician and +nurse is naturally the physical hygiene of the patient. More is needed +to be done in the bodily care of these persons than for most of the +inmates of our hospitals for the insane. It is perhaps no exaggeration +to claim that a deeply stuporous patient needs as much attention as a +suckling babe. In the first place, the patient must be fed. It is +important for mental recovery that the individual in stupor should be +stimulated to effort as much as possible. Consequently there is an +economy of time in the long run in taking pains to get the patient to +feed himself in so far as that is possible. He should be led to the +table and assisted in handling his own spoon and cup. If this is not +practicable, he should then be spoon-fed, and if this in turn is found +to be out of the question, tube-feeding should be resorted to. But this +last should never be looked on as a permanent necessity, but only as a +method of maintaining the patient’s health until such time as he may be +capable of independent taking of nourishment. In exactly the same way it +is of prime importance to get the patient to attend to the natural +habits of excretion. He should be led to the toilet or to a chair +commode, and efforts to this end should be persistent, just as are those +of a good child’s nurse who has the ambition of making her charge +develop normal habits. Naturally those who retain urine and feces should +be watched to see that this retention does not last long enough to +menace health. The physical aspects of treatment are exhausted with +consideration for cleanliness. On account of the stupor patients’ +inactivity and frequent tendency to wetting and soiling, this is a +particularly important consideration. It goes without saying that the +perineal region should be kept scrupulously clean. If any infections are +to be avoided, eyes, nose and mouth should also be cleansed frequently. +A patient who is so indifferent as to keep the eyelids open for such a +long time that the sclera dry and ulcerate is also apt to let flies +settle and produce serious ophthalmic disease. + +Less obvious and more important are the measures undertaken for the +mental hygiene of the case. On account of the tendency present in so +many patients for sudden action while in the midst of an apparently deep +and permanent inactivity, it is necessary that these cases be not +isolated but remain under constant observation. This is particularly +true of those who have demonstrated impulsive suicidal explosions. + +Not only on the basis of the psychological theory of the stupor process, +but from the observed phenomena of recovery, we gather that mental +stimulation is of first importance if an amelioration of the condition +is to be attempted. If the stupor reaction be a regression, which is +essentially a withdrawal of interest and energy rather than a fixation +on a false object, then excitement is desirable and interest must be +reawakened. The withdrawal is temporary (inasmuch as the psychosis is +benign), but just as a normal person wakes more readily on a clear +sunshiny day than when it rains, so the more cheering the environment +the more rapid the recovery. + +Consequently, although trying to those in charge, persistent attention +should be given the patient. Feeding and hygienic measures probably have +considerable value in this work. As soon as it is at all possible the +patients should be got out of bed and dressed. When up, efforts should +be directed towards making them do something, even if it be something as +simple as pushing a floor polisher. On account of their lack of +enthusiasm the stupor cases are often omitted from the list of those +given occupation and amusement. Even if they go through the motions of +work or play with no sign of interest, such exercise should not be +allowed to lapse. Then, too, the environment should be changed when +practicable. A patient may improve on being moved to another building. + +Perhaps the most potent stimulus that we have observed is that of family +visits. In most manic-depressive psychoses visits of relations have a +bad effect. The patients become excited, treat the visitors rudely, +perhaps even assault them, and all their symptoms are aggravated. But +the stupor needs excitement, and an habitual emotional interest is more +apt to arouse him than an artificial one. In another point the situation +differs. As a rule manic-depressive patients have delusional ideas or +attitudes in connection with their nearest of kin, so that contact with +these stirs up the trouble. The stupor regression going beneath the +level of such attachments leaves family relationships relatively +undisturbed. Hence, while the visit of a husband is likely to produce +nothing but vituperation or blows from a manic wife, the stuporous woman +may greet him affectionately and regain thereby some contact with the +world. + +So many cases begin recovery in this manner that it cannot be mere +chance. One patient’s improvement, for instance, dated definitely from +the day a nurse persuaded her to write a letter home. It is striking, +too, how quickly a patient, while somewhat dull and slow, will brighten +up when allowed to return home. A similar improvement under these +circumstances is often seen in partially recovered cases of involution +melancholia, in whom a psychological regression similar to that of +stupor takes place. Such experiences make one wonder whether perhaps +these alone of all our insane patients would not recover more quickly at +home than in hospitals, provided nursing care could be given them. + +This is a mere suggestion. Before treatment can be rational the nature +of any disease process must be known, and we do not pretend to have done +more as yet than outline the probable mental pathology of the benign +stupors. The next step is to put theory into practice and experiment +widely with various means to see if by appropriate stimulation the +average duration of these psychoses cannot be reduced. It is largely +with the hope of inducing other psychiatrists to carry on such work that +this book is written. There is no other manic-depressive psychosis +which, theoretically, offers such hope of simple psychological measures +being of therapeutic value. + + + + +CHAPTER XIV + +SUMMARY OF THE STUPOR REACTION + + +Having discussed in detail the various symptoms and theoretic aspects of +the benign stupors, it may be well to have these observations and +speculations summarized. + +It being established that stupors occur as a temporary form of +insanity[12] psychiatry is faced at once with the problem of describing +these conditions accurately in order to ascertain their nosological +position. To this end we first examined typical cases of deep stupor and +found that the clinical picture is made up of the following symptoms: In +the foreground stands _poverty of affect_. The patients are almost +unbelievably apathetic, giving no evidence by speech or action of +interest in themselves or their environment, unmoved even by painful +stimuli. Their faces are wooden masks; their voices as colorless when +words are uttered. In some cases sudden mood reactions break through at +rare intervals. The second cardinal symptom is _inactivity_. As a rule +there is a complete cessation of both spontaneous and reactive movements +and speech. So profound may this inhibition be that swallowing and +blinking of the eyes are often absent. The trouble is not a paralysis, +however, for reflexes without psychic components are unaffected. +Possibly related to the inactivity is the preservation of artificial +positions which is called _catalepsy_, a fairly frequent phenomenon. A +tendency opposite to the inactivity is seen in _negativism_. This +perversity is present in all gradations from outbursts of anger with +blows and vituperation to sullen, or even emotionless, muscular +rigidity. This last occurs most often when the patient is approached but +may be seen when observations are made at a distance. Frequently +_wetting_ and _soiling_ are due to negativism, when the patient has been +led to the toilet but relaxes the sphincters so soon as he leaves it. A +constant feature is a _thinking disorder_. On recovery memory is largely +a blank even for striking experiences during the psychosis and, when +accessible during the stupor to any questioning, a failure of +intellectual functions is apparent. An _ideational content_ may be +gathered while the stupor is incubating, during interruptions, or from +the recollections of recovered patients. Its peculiarity is a +preoccupation with the theme of death, which is not merely a dominant +topic but, often, an exclusive interest. Probably to be related to this +is a tendency, present in some cases, to sudden suicidal impulses, that +are as apparently planless and unexpected as the conduct of many +catatonics. Finally the disease is prone to exhibit certain _physical_ +peculiarities. A low fever is common and so are skin and circulatory +anomalies. A loss of weight is the rule, and menstruation is almost +always suppressed. + +As to the frequency of stupor no figures are available, for the simple +reason that the diagnosis in large clinics has not been made with +sufficient accuracy to justify any statistics. Most of these cases are +usually called catatonia, depression, allied to manic-depressive +insanity or allied to dementia præcox. The majority of the stupors +reported in this book were in women, but this is merely the result of +chance, since it has been easier in the Psychiatric Institute to study +functional psychoses in the female division, while the male ward has +been reserved largely for organic psychoses. The majority of the +patients seem to be between 15 and 25 years of age, so that it is, +presumably, a reaction of youthful years. In our experience most cases +occur among the lower classes, which agrees with the opinion of Wilmanns +who found this tendency among prisoners. + +This gives a brief description of the deep stupor. But even our typical +cases did not present this picture during the entire psychosis. They +showed phases when, superficially viewed, they were not in stupor but +suffered from the above symptoms as tendencies rather than states. There +are also many psychoses where complete stupor is never developed. This +gives us our justification for speaking of the _stupor reaction_, which +consists of these symptoms (or most of them) no matter in how slight a +degree they may be present. The analogy to mania and hypomania is +compelling. The latter is merely a dilution of the former. Both are +forms of the manic reaction. We consequently regard stupor and partial +stupor as different degrees of the same psychotic process which we term +the stupor reaction. To understand it the symptoms should be separately +analyzed and then correlated. + +The most fundamental characteristic of the stupor symptoms is the change +in affect which can be summed up in one word--apathy. It is fundamental +because it seems as if the symptoms built around apathy constitute the +stupor reaction. The emotional poverty is evidenced by a lack of +feeling, loss of energy and an absence of the normal urge of living. +This is quite different from the emotional blocking of the retarded +depression, for in the latter the patient shows either by speech or +facial expression a definite suffering. The tendency to reduction of +affect produces two effects on such emotions as internal ideas or +environmental events may stimulate. Exhibitions of emotion are either +reduced or dissociated. For instance, anxiety is frequently diminished +to an expression of dazed bewilderment; or, isolated and partial +exhibitions of mood occur, as when laughter, tears or blushing are seen +as quite isolated symptoms. This latter--the dissociation of +affect--seems to occur only in stupor and dementia præcox. It should be +noted, however, that inappropriateness of affect is never observed in a +true benign stupor. A final peculiarity is the tendency to interruption +of the apathetic habit, when the patient may return to life, as it were, +for a few moments and then relapse. + +Closely related to the apathy, and probably merely an expression of it, +is the inactivity which is both muscular and mental. It exists in all +gradations from that of flaccidity of voluntary muscles, with relaxation +of the sphincters, and from states where there is complete absence of +any evidence of mentation to conditions of mere physical and psychic +slowness. After recovery the stupor patient frequently speaks of having +felt dead, paralyzed or drugged. + +By far the commonest cause of emotional expression or interruption in +the inactivity is negativism. This is a perversity of behavior which +seems to express antagonism to the environment or to the wishes of those +about the patient. In the partial stupors it is seen as active +opposition and cantankerousness. In the more profound conditions it is +represented by muscular resistiveness or rigidity, or refusal to swallow +food when placed in the mouth. Occasionally, too, the patient may even +in a deep stupor retain urine so long that catheterization is necessary. +All the explanations which one may gather from the patients’ own +utterances, mainly retrospective, seem to point to negativism expressing +a desire to be left alone. The appearance of perverse behavior in +aimless striking or mere muscular rigidity seems to be an example of +dissociation of affect. + +Catalepsy is an important symptom because, although it occurred in +slightly less than a third of our cases, it seems to be a peculiarity of +the stupor reaction found but rarely in other benign psychoses. It seems +never to occur without there being some evidence of mental activity, +and, consequently, we are forced to conclude that it is of mental rather +than of physical origin. Just what it means psychically it is impossible +to state without much more extended observations. We conjecture +tentatively, however, that the retention of fixed positions is in part +merely a phenomenon of perseveration, and in part an acceptance of what +the patient takes to be a command from the examiner, and sometimes a +distorted form of muscular resistiveness. + +The intellectual processes suffer more seriously in stupor than in any +other form of manic-depressive insanity. Not only do the deep stupors +betray no evidence of mentation during the acme of the psychosis, but +retrospectively they usually speak of their minds being a blank. +Incompleteness and slowness of intellectual operations are highly +characteristic features of the partial stupors and of the incubation +period of the more profound reactions. The features of this defect are a +difficulty in grasping the nature of the environment, a slowness in +elaborating what impressions are received, with resulting +disorientation, poor performance of any set tests and incomplete memory +for external events when recovery has taken place. At times the thinking +disorder may develop with great suddenness or improve as quickly, and a +tendency to isolated evidences of mental acuity is another example of +the inconsistency which is so highly characteristic of stupor. We should +note, however, that these sporadic exhibitions of mentality are always +associated with brief emotional awakening. + +When we turn to examine the fragmentary utterances of stupor patients, +we are surprised by the narrowness and uniformity of the ideational +content. It seems to be confined to thoughts of death or closely related +conceptions. Thirty-five out of thirty-six consecutive cases at one time +or another referred literally to death. It is commonest during the +onset, as all but five of these patients spoke of it during the +incubation of their psychoses. Hence we conclude that death ideas and +stupor are consecutive phenomena in the same fundamental process. As +two-thirds of the series interrupted the stupor to speak of death or to +attempt suicide, we assume that this relationship persists. Only a +quarter gave any retrospective account of these fancies, so we presume +that their psychotic experiences were repressed with recovery. + +The usual form in which the idea appears is as a delusion of going to +die or, literally, of being dead. It may appear as being in Heaven or +Hell. A theoretically important group is that which includes the +patients who, in addition, speak of being in situations such as under +the water or underground, which we have mythological and psychological +evidence to believe are formulations of a rebirth fantasy. Not rarely, +preoccupation with death is expressed in sudden impulsive suicidal +attempts. + +The affective setting of these different formulations is important. A +delusion of literal death occurs with complete apathy. The wish to die +is apt to appear without the usual accompaniment of sadness or distress +but still with considerable energy when impulsive suicidal attempts are +made. A prospect of death, particularly when there is anticipation of +being killed, is apt in manic-depressive insanity to occur in a setting +of anxiety. Similarly one ordinarily observes fear in the patient who +has delusions of drowning or burial. In the stupor cases, however, this +painful affect seems to be reduced to a mere dazed bewilderment or +feeble exhibitions of a desire for safety, such as the slow swimming +movements of a patient who thought she was under the water. When these +ideas of danger become allied to everyday interests--husband or child +imperiled, etc.--a weak affect in the form of depression is apt to +occur. + +Physical symptoms are more common than in any other benign psychosis. Of +these the most nearly constant is a low fever, the temperature running +between 99° and 101°. Twenty-eight out of thirty-five cases had this +slight elevation with a tendency for it to occur immediately at the +beginning of marked stupor symptoms. Although the evidence does not +positively exclude any possibility of infection, it speaks distinctly +against this view. A possible explanation is that the low fever is a +secondary symptom. The suprarenal glands may function insufficiently as +a consequence of the emotional poverty, since all emotions which have +been experimentally studied seem to stimulate the production of +adrenalin. Without this normal hormone for the activity of the +sympathetic nervous system, there would be a disturbance of skin and +circulatory reactions that would interfere with the normal heat loss. +Suggestive evidence to support this view comes from the frequency with +which the extremities are cyanotic or cold, the skin greasy, sweating +profuse or absent, and so on. Further observations are necessary to +confirm or disprove this hypothesis, but we feel inclined to accept it +tentatively because it is plausible and consistent with the view that +stupor is essentially a psychogenic type of reaction. Another physical +anomaly, which is presumably of endocrine origin, is the suppression of +the menses. This probably results from lowered nutrition. In some cases +it ensues directly on a psychic crisis before any nutritional change can +have taken place. Finally, among the symptoms of possible physical +origin, epileptoid attacks were described in two of our cases. This is +chiefly of interest in that such phenomena are extremely rare in the +benign psychoses. + +We believe that the mental symptoms summarized above constitute a +specific psychotic type of reaction capable of appearing in any severity +from mere lethargy and indifference to profound stupor. Since the +prognosis is good, we feel obliged to classify this with the +manic-depressive reactions. Further justification for this grouping is +found in the occurrence of the stupor reaction as a phase in many +manic-depressive psychoses. A patient may swing from mania to stupor as +from mania to depression, and when the partial stupors are recognized as +milder forms of the same process, it seems to be a frequent type of +reaction. + +If stupor be a reaction type, its laws must be psychological. According +to the view of modern psychopathology, the essence of insanity is +regression with indolent thinking as opposed to progressive and +energetic mentation. One can look on stupor as being a profound +regression. Effort is abandoned (apathy and inactivity), while the +ideational content expresses a desire for a retreat from the world in +death. It is possible to think of this regression as a return to the +mental habit of the suckling period, when spontaneous effort is at its +minimum. This, too, is the time when petulance and tantrums are frequent +expression of a wish to be left alone, which may account for the +negativism as a consistent symptom of the same regressive progress. + +Just as we regress in sleep, to rise refreshed for a new day’s duties, +so the stupor case often shows excessive energy in a hypomanic phase +before complete normality is reached. This corresponds again to the +age-old association of the ideas of death and rebirth which we see +together so frequently in stupor. It is the psychology of wiping the +slate clean for a fresh start. + +The development and symptoms of stupor furnish evidence in support of +the hypothesis of this type of regression. Dissatisfaction of any kind +is the setting in which the psychosis begins and the commonest +precipitating factor is some reminder of death. That loss of energy +appears with the stupor is evident from the inactivity and apathy, while +the thinking disorder can be shown to be the result of the same loss. +The different “levels” of the stupor reaction also conform to a theory +of regression. First there is mere indifference and quietness; then +appear false ideas when normality is so far abandoned as to mean a loss +of the sense of reality; withdrawal of interest from the environment, +with its consequent centering of self, leads to the next stage--that of +the spoiled child reaction; then follows the exclusion of the world +around in the dramatization of death; finally, in the deepest stupor, +mentation is so far abandoned that we can gather no evidence of even +this delusion being present. + +Atypical features in stupor have to do mainly with interruptions, +interludes as it were, of elation, anxiety or perplexity. These are +explicable as awakenings from the nothingness of stupor into +imaginations such as characterize the other manic-depressive psychoses. +When such tendencies are present, the co-existence of the stupor process +may tone down the emotional response or prevent its complete repression +so that insufficient or dissociated affects appear. A combination of the +stupor tendency to apathy with the mood of another reaction is probably +the only combination of affects to be met with in psychiatry. + +The stupor reaction, then, is a simple regression, with a limitation of +energy, emotion and ideational content, the last being confined to +notions of death. All functional psychoses are regressions. How do the +others differ from this? We need only answer this question in so far as +it concerns the clinical states resembling benign stupors. Stupors occur +frequently in catatonic dementia præcox. In this disease there is a +regression of interest to primitive fantastic thoughts, and with this a +perversion of energy and emotion. This corrupts the purity of the stupor +picture so that inconsistencies, such as empty giggling, atypical +delusions and scattered speech, occur. Other impurities are to be found +in the frequent orientation of the dementia præcox stupor patient which +is discovered to be astonishingly good, or in free speech associated +with apathy and inactivity. Such symptoms usually appear quite early and +should enable one to make a positive diagnosis within a short time after +patient comes under observation. As a matter of fact, in many if not +most cases there is a slow onset characterized by the pathognomonic +symptoms of dementia præcox before the actual stupor sets in. + +Other psychoses superficially resembling stupor are the perplexity and +absorbed manic (manic stupor) states. We have reason to believe that +both these conditions are essentially the result of absorption in +kaleidoscopic ideas. Their appearance is that of inactivity and +indifference to the outside world, just as a dreamer seems placid and +apathetic. But these reactions are not without emotion which may +sometimes be obvious, and the richness of the mental content is sooner +or later manifest. + +Finally, from a practical standpoint, an important peculiarity of benign +stupor is the tendency for response to stimulation in amelioration of +the process. Close attention to these patients is advisable, therefore, +not merely for the sake of their physical health, but also because any +attention tends to keep them mentally alive or revive their waning +energy. Visits of relations often initiate recovery in a striking way. +From occurrences such as these, psychiatrists should gain hints for +valuable therapeutic experiments. + +So much for the technical, psychiatric aspects of the stupor problem. We +have frequently spoken of it, however, as a psychobiological reaction. +If this be a sound view, similar tendencies should appear in everyday +life, the psychotic phenomena being merely the exaggerations of a +fundamental type of human and animal behavior. Shamming of death in the +face of danger and animal catalepsy come to mind at once, but since we +know nothing of the associated affective states we should be chary of +using them even as analogies. We are on safer ground in discussing +problems of human psychology. + +It is evident that there are psychological parallels between the stupor +reaction and sleep, while future work may show physiological +similarities as well. Apathy towards the environment, inactivity and a +thinking disorder are common to both. But sleep reactions do not occur +in bed alone. Weariness produces indifference, physical sluggishness, +inattention and a mild thinking disorder such as are seen in partial +stupors. The phenomena of the midday nap are strikingly like those of +stupor. The individual who enjoys this faculty has a facility for +retiring from the world psychologically and as a result of this psychic +release is capable of renewed activity (analogous to post-stuporous +hypomania) that cannot be the result of physiological repair, since the +whole affair may last for only a few minutes. + +In everyday life there are more protracted states where the comparison +can also be made. When life fails to yield us what we want, we tend to +become bored--a condition of apathy and inactivity, forming a nice +parallel to stupor inasmuch as external reminders of reality and demands +for activity are apt to call out irritability. A form of what is really +mental disease, although not called insanity, is permanent boredom, a +deterioration of interest, energy and even intelligence by which many +troubled souls solve their problems. A sudden withdrawal from the world +we call stupor. When the same thing happens insidiously, the condition +is labeled according to the financial and social status of the victim. +He is a bum, a loafer, a mendicant or, more politely, a disillusioned +recluse. Frequently this undiagnosed dement has satisfied himself with a +weak, cynical philosophy that life is not worth while. + +It is but a step from valueless life to death and the same tendency +which makes the patient fancy he is dead, leads the tired man to sleep, +the poet to sigh in verse for dissolution, and the myth maker to +fabricate rebirth. The religions of the world are full of this yearning, +which reaches its purest expression in the belief and philosophy of +Nirvana. The ideational content of stupor has also its analogue in +crime. The desire for perpetuation of relationships unprosperous in this +world is not seen only in the delusion of mutual death. One can hardly +pick up a newspaper without reading of some unhappy man or woman who has +slain a disillusioned lover and then committed suicide. + + +FOOTNOTES: + +[12] Kirby, George H.: “The Catatonic Syndrome and Its Relation to +Manic-Depressive Insanity.” _Jour. of Nervous and Mental Disease_, Vol. +XL, No. 11, 1913. + + + + +CHAPTER XV + +THE LITERATURE OF STUPOR[C] + + +The cases of benign stupor which we report here are not clinical +curiosities. Taking the symptoms as the products of a reaction type, the +latter is really quite common. One, therefore, asks what other +psychiatrists have done with this material. How have they described +these stupors, how classified them? This chapter, essentially an +appendix, attempts to give a brief answer to this inquiry. No attempt is +made to catalogue all that has been written on or around this subject +but only to mention typical reports and viewpoints. + +The French, beginning with Pinel in the 18th Century, were the first to +write extensively of stupor. An excellent paper by Dagonet[13] appeared +in 1872, in which such literature as had appeared up to that time is +discussed. He defines “Stupidity” as a form of insanity in which +“delirious” ideas may or may not be present, which has for its +characteristic symptoms a state of more or less manifest stupor and a +greater or less incapacity to coördinate ideas, to elaborate sensations +experienced and accomplish voluntary acts necessary for adaptation. This +would seem to include our “partial stupor,” as well as the more marked +cases. + +He quotes an excellent definition from Louyer Villermay (Dict. des sc. +méd. t. LIII, p. 67). “Stupor is a term applied to stupefaction of the +brain. It is recognizable by the diminution or enfeeblement of internal +sensation and by a greater difficulty in exercising memory, judgment and +imagination. It is accompanied by a general numbness and a weakness of +feeling and movement. The patient, then, has an indefinite and stupid +expression, he understands questions put to him with difficulty, and +answers them with effort or not at all. He seems overwhelmed with sleep, +he forgets to withdraw his tongue after showing it to the doctor, he +complains of no uncomfortable sensation, of no illness, he seems to take +no interest in what goes on about him.... The stupor patient is a fool +who does not speak, in this being more tolerable than the one who speaks +[delightful naiveté!]. One who is dumbfounded by surprise or fright is +also to be called stuporous.” + +Dagonet says stupor results from various causes, such as exhaustion, or +emotional and intellectual factors. Clinically it varies in kind and +degree according to the situation in which it develops. When it develops +during normal mental health, it disappears when its cause does. In +insanity it appears in the course of a psychosis of some duration, of +which it seems a part, an exaggeration of some symptom of the general +condition. Evidently he views stupor as a type of reaction: as a more or +less complete suspension of the operation of intellectual faculties, a +more or less sudden subtraction of nervous forces. This reaction can +result from a fright or the memory of it, a brain lesion or trauma, the +action of narcotics, exhausting fevers, excessive grief, the terrors of +alcoholic hallucinations, epileptic seizures, profound anemia and +nervous exhaustion consequent on sexual excess. He is careful to say +that both symptoms and treatment vary with the varied etiologies. + +He credits Pinel with being the first to call attention to stupor. This +author claimed that some persons with extreme sensibility could be so +upset by any violent emotion as to have their faculties suspended or +obliterated. He noted, too, that stupors frequently terminated in manic +phases of 20 to 30 days’ duration. Pinel also emphasized the apathy of +these cases. Esquirol called stupor “acute dementia,” a term which +persisted in French literature for a long time. He described an +interesting circular case where alternations between mania and typical +stupor took place. He mentions too the dangerous, impulsive tendencies +of many patients. Georget emphasized the fact which Pinel had also +noted, that retrospectively the stupor patient says his mind was a blank +during the attack. In 1835 Etoc-Demazy published on the subject. He +regarded stupor not as a separate form of insanity but a complication +ensuing on monomania or mania. He recognized the partial as well as +complete stupor. He thought the condition was due to cerebral edema, as +did other writers of that period. Dagonet remarks about this last--a +lesson not learned in fifty years by the profession--that demonstrable +edema does _not_ produce the typical symptoms of stupor. Baillarger in +1843 (Annales Médico-psychologiques) was the first whose ambition to +simplify psychiatric types led to denial of a separate kind of reaction. +He claimed that stupor was not a form of insanity but an extension of a +“délire mélancholique.” As Dagonet remarks, every symptom by which he +characterizes stupor is a psychiatric symptom and insanity can consist +just as well in the diminution as the perversion or exaltation of normal +faculties. Some of Baillarger’s cases had false ideas, some apparently +none at all. Dagonet thinks this justifies two types, one a dream-like +state and another where no ideas are present, although he admits one may +be an exaggeration of the other. Brierre de Boismont (Annales +Médico-psychologique, 1851, p. 442) compares these two kinds of stupors +to deep sleep when intelligence is completely suspended and to sleep +with dreams. (These two types would correspond to our “absorbed mania” +and true deep stupor.) He urges strongly the separation of stupor from +melancholia as an entirely different type of reaction, in this +connection citing the views pro and con of various authors. Of these +Delasiauve is particularly cogent in discriminating stupor from +melancholia on the grounds of the difference of the emotional reactions +and of the intellectual disorder and the real paucity of thought in the +former psychosis. + +After quoting these and other authors, Dagonet offers an explanation for +the diversity of opinion. He says that stupor following another +psychosis may retain some of its symptoms, so that a mixture obtains, as +often in medicine. He then gives excellent descriptions of three types: +the deep stupor with paralysis of the faculties, the cases that are +absorbed in false ideas, and ecstatic cataleptics. + +The remainder of his paper is concerned with cases and discussions about +them. He cites examples of stupor following fear or other emotional +shocks, following grave injuries such as the loss of a limb, following +head trauma and with typhoid fever. As to the last he points out that +delirious features are prominent. Many authors have assigned sexual +excesses as a cause of stupor. The psychosis, Dagonet says, is not pure +but more a mixture of hypochondria and depression. Relationship with +mania is next considered. He says that stupor may succeed, alternate +with or precede mania. His cases seem mainly to have been what we call +absorbed manics or manic stupors. In fact, he uses the last term. The +commonest introductory psychosis, he claims, is depression, but from his +brief case reports it would seem that most of his patients were not +stuporous, in the narrow sense of the term, but severely retarded +depressions. In fact, in perusing his case material comprising “stupors” +in the course of many types of functional insanity, or as a complication +of epilepsy or general paralysis, it is evident that in practice he does +not follow the discriminative definitions of the earlier portion of his +paper. For him, apparently, patients who are markedly inaccessible to +examination from whatever cause are “stuporous.” He closes with +excellent remarks on physical and psychic treatment. As to prognosis he +has nothing to say beyond the opinion that most of the cases recover. + +If Dagonet be accepted as summarizing the early French work, we can +conclude that their generalizations were on the whole quite sound. These +were: that stupor is an abnormal mental reaction, usually psychogenic +but often the result of exhaustion, that it consists in a paralysis of +emotion, will and intelligence; that the prognosis is usually good; that +mental stimulation may produce recovery. What remained to be done after +this work was the refinement in detail of these generalizations, +particularly in respect to the differentiation of prognostically benign +and malignant types. But other Frenchmen did not take up this work, +apparently, for the brilliant psychopathologists of the next generations +attended to stupor only in so far as it was hysterical. + +An Englishman, however, soon took up the task, adding more exactness to +his formulations. Newington[14] published his important paper in 1874. +A nascent stage of stupor, he thinks, is a common reaction to great +exhaustion, “such as hard mental work, prolonged or acute illness, +dissipation, etc.” Such conditions, like the grave psychotic forms, he +regarded as due to physical exhaustion of the brain cells, but, since he +thought psychic stress could produce this exhaustion, this “organic” +view did not bias his general formulations. He makes a division into two +stupors: Anergic Stupor and Delusional Stupor. The former may be +primary, being generally caused by a sudden intense shock (Esquirol’s +“Acute Dementia”), or secondary (a) to convulsions of any kind, (b) to +mania in women, (c) to any other prolonged nervous exhaustion. The +delusional form results from (a) intense melancholia, (b) from general +paralysis in which it may be intercurrent, (c) from epileptic seizures. +When one examines his points of difference between these two types, it +becomes clear that Newington really gave an excellent differentiation of +benign and malignant stupor--in fact, it is the only serious attempt at +such discrimination prior to this present work. What is more remarkable +is the fact that, although he clearly saw the clinical differences, he +failed to see that the two types differed prognostically. His +description is given in a table sufficiently concise to justify its +quotation _in extenso_. + + _ANERGIC STUPOR_ _DELUSIONAL STUPOR_ + + _Etiology_--Hereditary and Hereditary. + individual liability to + sudden loss of _vis nervosa_. + + _Onset_--Rapid. Usually insidious, may be almost + instantaneous. + + _Symptoms_--Intellect greatly Conduct shows reasoning power. + impaired. + + _Memory_--Seems to be swept Found after recovery to have + away as far as possible. been preserved to a great + extent. + + _Emotional Capacity_--Nil or Evidence of grief, fear, etc., in + almost so. Tears frequent facial expressions and wringing + but due to relaxation of and clasping of hands. + sphincter muscles. Features Tears rare. Great contraction + relaxed, eyes vacant and not of features [grimacing?]. + constantly fixed. Eyes fixed on one + point, usually upwards or + downwards, or else obstinately + closed. + + _Volition_--Almost absent. Frequently great stubbornness, + refusal to do what is + wanted. On the other hand, + intense determination in + following out own plan. + + _Motor System_--Weak and uncertain. But little interfered with, + Patient has to be independently of sheer + led about and if placed on a asthenia, produced by + seat or in some position does patient’s conduct. May stand + not move. (“Cataleptoid” behind door or kneel on floor + condition.) in constrained position even + for days. + + _Sensory System_}--Both dull. Ditto. There seems to be a + _Reflex System_ } much greater ability to bear + severe pain. + + _Pupils_--Dilated. Tendency to contraction. + + _Sleep_--Generally good. Intense sleeplessness. + + _General bodily condition_-- Affected _pari passu_ with + Emaciation, sometimes extreme, mental state and seems + usually rapid, with governed by it. + rapid recovery of flesh. + Often not much loss of + weight, though whole tone is + lowered. + + _Vascular System_--Pulse slow, Pulse weak and often quick + sometimes almost imperceptible. and thready. Complexion + Cyanotic appearance, edema anemic and sallow. The + and iciness of extremities. other appearances may be + Great decrease of vitality present but come on later + in peripheral structures, and are less marked. + as shown by asthenic + eruptions and production of + vermin. + + _Digestive System_--Tongue Tongue dry, small and furred. + clean or if furred it is moist. Refusal of food. Great + Appetite _apathetic_, bowels constipation. Dirtiness of + not irregular, but habits habits rare. + very dirty. + +If one compares these data with those given in the chapter on Malignant +Stupors, it is seen that in the main Newington has made the same +discrimination as we have. He is certainly wrong in denying “negativism” +to his anergic type. Probably, too, he attempts too fine a distinction +between the physical symptoms of the two groups. His conclusions are +interesting: that in the anergic cases there is an _absence_ of +cerebration, while amongst the delusional there is an abnormal +_presence_ of intense but perverted cerebration. This is not unlike our +own view. He thinks the difference in memory is the most important +differential point. Sex is important in determining the nature of the +stupor, for he found the anergic type following mania in females only. +He observed such an end to manic attacks in 6 out of 36 cases. All his +cases were under 30 and he regards the prognosis as good on the whole. +As to treatment he emphasizes the necessity for “moral pressure” as a +stimulus and cites a case of rapid improvement after a change of scene. + +Since 1874 very little advance has been made by British psychiatrists, +as seen by a perusal of Clouston’s[15] summary in 1904. He regards sex +exhaustion as a highly frequent cause, although Dagonet had shown 32 +years before that sex abuse does not produce a true stupor. He thinks +stupor usually follows depression or mania and says that “the +‘Confusional Insanity’ of German and American authors is just a lesser +degree of stupor.” Omitting his stupors in general paralysis and +epilepsy he makes three clinical divisions: _melancholic or conscious +stupor_, which is not a product of delusions, although delusions of +death or great wickedness may be present, impulsiveness and fits may be +observed; _anergic or unconscious stupor_, which corresponds roughly to +our deep, benign stupor; and _secondary stupor_ after acute mental +disease, which resembles our partial stupor. He warns against a rash +diagnosis of dementia in this last group. His views on the importance of +mental causation and the relation to manic-depressive insanity may be +gathered from these sentences: “The condition of the mental portion of +the convolutions in stupor is probably analogous to the stupidity of a +nervous child when terrified or bullied.” “Stupor is frequently one of +the stages of alternating insanity following the exalted condition. It +is more apt to occur in those where the exalted period is acutely +maniacal. The stupor is usually melancholic in form.” Since he claims +that the anergic is a “very curable form of mental disease,” while only +50% of the melancholic cases recover, it seems clear that this division +is not prognostically final. The “melancholic” is evidently Newington’s +“delusional” without his more accurate discrimination of symptoms. + +From the standpoint of accurate description the opinion may be ventured +that there is a gap in the literature from the early French writers and +Newington up to the paper by Kirby, which has been discussed in the +first chapter. This gap is filled by literature of the German schools +and their adherents in other countries. German psychiatry has been +concerned mainly with classification or the elaborate examination of +certain symptoms. Inevitably such a program militates against detached +objective clinical description. It is hard to record symptoms that +interfere with classification. German psychiatry has tended to make the +insane patient a type rather than an individual. Hence the gap in the +descriptive literature of stupor. + +The necessity of establishing the possibility of some stupors having a +good prognosis has arisen from Kraepelin’s work. He can rightly be +viewed as the father of modern psychiatry because he introduced a +classification based on syndromes and taught us to recognize these +disease groups in their early stages. Inevitably with such an ambitious +scheme as the pigeon-holing of all psychotic phenomena some mistakes +were made. Most of these appear in the border zone between dementia +præcox and manic-depressive insanity. The latter group being narrowly +defined, the former had to be a waste basket containing whatever did not +seem to be a purely emotional reaction. Clinical experience soon proved +that many cases which, according to Kraepelin’s formulæ, were in the +dementia præcox group, recovered. Adolf Meyer was one of the first to +protest and offered categories of “Allied to Manic-Depressive Insanity” +or “Allied to Dementia Præcox,” as tentative diagnostic classifications +to include the doubtful cases. + +Difficulties with stupor furnish an excellent example of the confusion +which results from the adoption of rigid terminology. The earlier +psychiatrists were free to regard a patient in stupor as capable of +recovery as well as deterioration. When Kahlbaum included stupor with +“Catatonia,” the situation was not changed, for he did not claim a +hopeless prognosis for this group. But when Kraepelin made catatonia a +subdivision of dementia præcox, all stupors (except obvious phases of +manic-depressive insanity) had to be hysterical or malignant. Faced with +this dilemma psychiatrists have either called recoveries “remissions” +or, like E. Meyer, claimed that one-fifth or one-fourth of catatonics +really get well. + +As a matter of fact it seems clear that stupor is a psychobiological +reaction that can occur in settings of quite varied clinical conditions. +It is not necessary to detail publications describing stupors in +hysteria, epilepsy, dementia præcox or in the organic psychoses. It may +be of interest, however, to cite some examples of acute, benign stupors +and the discussion of them which appear in the literature of recent +years. + +An important group is that of stupors occurring as prison psychoses. +Stern[16] mentions that acute stupors are found in this group. +Wilmanns[17] examined the records for five years in a prison and +discovered that there were two forms of psychotic reaction, a paranoid +and a stupor type. It is interesting psychologically that the former +appeared largely among prisoners in solitary confinement, while the +stupors developed preponderantly among those who were not isolated. The +stupors recovered more quickly. He describes the psychosis thus: The +prisoner becomes rather suddenly excited, destructive and assaultive; +then soon passes into an inactive state, where he lies in bed, mute, +with open expressionless eyes. He is clean, however; eats spontaneously +and attends to his own hygienic needs. Some cases are roused by +transport from the jail to the hospital but sink into lethargy again +when they reach their beds. Physically, they show disturbances of +sensation which vary from analgesia to hypesthesia. There are a rapid +pulse, positive Romberg sign, exaggerated reflexes, fibrillary twitching +of the tongue and tremor of the hands. Recovery takes place gradually. +They begin to react to physical stimuli and to answer questions, +although still inhibited, until consciousness is quite clear. When +speech begins, it is found that they are usually disoriented for place +and time as the result of an amnesia which sets in sharply with the +excitement. This memory defect gradually improves _pari passu_ with the +other symptoms. + +Two attacks in the same prisoner of what seem to have been typical +stupor are reported by Kutner[18] and Chotzen.[19] The patient was a +recidivist of unstable mental make-up. At the age of 34 he was sent to +prison for three years. Shortly after confinement began, he became +stuporous, being mute and negativistic, soiling, refusing food and +showing stereotypy. On being shifted to another institution he appeared +suddenly much better, although he remained apathetic and dull for some +months. A striking feature was a complete amnesia, not merely for the +stupor but also for his trial and entrance to the prison. At the age of +42, he was again incarcerated. A practically identical picture again +developed, with recovery when his environment was changed, and with a +similar amnesia. Recovery seemed to be complete and there were no +hysterical stigmata. The interesting features of this case are that a +typical stupor seems to have been precipitated by imprisonment, while +the retroactive amnesia covering a painful period of the patient’s life +reminds one of hysteria. + +A case which is more difficult to interpret is reported briefly by +Seelig.[20] A man of 20 with bad inheritance tried to steal 100 marks. +When sent to jail he became ill shortly before his trial was due and was +sent to a hospital. There he seemed anxious, was shy, and gave slow +answers, with initial lip motions and had to be urged to take hold of +objects. All this sounds more like a pure depression than a stupor. But +he also had paralogia. This might make one think of a Ganser reaction on +the background of depression. S., however, calls it an hysterical +stupor, although he agreed with Moeli that it was hard to differentiate +from a catatonic state. + +Löwenstein[21] reports an interesting case of a dégénéré who had had +hysterical attacks. He suddenly developed stupor symptoms, which lasted +with interruptions for nearly two years. After recovery and during the +interruptions the patient explained his mutism, refusal to swallow, his +filthiness and general negativism as all occasioned by delusions. He was +commanded by God to act thus, the attendants were devils, and so on. He +spoke, too, of being under hypnotic influence. In addition there were +other delusions such as that he had killed his brother. The attack came +on with the belief that he was going to die, otherwise none of the ideas +were typical of the stupors we have studied. Another incongruous symptom +was that he did not seem to be really apathetic, he reacted constantly +to the environment. The author comments on the absence of senseless +motor phenomena, such as would be expected in a “catatonic.” His +complete memory of the psychosis also speaks against the usual form of +stupor. It seems possible that this psychosis was neither hysterical nor +a benign stupor in our sense, but, rather, an acute schizophrenic +reaction such as one occasionally sees. From the account which +Löwenstein gives, one gathers that the patient was absorbed in a wealth +of imaginations. + +Gregor[22] tells of a stupor which is unusual in that it consisted only +of symptoms connected with inactivity, which did not affect the +intellectual processes. The patient was a rubber worker who suddenly +developed a depression with self-accusation and convulsions. She was +soon admitted to a clinic and then showed mutism and catalepsy. Later +she became totally immobile with no apparent psychic reactions, and +soiled. Gregor studied pulse, respiration and respiratory volume in +their reflex manifestations and found nothing unusual. Next he tried to +discover if there were voluntary alterations in respiration. He +discovered that the respiratory curve could be changed by calling out +words to her, by odors associated with suggestions, menaces, etc. [This +is suggestive of the dissociation of affect, which we have discussed.] +After two months she recovered, _with complete recollection of the +stupor period_. It was then proven that the absence of reactions was not +the same as the lack of perception of stimuli. + +Froederström[23] reports a case that suggests hysteria, where the stupor +lasted for 32 years. A girl at the age of 14 fell on the ice, had a +headache, went to bed and stayed there for 32 years. She lay there +immobile, occasionally spoke briefly and took nourishment, when it was +put at a definite place at the edge of the bed. At first (according to a +late statement of her brothers) this consisted only of water but was +soon changed to two glasses of milk a day. After being in this state for +ten years she was placed in a hospital for two weeks, where she was +mute, did not react to pin pricks and had to be fed. It seems that at +home she secretly looked after herself, for she kept her hair and nails +in condition. Sometimes she sat up and stared at the ceiling. + +After attending to the patient for 30 years, her mother died. The +patient cried for several days when told of it, and after this she took +nourishment of her own accord. Two years later a brother died. Again she +cried on hearing the news. Her father, who looked after her when the +mother was dead, also died. Then a governess came into the home, who +noticed that furniture was moved about when she was alone. + +At the age of 46 she suddenly woke up and asked at once for her mother. +She claimed total amnesia for the period of her stupor, including the +stay at the hospital. She could summon memories of her childhood, +however. Her brothers she did not recognize and said, “They must be +small.” She recalled the fall on the ice and coming home with headache, +toothache and pain in the back. Her general knowledge was limited but +she could read and write. Her expression and appearance was that of a +young person, only her atrophic breasts and the fat on her buttocks +betraying her age. She had been well for four years at the time the +report was made. + +He thinks that a certain tendency to exaggeration and simulation speak +for hysteria. We would be more inclined to view the fact that she looked +after herself in spite of complete amnesia as evidence of hysteria. + +Another protracted case suggestive of hysteria is that reported by +Gadelius.[24] The patient was a tailor, 32 years old, who had always +been rather taciturn and slow. A year before admission he began to have +ideas of persecution and to shun people. Then he developed a stereotyped +response, “It is nice weather,” whenever he was addressed. A month +before admission inactivity set in. He would sit immobile in his chair +with closed eyes and relaxed face; he resisted when an attempt was made +to put him to bed. His color was pale. + +He was taken to hospital on November 1, 1882, where he was observed to +be immobile and to have little reaction to pin pricks. When a limb was +raised, it fell limply. However, he would leave bed to go to the toilet. +Tube-feeding became necessary, but when the tube was inserted in his +nose, he woke up. He then showed an amnesia not merely for his illness +but for his whole life: he did not know his father, that he was married +or that he had a mother. Towards the end of November, he became limp +again and answered, “I don’t know” to most questions. In December, +however, he improved again and for a few months these variations +occurred. From April, 1883, to May, 1886, he was in deep stupor, almost +absolutely immobile and close to being completely anesthetic even with +strong Faradic currents. Towards the end of this period he walked about +_whenever he thought he was not watched_. He was very cautious about +this and became motionless any time he became aware of observation. +(Gadelius thinks this was not simulation but the expression of an +automatism on the basis of a vague fixed idea.) + +This condition persisted apparently for five years more, by the end of +which time the anesthesia had turned into a hyperesthesia. A year later +he began to eat. It was now found that he had an amnesia for his illness +and former life, so that he did not even recognize a needle or pair of +scissors. He knew that he was born in the month of February and retained +some facility in calculation, in speech, walking and usual motions. Then +he regained all his memories and resumed his trade as tailor. He was +discharged in June, 1893, nearly eleven years after admission. + +It seems safe to say that elements at least of hysteria appear in this +history, such as the profound retroactive amnesia and appearance of +simulation in the conduct of the patient. Accurate and rapid grasp of +the environment is necessary for such a watch as he kept on the eye of +his attendants. Mental acuity of this grade combined with amnesia looks +more like an hysterical than a manic-depressive process. + +Leroy[25] describes a case much like ours which is interesting from a +therapeutic standpoint. The patient was a woman who passed from a severe +depression with hallucinations and anxiety into a long stupor, from +which she recovered completely. There was no negativism and no affect, +although the latter appeared so soon as contact began to be established. +When well she had a complete amnesia for the onset of the psychosis. +Leroy attributed the recovery, in part at least, to the thorough +attention given the patient. Kraepelinian rigidity is seen, however, in +the author’s refusal to regard the case as “circular” because of the +lack of all cyclic symptoms. He takes refuge in the meaningless label +“Mental Confusion.” + +An important group of cases is that of the stupors occurring during +warfare. Considering stupor as a withdrawal reaction, it is surprising +there were so few of them, although partial stupor reactions as +functional perpetuation of concussion were very common. The editor saw +several typical cases in young children in London who passed into long +“sleeps” apparently as a result of the air raids. Myers[26] has given +us the best account of stupors in actual warfare. A typical case was +that of a man who was found in a dazed condition and difficult to +arouse. He could give little information about himself, could neither +read nor write and never spoke voluntarily. A week later his speech was +still limited and labored and no account of recent events could be +obtained from him. Under hypnosis he was induced to talk of the accident +which had precipitated this disorder. He became excited in telling his +story, evidently visualizing many of the events. In several successive +séances, more data were obtained and a cure effected. Myers points out +that in all his cases there was a mental condition which varied from +slight depression to actual stupor, all had amnesias of variable extent +and all had headaches. The mental content seemed to be confined to +thoughts of bombardment, with a tendency for the mind always to wander +to this topic. The author thinks that pain is a guardian protecting the +patient from too distressing thoughts. An effort to speak would cause +pain in the throat of a case of mutism and, sometimes, when a +distressing memory was sought after under hypnosis, physical pain would +wake the sleeper. His view is that pains tend to preserve the mutism and +amnesia, so that there are “inhibitory processes” causing the stupor, +which prevent the patient from further suffering. He does not find +either in theory or experience reason to believe that these conditions +are the result of either suggestion or “fixed ideas.” He thinks it +natural that the last symptom of the stupor to disappear should be +mutism, as speech and vision are the prime factors in communicating with +environment. [As has been noted frequently in this book, mutism is a +common residual symptom of the benign stupor.] Myers believes that in +nearly every instance mutism follows stupor and is merely an attenuation +of the latter process. When deafness is associated with mutism, he +thinks it is often due merely to the inattention of the stuporous state. + +In this connection we should mention that Gucci[27] points out that +stupor patients with mutism of long duration may, when requested, read +fluently and then relapse again into complete unreactiveness towards +auditory impressions. This, we would say, is probably an example of a +more or less automatic intellectual operation occurring when the patient +is sufficiently stimulated, although he cannot be raised to the point of +spontaneous verbal productivity. + +As these scattered reports about benign stupors are so unsatisfactory, +one naturally turns to text-books. Little more appears in them. +Kraepelin treats stupors occurring in manic-depressive insanity as +falling into two groups, the depressive and manic. The former seems to +be nearer to our cases, judging by the statements in his rather sketchy +account. He regards stupor as being the most extreme degree of +depressive retardation. [This possibility has been discussed in the +chapter on Affect.] His description seems perhaps to include cases which +we would regard as perplexity states or absorbed manias. Activity is +reduced, they lie in bed mute, do not answer, may retract shyly at any +approach, but on the other hand may not ward off pin pricks. Sometimes +there is catalepsy and lack of will, again there may be aimless +resistance to external interference. They hold anything put into their +hands, turning it slowly as if ignorant of how to get rid of it. They +may sit helpless before food or may allow spoon-feeding. Not rarely they +are unclean. As to the mental content, he says they sometimes utter a +few words, which give an insight into confused delusions that they are +out of the world, that their brains are split, that they are talked +about, or that something is going on in the lower part of the body. The +affect is indefinite except for a certain bewilderment about their +thoughts and an anxious uncertainty towards external interference. +Intellectual processes suffer. They are disoriented and do not seem to +understand the questions put to them. An answer “That is too +complicated” may be made to some simple command. Kraepelin thinks that +the disorder is sometimes more in the realm of the will than of +thinking, for one patient could do a complicated calculation in the same +time as a simple addition. After recovery the memory for the period of +the psychosis is poor and quite gone for parts of it. Occasionally there +may be bursts of excitement, when they leave the bed; they may scold in +a confused way or sing a popular song. + +His manic stupor is a “mixed condition,” a combination of retardation +with elated mood. The condition is different from the depressive stupor +in that activity is more frequent, either in constant fumbling with the +bed clothes or in spasmodic scolding, joking, playing of pranks, +assaultiveness, erotic behavior or decoration. The affect is usually +apparent in surly expression or happy, or erotic, demeanor. They are +usually fairly clear and oriented and often with good memory for the +attack but with evasive explanations for their symptoms. One cannot make +any classification of the ideas he quotes, but it is apparent from all +his description that the minds of these “manic stupors” are not a blank +but rather that there is a fairly full mental content. + +Wernicke, unhampered by classifications of catatonia and +manic-depressive insanity with inelastic boundaries, calls all stupor +reactions akinetic psychoses with varying prognosis. He does not make +Kraepelin’s mistake of confusing the apathy of stupor with the +retardation of depression, stating distinctly that the processes are +different. + +Bleuler also has grasped this discrimination. He points out that the +thinking disorder in what he terms “Benommenheit” (dullness) +differentiates such conditions from affectful depression with +retardation. He writes, of course, mainly of dementia præcox,[28] but +makes some remarks germane to our problem. In the first place he denies +the existence of stupor as a clinical entity, except perhaps as the +quintessence of “Benommenheit”, it is the result of total blocking of +mental processes. Consequently, he says, one can observe the external +features of stupor in all akinetic catatonics, in marked depressive +retardation, when there is a lack of interest, affect or will, in +autism, with twilight states, as a result of negativism or, finally, +when numerous hallucinations distract the patient’s attention into a +world of fancy. He notes that in all stupors (with the exception, +perhaps, of “Benommenheit”) the symptoms may disappear with appropriate +psychic stimulation or that some reaction, no matter how larval, may be +observed. He speaks, for instance, of the visits of relatives waking the +patient up. + +His only real group is “Benommenheit,” which he separates out as a true +clinical entity. This seems to correspond roughly with our “Partial +Stupors.” It is essentially an affectless, thinking disorder, usually +acute, sometimes chronic, occurring among schizophrenics. He believes +that it is the result of some organic process (intracranial pressure or +toxin). Activity is much reduced or absent; they have poor +understanding, answer slowly or confusedly; their actions are sometimes +as ridiculous as those of people in panic (e.g., throwing a watch out +of the window when the house is on fire); the defect is best seen in +writing, for large elisions are found in sentences. He was able to +analyze only one case and she retained her affect; it was even labile +and marked. One suspects that such a case might, perhaps, not really +find a place in the “Benommenheit” group even as Bleuler himself +describes it. + +With the exception of Kirby, whose work has already been discussed in +the introduction, we have been able to find only one author who has +attempted any symptomatic discrimination of the recoverable and +malignant catatonic states. Raecke[29] made a statistical study and +found that 15.8% recovered, 10.8% improved, 54.4% remained in +institutions, while 30% died. With the etiology mainly exogenous 20% +recovered and 14.3% improved. A good outcome was seen in 30.2% of +hereditary cases, while only 22.7% did well in the non-hereditary group. +His most important contribution is in his formulation of good and bad +symptoms. He thinks that dull, apathetic behavior with uncleanliness and +loss of shame are not so unfavorable as has been thought. Malignant +symptoms are grimacing with prolonged negativism but without essential +affect anomaly, decided echopraxia and echolalia and protracted +catalepsy. We would agree with this, although command automatisms have +not been prominent either in our benign or malignant stupors. + +Two writers have made special observations that should be confirmed and +amplified before their significance can be established. Whitwell[30] +thinks that in addition to a diminished activity of the heart there +exists a pathological tension. Ziehen says that he also has frequently +seen angiospastic pulse-curves in exhaustion stupor or acute dementia, +but that other pulse pictures may be seen as well. Any such studies +should be correlated rigorously with the clinical states before they can +have any meaning. Wetzel[31] tested the psychogalvanic reflex in stupors +and in normal persons who simulated stupors. He found them different. + +Only one publication has come to our attention in which an attempt is +made at psychological interpretation of various symptoms in stupor. +Vogt[32] derives much from a restriction of the field of consciousness. +Only one idea is present at a time, hence there is no inhibition and +impulsiveness occurs. Similarly, if the idea appear from without, it, +too, is not inhibited, which produces the suggestibility that in turn +accounts for catalepsy. Stereotypy and perseveration are other evidences +of this narrowness of thought content. Negativism is a state, he says, +of perseverated muscular tension. [This would apply only to muscular +rigidity.] So far as it goes, this view seems sound. Of course it +leaves the problem at that interesting point, Why the restriction of +consciousness? + +If stupor be a psychobiological reaction, it should occur, occasionally, +in organic conditions just as the deliria of typhoid fever may contain +many psychogenic elements. Gnauck[33] reports such a case. The patient, +a woman, was poisoned by carbon dioxide. At first there was +unconsciousness. Then, as she became clearer, it was apparent that she +was clouded and confused. She soiled. Neurological symptoms were +indefinite; enlargement of the left pupil, difficult gait and +exaggerated tendon reflexes. Months later she was still apathetic, +although her inactivity was sometimes interrupted by such silly acts as +cutting up her shoes. After five months she recovered with only +scattered memories of the early part of her psychosis. What seems like a +typical stupor content was recalled, however. She thought she was +standing in water and heard bells ringing. + +Stupor-like reactions are not infrequent in connection with or following +fevers. Bonhoeffer[34] describes a type that follows a febrile +Daemmerzustand of a few hours or a day at most. The affect suddenly +goes, disorientation sets in. Although outbreaks of anxiety may be +intercurrent, the dominant picture is of stupor. Reactions are slowed, +often there is catalepsy. Sometimes there is a retention defect and +confabulation to account for the recent past. Again the retention may be +good. In the foreground stands a strong tendency to perseveration. This +may affect speech to the point of an apparent aphasia or produce +paragraphia. Plainly organic aphasia and focal neurological symptoms are +sometimes seen. + +As Knauer[35] has gone thoroughly into the question of the febrile +stupors, the reader is referred to his paper for a digest of the +literature on this topic. Mention has already been made in Chapter IX to +this publication, where the close resemblance of these rheumatic, to our +benign functional, stupors has been noted. Discrimination seems to be +possible only on the basis of delirium-like features being added in the +organic group. + + +FOOTNOTES: + +[C] This chapter has been written mainly from material in Dr. Hoch’s +notes which was manifestly incomplete. No claim is made for its +exhaustiveness. + + _The Editor._ + +[13] Dagonet, M. H.: “De la Stupeur dans les Maladies Mentales et de +l’Affection mentale désignée sous le Nom de Stupidité.” _Annales +Medico-Psychologiques_, T. VII, 5e Serie, 1872. + +[14] Newington, H. Hayes: “Some Observations on Different Forms of +Stupor, and on Its Occurrence after Acute Mania in Females.” _Journal of +Mental Science_, Vol. XX, 1874, p. 372. + +[15] Clouston: “Mental Diseases.” J. & A. Churchill, 1904. + +[16] Stern: “Ueber die akuten Situations-psychosen der Kriminellen.” +Abstracted, _Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate Bd. +V, S. 554. + +[17] Wilmanns, K.: “Statische Untersuchungen über Gefängnisspsychosen.” +_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 847. + +[18] Kutner: “Ueber katatonischer Zustandsbilder bei Degenerierten.” +_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 375. + +[19] Chotzen: “Fall von degenerativem Stupor.” Abstracted, _Zeitschr. f. +d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 1077. + +[20] Seelig: “Psychiatrischer Verein in Berlin, 1904.” _Neurol. +Centralbl._, 1904, S. 421. + +[21] Löwenstein: “Beitrag zur Differentialdiagnose des katatonische u. +hysterische Stupors.” _Allg. Zeitschr. f. Psychiatrie_, Bd. LXV. + +[22] Gregor: “Über die Diagnose psychischer Prozesse im Stupor.” Leipzig +Meeting, 1907. Reported in _Neurol. Centralbl._, 1907. S. 1083. + +[23] Froederström: “La Dormeuse d’Okno. 32 ans de Stupeur, Guérison +complète. Nouvelles Iconographies de la Salpétrière,” 1912, No. 3. +Reviewed by E. Bloch, _Neur. Centralbl._, 1913, S. 852, and by Forster, +_Zeitschr. f. d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 510. + +[24] Gadelius: “Ett ovanligt fall af stupor med nära 9-arig oafbruten +tvangsmatning; uppvaknande; total amnesi; helsa” (_Hygiea_, 1894, LVI., +Part 2, No. 10, p. 355). Abstracted by Walker Berger, _Neurol. +Centralbl._, 1895, S. 186. + +[25] Leroy: “Un cas de stupeur, guéri au bout de deux ans et demi.” +_Bull. de la Soc. Clin. de Méd. Ment._, III, 276, 1910. Abstracted in +_Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate, Bd. II, S. 495. + +[26] Myers, Charles S.: “Contributions to the Study of Shell Shock.” +_Lancet_, January 8, 1916, pp. 65-69. _Lancet_, September 6, 1916, pp. +461-467. + +[27] Gucci, R.: “Sopra una particolarità del mutismo per stupore +communicazione preventive.” _Archivio italiano per le malattie nervose_, +1889, XXVI, 69-108. Reviewed in _Neurol. Centralbl._, 1889, S. 659. + +[28] “Dementia Præcox oder Gruppe der Schizophrenie” Aschaffenburg’s +“Handbuch der Psychiatrie.” + +[29] Raecke: “Zur Prognose der Katatonie.” _Arch. f. Psychiatrie_, Bd. +XLVII, 1, 1910. + +[30] Whitwell: “A Study of the Pulse in Stupor.” _Lancet_, Oct. 17, +1891. Reviewed by Ziehen, _Neurol. Centralbl._, 1892, S. 290. + +[31] Wetzel: “Die Diagnose von Stuporen.” Baden-Baden Meeting of May, +1911. Reported in _Neurol. Centralbl._, 1911, S. 886. + +[32] Vogt, Ragner: “Zur Psychologie der Katatonischen Symptome.” +_Centralbl. für Nervenheilkunde_, 1902, S. 433. + +[33] Gnauck, R.: “Stupor nach Kohlenoxydvergiftung” (_Charité-Annalen_, +1883, p. 409). Reviewed by Moeli, _Neurol. Centralbl._, 1883, S. 237. + +[34] Bonhoeffer: “Die Symptomatischen Psychosen,” 1910. + +[35] Knauer, A.: “Die im Gefolge des akuten Gelenkrheumatismus +auftretenden psychischen Storungen.” _Zeitschr. f. d. ges. Neurol. u. +Psychiatrie_, Bd. XXI, S. 491-559. + + + + +INDEX + + +absorption, 163 + +activity, reduction of, 36, 100, 120 + +acute dementia, 251 + +adaptation, 107, 192 + +adrenalin, 180 + +affect, 9, 22, 32, 44, 113, 116, 117, _123_, 170 + +affect, dissociation of, 128, 201, 205, 237 + +affect, inappropriate, 216, 237 + +affect, poverty of, 234 + +affect, shallow, 127 + +affectlessness, 171, 172 + +affects, combination of, 245 + +agitation, 156 + +akinesis, 121 + +akinetic psychoses, 4, 274 + +albuminuria, 40 + +allied to dementia præcox, 236, 260 + +allied to manic-depressive, 236, 260 + +allopsychic, 135 + +ambivalence, 147 + +amnesia, 9, 24, 68, 70, 267, 269 + +anergic or unconscious stupor, 258 + +anergic stupor, 255, 256 + +anesthesia, 196, 212, 268 + +anger, 118, 139 + +angiospastic, 276 + +animal, turning into, 171 + +Antæus, 190 + +apathy, 36, 48, 112, 122, 123, 151, 152, 163, 181, 195, 225, 237 + +apathy, resemblance to absorption, 202 + +anxiety, 122, 123, 126, 137, 153, 162, 166, 198, 226 + +apoplexy, 224 + +arteriosclerotic dementia, 80 + +attention, 195 + +atypical features, explanation of, 200 + +autoerotism, 199 + +automatism, 268 + + +Baillarger, 252 + +behavior, 195 + +“Benommenheit,” 67, 273, 274 + +bewilderment, 79, 112, 120, 126 + +Bleuler, 67, 273 + +blocking, 163 + +blood-pressure, 181 + +blushing, 9 + +Bonhoeffer, 277 + +boredom, 247 + +bowels, interest in, 217 + +brain tumor, 5 + +breath, holding, 62 + +Brierre de Boismont, 252 + +burial, 111, 192 + + +Calculation, 23, 24 + +Calvary, 111 + +Cannon, 180 + +Cases + Adele M. (Case 24), 220 + Alice R., 135, 140, _192_ + Anna G. (Case 1), _6_, 47, 48, 68, 74, 77, 109, 127, 136, 140, 145, + 147, 183 + Anna L. (Case 16), 135, _149_, 158 + Anna M., 135 + Annie K. (Case 5), _24_, 69, 72, 105, 110, 111, 136, 139, 141 + Bridget B., 135 + Caroline de S. (Case 2), _11_, 68, 109, 141, 178, 193 + Catherine H. (Case 23), _216_ + Catherine M. (Case 18), _158_ + Catherine W. (Case 25), _221_ + Celia C. (Case 17), _155_ + Celia H. (Case 19), _167_ + Charles O., 143, 144, 178 + Charlotte W. (Case 12), _83_, 106, 112, 113, 116, 127, 136, 141, 144, + 166, 201 + Emma K., 71, 140 + Harriett C., 138 + Helen M., 130 + Henrietta B., 138, 140 + Henrietta H. (Case 8), _42_, 74, 77, 105, 106, 110, 111, 115, 136 + Isabella M., 136, 144, 147 + Johanna B., 135, 138 + Johanna S. (Case 13), _91_, 120, 127, 136 + Josephine G., 138 + Laura A., 71, 77, 135, 138, 140, 142, 193 + Maggie H. (Case 14), 71, 96, 109, 140, 194 + Margaret C. (Case 10), _55_, 75, 78 + Mary C. (Case 7), _39_, 42, 71, 74, 77, 121, 136, 138, 178, 194 + Mary D. (Case 4), _20_, 47, 69, 70, 71, 74, 76, 109, 136, 145 + Mary F. (Case 3), _14_, 68, 105, 110, 111, 115, 140, 142, 164, 183 + Mary G., 140, 141 + Meta S. (Case 15), _99_, 109, 127, 135 + Nellie H. (Case 22), _214_ + Pearl F. (Case 9), _51_, 75, 142 + Rose S. (Case 21), _210_ + Rose Sch. (Case 6), _35_, 74, 75, 145 + Rosie K. (Case 11), _62_, 75, 105, 112, 178 + Winifred O’M. (Case 20), _207_ + +catalepsy, 13, 21, 31, 32, 36, 86, 94, 95, 102, 115, 128, _143_, 144, +145, 147, 209, 211, 235, 239 + +catatonia, 4, 5, 50, 128, 205, 236, 261 + +catheterization, 85, 86, 102 + +cemetery, 105, 112 + +childbirth, 159 + +childhood, 188, 195 + +Chotzen, 262 + +Christ, 86, 115 + +Christian Science, 150 + +circular psychosis, 5, 126 + +circulation, 180 + +Clark, 184 + +clouding, 67 + +Clouston, 258 + +cocoon, 109 + +coffin, 88, 106, 114 + +coma, 176, 223 + +concussion, aerial, 224 + +confusion, 163 + +constipation, 92 + +convent, 117 + +convulsive attacks, 15 + +crime, 248 + +crucifix, 88 + +crucifixion, 86, 106, 114, 161 + +crustaceans, 148 + +cut-up idea, 94 + +cyanosis, 32, 63, 180 + + +Dagonet, 3, 249, 250, 253, 254, 258 + +death, feigned, 5, 83, 137, 196, 246 + +death, mutual, 192 + +death, projected, 198 + +death, relation with affect, 110 + +death ideas, 3, 46, 47, 50, 52, 58, 65, 83, 97, _104_, 107, 109, 110, +111, 114, 115, 119, 122, 136, 137, 138, 152, 153, 156, 159, 163, 166, +187, 190, 191, 192, 199, 212, 225, 235, 240 + +death of others, 192 + +deep stupor, _1_, 6, 41, 199 + +deep stupor, explanation of, 197 + +Delasiauve, 253 + +delirium, 176 + +delusional stupor, 255, 256 + +delusions, 165 + +délire mélancholique, 252 + +dementia præcox, 4, 5, 62, 123, 127, 128, 205, 225 + +depression, 5, 117, 123, 137, 156, 236, 253 + +depression, differentiation of, 48, 124, 226 + +dermatographia, 102, 180 + +deterioration, 210 + +diabetes, 224 + +diarrhea, 45, 64, 178 + +dissociation, 225 + +distress, 119, 122, 154, 156, 162 + +dreams, 161, 190 + +drooling, 132, 181 + +drowning, 87, 192 + + +Earth, 107, 111, 190 + +echolalia, 275 + +echopraxia, 275 + +ecstasy, 91, 162, 191 + +_élan vital_, 123 + +elation, 44, 91, 123, 127, 151, 157 + +electric chair, 85, 110, 119 + +electricity, 150 + +emaciation, 8, 32, 58 + +emotion, 62 + +emotion, inconsistency of, 126 + +emotions and contact with reality, 164 + +energy, 187, 194 + +epilepsy, 5, 183, 199, 224, 242, 254 + +epileptic aura, 184 + +epileptic confusion, 80 + +epileptic deterioration, 80 + +erotic, 161 + +erotic ideas, 90 + +Esquirol, 251 + +Etoc-Demazy, 251 + +Euripides, 2 + +excretion, habits of, 230 + +extroversion, 195 + + +family visits, 232 + +father, 104, 109, 110 + +fear, 111 + +fever, 8, 13, 26, 32, 38, 40, 45, 64, 102, 160, _176_, 235, 241 + +filthiness, 210 + +fire, 151, 157 + +flippancy, 129 + +flushing, 27, 127, 128, 180 + +food, refusal of, 99, 104 + +Forel, 182 + +Froederström, 265 + + +Gadelius, 267, 268 + +Ganser reaction, 263 + +Georget, 251 + +German psychiatry, 259 + +Gnauck, 277 + +giggling, 206 + +God, 115, 160, 162 + +Golden Age, 187 + +Gregor, 265 + +Gucci, 271 + +guilt, 157 + + +hair, loss of, 32, 58, 180 + +heat production and loss, 179, 181, 242 + +Heaven, 87, 88, 104, 106, 108, 109, 111, 114, 115, 117, 118, 160, 162, +166, 171, 191, 240 + +Hell, 240 + +Hoch, 164 + +hyperæmia, 8 + +hyperesthesia, 268 + +hypochondria, 225, 253 + +hypomania, 243 + +hypnotism (see mesmerism), 145, 213 + +hysteria, 3, 135, 184, 225, 264, 267, 269 + + +ideational content, 82, 235 + +immobility, 85, 94, 196 + +immorality, 150 + +impulsiveness, 50, 113, 128, 172 + +impurities in stupor reaction, 66 + +inaccessibility, 141 + +inactivity, 17, 30, 40, 48, 56, 62, 88, 97, 102, 123, _132_, 152, 163, +194, 225, 234, 238 + +inactivity, patients’ explanation of, 134 + +incest ideas, 209 + +inconsistency of reaction, 134, 214, 215, 245 + +incontinence (see _wetting_ and _soiling_), 52, 57 + +indifference, 123, 124, 142 + +infantile reactions, 196 + +infections, 5, _178_, 241 + +insight, 157 + +insomnia, 39 + +instinct of self-preservation, 188, 191, 198 + +interest, 99, 195 + +internal secretions, 178 + +internal thoughts, 163 + +interruptions of stupor, 130, 197, 238, 244 + +introversion, 164, 227 + +involuntary nervous system, 178, 180 + +involution melancholia, 129, 195, 225, 226 + + +jaundice, 21 + +Jung, 107 + + +Kahlbaum, 4, 260 + +Kirby, 4, 6, 164, 234 + +Knauer, 175, 278 + +Kraepelin, 4, 260, 269, 271, 272, 273 + +Kutner, 262 + + +laughter, 56, 141 + +Leroy, 269 + +leucocytosis, 8, 13, 40, 64, 178 + +levels, principle of, 198, 244 + +Löwenstein, 264 + + +MacCurdy, 2, 184 + +make-up, mental, 5 + +malignant stupors, _205_ + +mania (or manic), 5, 126, 137 + +mania, absorbed, 125, 226, 245 + +manic content, 166 + +manic-depressive insanity, 149, 167 + +manic-depressive insanity, mixed conditions in, 202 + +manic-depressive insanity, pathology of, 174 + +manic episodes, 191 + +manic stupor, 125, 245, 253 + +marriage, 160, 169 + +masturbation, 196, 209, 219 + +melancholic or conscious stupor, 258 + +memory (see thinking disorder), 40, 67, 168, 195 + +menstruation, 8, 56, 61, 100, 168, _182_, 236, 242 + +mesmerism, 86, 114, 117, 141, 144 + +Meyer, Adolf, 260 + +Meyer, E., 261 + +midday nap, 247 + +mixed conditions, 202, 273 + +Moeli, 264 + +Moses, 108 + +mother’s body, 108 + +movement, spontaneous, 133 + +muscular resistiveness, 224 + +mutism, 10, 22, 31, 57, 62, 88, 104, 124, 134, 209, 271 + +mutual death, 165, 192, 196, 248 + +Myers, 270, 271 + +mystics, 3 + +mythology, 107, 108, 190, 240 + + +negativism, 5, 31, 52, 56, 65, 128, _138_, 139, 199, 209, 225, 235, 238, +243, 276 + +negativism, explanation of, 196 + +nephritis, 224 + +neuropsychic defect, 174 + +neurotic, 150 + +nervous, 159 + +Newington, 3, 254, 255, 257 + +Nirvana, 166, 188, 200, 248 + +nourishment, 229, 242 + + +Œdipus, 165 + +œstrous cycle, 182 + +onset, 96 + +onset, depressive, 99 + +ophthalmic disease, 230 + +Orestes, 2 + +organic delirium, 175 + +organic dementia, 67 + +organic stupor, 223 + +orientation (see thinking disorder), 9, 53, 154, 156, 159, 170, 245 + +Osiris, 108 + + +pain, 133 + +Papanicolaou, 182 + +paragraphia, 80 + +paralysis, feeling of, 105 + +paralysis, general, 5, 254 + +partial stupor, _34_, 206 + +perplexity, 125, 152, 153, 154, 155, 156, 160, 162, 164, 165, 169, 172, +208, 226, 245 + +perplexity, differentiation of, 227 + +perseveration, 145, 148, 276 + +personality, 1 + +perversity, 138 + +physical disease, 175 + +physical symptoms, _174_, 176 + +Pinel, 249, 251 + +poison, 97, 172 + +primitive ideas, 108 + +prison, 105, 169 + +prognosis, 4, 5, _206_ + +prostitution, 157, 161 + +psychoanalysis, 161 + +psychobiological reaction, 246 + +psychogalvanic reflex, 276 + +psychological explanation, 186 + +psychological factors, 175 + +pulse, 63, 92, 128, 180 + + +Rank, 107 + +reality, 107, 187 + +recuperation, 189 + +rebirth, _107_, 110, 114, 115, 119, 120, 121, 122, 187, 189, 190, 191, +240 + +regression, 187, 188, 191, 192, 194, 198, 199, 243 + +religious visions or ideas, 2, 162 + +resentment, 98 + +resistiveness, 54, 97, 102, 112, 127, 129, 133, 141, 147, 156, 211, 225 + +respiration, 180 + +resurrection, 159 + +restlessness, 53, 120, 169 + +retention of urine, 224, 230 + +rheumatism, 175 + +rigidity, muscular, 142, 179 + +Romberg sign, 262 + +rousing, 176 + + +sadness, 111, 113, 121, 122, 124 + +St. Catherine of Siena, 2 + +St. Paul, 2 + +saliva, 30, 63, 181 + +scattered speech, 207, 208 + +schizophrenia, 67, 214 + +seclusiveness, 207 + +secondary stupor, 259 + +Seelig, 263 + +self-injury, _50_, 57 + +sexual excess, 251, 253, 258 + +sexual ideas, 209, 219 + +sexual sensations, 209 + +ship, 87, 106, 118 + +sick, 136 + +skin, dry, 180 + +skin, greasy, 43, 180 + +sleep, 188, 189, 247 + +slowing of thought, 125 + +slowness, 85, 119, 160 + +smearing of feces, 142 + +smiling, 127 + +social status, 236 + +soiling, 30, 132, 172, 196, 225, 230, 235 + +somatopsychic, 135 + +sphincters, control of, 133 + +spirits, 89 + +spoiled child reaction, 129, 139 + +starvation, 182 + +stereotypy, 276 + +Stern, 261 + +stimulation, mental, 231, 246 + +Stockard, 179, 182 + +stubbornness, 142 + +stupidity, 93 + +stupor, diagnosis of, _223_ + hysterical, 225 + malignant, _205_, 206 + organic, 223 + reaction, _35_, 236 + relation to manic-depressive insanity, 173 + +sudden mental loss, 71 + +suggestibility, 145, 198, 276 + +suicidal impulses, _50_, 84, 104, 116, 118, 128, 172, 230, 235, 240 + +suicide, 188 + +sulkiness, 129 + +sullenness, 142 + +suprarenals, 242 + +swallowing, 133 + +sweating, 63, 102, 179, 180 + +swimming movements, 94 + +syncopal attacks, 64 + + +tears, 95, 98, 117, 128, 153 + +tense of ideas, 116 + +thinking disorder, 22, 31, 37, 39, 41, 45, 48, 59, _67_, 75, 124, 125, +148, 152, 157, 235, 239, 247 + +thinking disorder, explanation of, 195 + +tongue, coated, 13 + +toxins, 175 + +trauma, 5, 224 + +treatment, _229_ + + +ulceration of eyes, 133 + +unconscious ideas, 163 + motives, 186 + +unconsciousness, physiological, 199, 224, 277 + +underground, 240 + +understanding, 67 + +uneasiness, 93, 94, 95, 121 + +unfaithfulness, 97 + +unhappiness, 192 + +urine, retention of, 31 + + +Villermay, 250 + +Vogt, 276 + +vomiting, 45 + + +water, 94, 95, 106, 107, 114, 120 + +weakness, 137, 160 + +wealth, 169 + +wedding ring, 117 + +weight (see emaciation), 38, 52, 61 + +Wernicke, 3, 273 + +wetting, 30, 40, 132, 151, 170, 172, 196, 225, 230, 235 + +Wetzel, 276 + +whining, 171, 225 + +Whitwell, 276 + +Wilmanns, 261 + +womb, 108 + +worry, 110 + +writing, 27 + + +Ziehen, 276 + + + + +[Transcriber’s Note: + + +The following corrections have been made: + +p. 1: antequated to antiquated (antiquated methods) + +p. 11, 97, 100: period to colon (Under Observation:) + +p. 53: extra “when” removed (from “In June, 1914, when she was seen +smiling at times.” to “In June, 1914, she was seen smiling at times.”) + +p. 64: period to colon (Physical condition during the stupor:) + +p. 84: 24 italicized to match other dates (October 24) + +p. 91: missing blank line added between Case 12 and 13 + +p. 93: aswer to answer (in answer to questions) + +p. 145: diaeresis added to coöperation to match other instances + +p. 150: fatiguable to fatigable (nervous and fatigable) + +p. 153: phenomenom to phenomenon (unusual phenomenon for a stupor +patient) + +p. 159: comma added (correcting his grammar, and cried easily.) + +p. 161: missing “in” added (appeared in the statement that her father) + +p. 171: missing open quote added (she wants to go “to the river,”) + +p. 198: funadmental to fundamental (most fundamental symptoms) + +p. 211: salivia to saliva (drooling saliva) + +p. 220: inaccesibility to inaccessibility (disinterestedness and +inaccessibility) + +p. 252: dimunition to diminution (just as well in the diminution) + +p. 256: or to of (relaxation of sphincter muscles) + +p. 262, Footnote 19: v. to u. (Zeitschr. f. d. ges. Neur. u. +Psychiatrie) + +p. 265, Footnote 23: Zeitsch. to Zeitschr. to match other instances +(Zeitschr. f. d. ges. Neur. u. Psychiatrie) + +p. 271, Footnote 27: Archivo to Archivio (Archivio italiano per le +malattie nervose) + +p. 280, Index: catherization to catheterization + +p. 282, Index: ophtalmic to ophthalmic (ophthalmic disease) + +Irregularities in capitalization (e.g. Dementia vs. dementia) and +hyphenation (e.g. off-hand vs. offhand) have not been corrected. A +repetitive sentence on p. 46 (Then she became stupid, although neither +sad nor happy. Then, she claimed, she got stupid, but neither sad nor +happy.), and two spaced em-dashes on p. 87 have also been retained. +Minor punctuation errors (e.g. missing period, missing close or open +quote where intended placement is clear) have been corrected without +note. The abbreviations “p.m.”, “e.g.” and “i.e.” have been +standardized, with no space.] + + + + + +End of the Project Gutenberg EBook of Benign Stupors, by August Hoch + +*** END OF THIS PROJECT GUTENBERG EBOOK BENIGN STUPORS *** + +***** This file should be named 30065-0.txt or 30065-0.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/3/0/0/6/30065/ + +Produced by Bryan Ness, S.D., and the Online Distributed +Proofreading Team at http://www.pgdp.net (This book was +produced from scanned images of public domain material +from the Google Print project.) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Benign Stupors + A Study of a New Manic-Depressive Reaction Type + +Author: August Hoch + +Release Date: September 22, 2009 [EBook #30065] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK BENIGN STUPORS *** + + + + +Produced by Bryan Ness, S.D., and the Online Distributed +Proofreading Team at http://www.pgdp.net (This book was +produced from scanned images of public domain material +from the Google Print project.) + + + + + + + + + + BENIGN STUPORS + + + THE MACMILLAN COMPANY + + NEW YORK BOSTON CHICAGO DALLAS + ATLANTA SAN FRANCISCO + + MACMILLAN & CO., Limited + + LONDON BOMBAY CALCUTTA + MELBOURNE + + THE MACMILLAN CO. OF CANADA, Ltd. + + TORONTO + + + + + BENIGN STUPORS + + _A STUDY OF + A NEW MANIC-DEPRESSIVE REACTION TYPE_ + + BY + + AUGUST HOCH, M.D. + + LATE DIRECTOR OF THE PSYCHIATRIC INSTITUTE OF THE + NEW YORK STATE HOSPITALS, WARD'S ISLAND, NEW + YORK. LATE PROFESSOR OF PSYCHIATRY, CORNELL + UNIVERSITY MEDICAL COLLEGE, NEW YORK + + New York + THE MACMILLAN COMPANY + 1921 + + _All rights reserved_ + + + PRINTED IN THE UNITED STATES OF AMERICA + + + Copyright, 1921, + By THE MACMILLAN COMPANY + Set up and printed. Published July, 1921. + + + Press of + J. J. Little & Ives Company + New York, U. S. A. + + + TO + MY FORMER COLLEAGUES + IN THE + NEW YORK STATE HOSPITAL SERVICE + + + + +EDITOR'S PREFACE + + +A word should be said as to the origin and history of this book. When +the late Dr. Hoch became Director of the Psychiatric Institute of the +New York State Hospitals in 1910, he found there an interest in just the +kind of psychiatric research which it was his ambition to further. His +predecessor, Adolf Meyer, had developed the conception that the +psychoses should be looked on as psychobiological reactions rather than +rigid nosological entities and had inculcated the habit of scrupulously +thorough examination and record of what the patient said and did. Meyer +had broken away from the sterile habit of making diagnoses in accordance +with the set terms used to label symptoms; and his work and that of his +assistants thus led to a collection of valuable material which could +serve as a useful starting point for the keen clinical investigation of +Hoch. Specifically, attention had already been fixed on the study of the +so-called functional psychoses, comprising what are generally termed +Dementia Prcox and Manic-Depressive Insanity. An urgent problem in this +field was to separate different reaction types in order to discover +which were recoverable and which chronic or progressive. In order to +understand psychological reactions, interrelation rather than mere +coincidence of symptoms must be studied and, to aid in this, free use +was made of the fundamental principles of unconscious mentation as +exposed in the theories of Freud and his followers. + +Almost at the outset it had been discovered that many patients presented +clinical pictures that would not fit into existing diagnostic pigeon +holes. Dr. George H. Kirby, whose skill and industry had made the most +valuable contributions to the archives of the Institute, published in +1913 a brief paper in which he pointed out, not only that many cases +with "catatonic" symptoms recovered, but also that clinically the +behavior of stupor showed it to be related to manic-depressive insanity +as well as dementia prcox. Dr. Hoch took up the problem at this point. +Using Dr. Kirby's material and adding to it his earlier observations as +well as current cases, he endeavored to work out the essentials of the +stupor reaction. It was his ambition to describe stupor not only in its +psychiatric bearing but also as a life reaction. + +The significance of this task is to be realized only when one considers +the general import of the functional psychoses. They are, biologically, +failures of adaptation. The chronic and deteriorating cases give up the +struggle permanently, while the temporary insanities lay bare the soul +of man as he catches a glimpse of unreality but turns back to face the +world as it is. When one realizes that emotional disturbances are +characteristic of the benign psychoses, it is easy to imagine how much +such studies may ultimately illuminate the problems of normal life. + +The technical value of this work to psychiatry is more immediate. +Kraepelin laid the foundations for systematic classification with his +dementia prcox and manic-depressive groups. But the rigidity of the +latter, allegedly descriptive, term has confused the problem of +classifying many benign psychoses. It was Hoch's ambition to prove that, +although elation and depression were the commonest mood anomalies in +this group, they had no more theoretic importance than anxiety, +distressed perplexity or apathy. These other moods, although less +frequent, are just as characteristic of the psychoses in this group. In +other words, the name "Anxiety-Apathy Insanity" would be as appropriate, +theoretically, as Kraepelin's term. In 1919 Hoch and Kirby published a +report on the perplexity cases. This present book was designed to show +that the symptom complex centering around apathy is as distinct as that +which is recognized by all psychiatrists as mania with its predominant +characteristic of elation. + +In 1917 ill health forced Dr. Hoch to resign from his official duties. +He retired to California with the purpose of adding to psychiatric +literature the fruits of his long experience and unrivaled judgment. His +first task was this book. In the midst of this work came a sudden +collapse. As I had been in close touch with his researches, coperating +in psychological speculations, and was free to devote some time to it, +he asked shortly before his death that I complete the book. This +obligation is incommensurate with the debt I owe for years of +inspiration, tuition and criticism. + +The task has been mainly literary. I found the first five chapters +practically completed, while it has not been difficult, as a rule, to +discover from his copious notes what his intentions were as to the +details of the following chapters. I have been greatly aided by the +assistance of Dr. Adolf Meyer and of Dr. Kirby. The latter has been good +enough to read the entire manuscript, making invaluable suggestions and +criticisms. + + John T. MacCurdy. + +New York. + + + + +TABLE OF CONTENTS + + + CHAPTER PAGE + + EDITOR'S PREFACE vii + + I. INTRODUCTION AND TYPICAL CASES OF DEEP + STUPOR 1 + + II. THE PARTIAL STUPOR REACTIONS 34 + + III. SUICIDAL CASES 50 + + IV. THE INTERFERENCES WITH THE INTELLECTUAL + PROCESSES 67 + + V. THE IDEATIONAL CONTENT OF THE STUPOR 82 + + VI. AFFECT 123 + + VII. INACTIVITY, NEGATIVISM AND CATALEPSY 132 + + VIII. SPECIAL CASES: RELATIONSHIP OF STUPOR TO + OTHER REACTIONS 149 + + IX. THE PHYSICAL MANIFESTATIONS OF STUPOR 174 + + X. PSYCHOLOGICAL EXPLANATION OF THE STUPOR + REACTION 186 + + XI. MALIGNANT STUPORS 205 + + XII. DIAGNOSIS OF STUPOR 223 + + XIII. TREATMENT OF STUPOR 229 + + XIV. SUMMARY OF THE STUPOR REACTION 234 + + XV. THE LITERATURE OF STUPOR 249 + + INDEX 279 + + + + +BENIGN STUPORS + +CHAPTER I + +INTRODUCTION AND TYPICAL CASES OF DEEP STUPOR + + +The fact that psychiatry lags in development and recognition behind +other branches of medicine is due in part to the crudity of its clinical +methods. The evolution of interest in science is from simple, obvious +and tangible problems to more intricate and impalpable researches. +Refined laboratory work has been done in psychiatric clinics, +particularly along histopathological lines, but clinical studies follow +antiquated methods. The internist does not say, "The patient has sugar +in his urine, therefore he has diabetes and therefore he will die." He +finds a glycosuria and looks for its cause. If this symptom is found to +be related to others in such a way as to justify the diagnosis of +diabetes, a therapeutic problem arises, that of adjusting the chemistry +of the body. The prognosis depends not on the disease but the +interreaction of the organism and the morbid process. Both in diagnosis +and treatment an individual factor, the patient's metabolism, is of +prime importance. Now in psychiatry, although the personality is +diseased, this personal factor has been almost entirely neglected. +Text-books furnish us with composite pictures which are called diseases, +not with descriptions of reactions brought about by the interplay of +personal and environmental factors. Educated people are not satisfied +with novels that fail to depict real characters. Clinical psychiatry, +however, has been content with the dime-novel type of character +delineation. This is all the more disappointing, inasmuch as the study +of insanity should contribute largely to our knowledge of everyday life. +This defect can only be remedied by looking on every case as a problem +in which the origin of each symptom is to be studied and its relation +traced to all other symptoms and to the personality as a whole. This is +an ambitious task and we do not pretend to any great achievement, merely +to a beginning. + +No better psychoses could be chosen for a preliminary effort than benign +stupors. Every psychiatrist has seen them, although they are wrongly +diagnosed as a rule, and they play no small rle in the world's history. +Euripides represents Orestes as having a stupor which is pictured as +accurately as any modern psychiatrist could describe an actual case.[1] +St. Paul is chronicled as falling to the ground, being thereafter blind +and going without food or drink for three days. While apparently +unconscious he had a religious vision. St. Catherine of Siena had +several unquestionable stupors, which are fairly well described. In +fact the mystics in general seem to have had communion with God and the +saints most often when they seemed unconscious to bystanders.[2] The +obsession with death, which seems so intimate a part of the stupor +reaction, is a fundamental theme in poetry, religion and philosophy. The +psychology of this interest is, speaking broadly, the psychology of +stupor. So, from a general standpoint, our problem is related to the +study of one of the most potent ideas which move the soul of man. + +Psychiatrically, stupors have long remained an unsolved riddle. In the +century prior to 1872 (See the digest of Dagonet's publication in +Chapter XV) French psychiatrists wrote some good descriptions of stupor +and offered brilliant, though sketchy generalizations about the +condition. Two years later an English psychiatrist (Newington, See +Chapter XV) improved on the French work. Little light has been thrown on +the subject since then. The researches of the later French School showed +that stupor often occurs in the course of major hysteria, but this left +many of these episodes obviously not hysterical. When serious attempts +were made at classification, this ubiquitous symptom complex was hard to +handle. Wernicke wisely refrained from attempting more than a loose +descriptive grouping. He called all conditions with marked inactivity +and apathy "akinetic psychoses" and said that some recovered, some did +not. Taxonomic zeal began to blind vision when Kahlbaum formulated his +"Catatonia" and included stupor in the symptom complex. The condition +which we call stupor occurs in the course of many different types of +mental disease. It is true that it is frequent in catatonia but is not +exclusively there. Mongols have black hair and straight hair, but one +cannot therefore say that any black and straight haired man is a Mongol. +Fortunately Kahlbaum prevented serious error by leaving the prognosis of +his catatonia open. When Kraepelin included it in his large group of +Dementia prcox, however, it implied that stupor could not be an acute, +recoverable condition.[3] He unquestionably advanced psychiatry greatly +but his scheme was too ambitious to be accurate. Many observers saw +patients, classified as dements according to Kraepelin's formul, +return, apparently normal, to normal life. Finally Kirby[4] published a +series of cases which showed decisively that this classification was too +rigid. + +Since his paper is the foundation for this present study, it should be +reviewed carefully. He first points out that Kraepelin's "Dementia +prcox" includes much more than it should with its inevitably bad +prognosis. He shows how others have found patients with catatonic +symptom complexes proceed to recovery and speaks of these symptoms +occurring in epilepsy and even in frankly organic conditions, such as +brain tumor, general paralysis, trauma and infections. Kirby's first +claim is that there are probably fundamentally different catatonic +processes, deteriorating and non-deteriorating. Lack of knowledge has +prevented us from understanding the meaning of the symptoms and hence +making the discrimination. He points out that stupor seems to represent +an attitude of defense, similar to feigned death in animals, and that in +a number of his cases it was clear that the stupor symbolized the death +of the patient. Apparent negativism, he found to be often a consciously +assumed attitude of aversion towards an unpleasant emotional situation. +In cases where there had been no prodromal symptoms pointing definitely +to dementia prcox the outcome was almost always good. To discriminate +the cases with good outlook from those with bad, he discerned no +difference in the stupors themselves, but observed that the mental +make-up and initial symptoms differed sufficiently for diagnosis to be +made. His most important point is, perhaps, that these benign stupors +showed a definite relationship to manic-depressive insanity in that some +patients passed directly from stupor to typical manic excitement, while +in others a "catatonic" attack replaced a depression in a circular +psychosis. + +Kirby introduces, then, the idea of stupor being a type of reaction +which can occur either in dementia prcox or in manic-depressive +insanity. The matter cannot be left there, in fact it raises new +problems: what constitutes the reaction? how are the various symptoms +interrelated? are they different in deteriorating and acute cases? what +is the teleological significance of the reaction? if it be an integral +part of the manic-depressive group, how does it affect our conceptions +of what manic-depressive insanity is? More than five years have been +spent in endeavors to answer these questions and the results of the +study are now presented. + +Naturally the first point to be settled is: what constitutes the stupor +reaction itself. We can say at the outset that it is seen in the purest +form in benign cases, hence they make up the material of this book. To +discover the symptoms of the disorder one cannot do better than to study +them in their most glaring form in deep stupors, where consistently +recurring phenomena may be assumed to be essential to the reaction. + + + CASE 1.--_Anna G._ Age: 15. Admitted to the Psychiatric + Institute July 25, 1907. + + _F. H._ The mother and two brothers were living and said to + be normal. The father died of apoplexy when the patient was + seven. + + _P. H._ The patient was sickly up to the age of seven, but + stronger after that. It is stated that she got on well at + school, though she was somewhat slow in her work. She was + inclined to be rather quiet, even when a child, a bit shy, + but she had friends and was well liked by others. After + recovery she made a frank, natural impression. She was + always rather sensitive about her red hair. She began to + work a year before admission and had two positions. The + last one she did not like very well, because, she alleged, + the girls were "too tough." + + Three weeks before admission she came home from work and + said a girl in the shop had made remarks about her red + hair. She wanted to change her position, but she kept on + working until six days before admission. At that time her + mother kept her at home as she seemed so quiet, and when + the mother took her out for a walk she wanted to return, + because "everybody was looking" at her. For the next two + days she cried at times, and repeatedly said, "Oh, I wish I + were dead--nobody likes me--I wish I were dead and with my + father" (dead). She also called to various members of the + family, saying she wanted to tell them something, but when + they came she would only stare blankly. For a day she + followed her mother around, clung to her, said once she + wanted to say something to her, but only stared and said + nothing. + + Four days before admission she became quite immobile, lay + in bed, did not speak, eat or drink. She also had some + fever. + + The patient herself, when well, described the onset of her + psychosis as follows: She knew of no cause except that her + brother, some time before the onset (not clear how long), + was run over by an automobile and had his foot hurt. She + claimed that while still working she lost her ambition, + lost her appetite, did not feel like talking to any one; + that when she went out with her mother it merely seemed to + her that people stared at her. The day before she went to + the Observation Pavilion her cousin came to see her, and + she thought she saw, standing beside this cousin, the + latter's dead mother. She also thought there was a fire, + and that her sister was sweeping little babies out of the + room. Then, she claimed, she felt afraid (this still on the + day before going to the Observation Pavilion) because she + had repeated visions of an old woman, a witch. This woman + said, "I am your mother, and I gave you to this woman + (i.e., patient's real mother) when you were a baby." She + also was afraid her mother was "going away." + + At the _Observation Pavilion_ she was described as + constrained, staring fixedly into space, mute, requiring to + be dressed and fed. + + _Under Observation:_ 1. For five months the patient + presented a marked stupor. She was for the most part very + inactive, totally mute, staring vacantly, often not even + blinking, so that for a time the conjunctiv were dry. She + did not swallow, but held her saliva; did not react to pin + pricks or feinting motions before her eyes. Sometimes she + retained her urine, again wet and soiled the bed. Often + there was marked catalepsy, and the retention of very + awkward positions. As a rule she was quite stiff, offering + passive resistance towards any interference. She had to be + tube-fed at first. Later she was spoon-fed, and then would + swallow, in spite of the fact that during the interval + between her feeding she would let saliva collect in her + mouth. For a time she had a tendency to hold one leg out of + bed, and when it was put back would stick the other out. + Sometimes she walked of her own accord to the toilet chair, + but on one occasion wet the floor before she got there. + + During the first month after admission, this stupor was + interrupted for two short periods by a little freer action: + she walked to a chair, sat down, smiled a little, fanned + herself very naturally when a fan was given to her, though + even then did not speak. + + There was, as a rule, no emotional reaction, but after some + months she several times wept when her mother came, though + without speaking. Once when taken to the tub she yelled. + + Her _physical condition_ during this stupor was as follows: + She menstruated freely on admission, then not again until + she was well. Several times she had rises of temperature to + 102 or 103 with a high pulse and respiration; again a + respiration of 40, with but slight rise of temperature, + though the pulse had a tendency to go to 130 and over. She + was apt to show marked skin hypermia wherever touched. + With the fever there was found a leucocytosis of from + 11,900 to 15,000, with marked increase of polynuclear + leucocytes (89%). She got very emaciated, so that four + months after admission she weighed 68 lbs. (height 5' 2"). + + 2. About five months after admission she was often seen + smiling, and again weeping, and she began to talk a little + to the nurses, though not to the doctors. She also began to + eat excessively of her own accord, and rapidly gained + weight, so that by January she weighed 98 lbs., a gain + of 30 lbs. in two months. Yet she continued to be sluggish. + + 3. For two more months she was apathetic and appeared + disinterested, often would not reply, again, at the same + interview, she would do so promptly and with natural voice. + This condition may be illustrated by the summary of a note + made on January 29, 1908, which is representative of that + period. It is stated that she sat about apathetically all + day, appeared sluggish, but was fairly neat about her + appearance and cleanly in her habits. There was at no time + any evidence of affect, except when asked by the examiner + to put out her tongue so that he could stick a pin in it + she blushed and hid her face. When asked whether she + worried about anything, she denied this. When questions + were asked, she sometimes answered promptly and in normal + voice, again simply remained silent in spite of repeated + urging. On the whole, it seemed that simple impersonal + questions were answered promptly; whereas difficult + impersonal questions or questions which referred to her + condition were not answered at all. She proved to be + oriented. Thus she gave the day of the week, month, year, + the name of the hospital, names of the doctors and nurses + promptly. She also counted quickly and did a few simple + multiplications quickly. But she was silent when asked + where the hospital was located, how long she had been here, + whether she was here one or six months, how she felt. + Questions in regard to the condition she had passed + through, or involving difficult calculations, she did not + answer. However, some questions regarding her condition + asked in such a way that they could be answered by "yes" or + "no" were again answered quite promptly. Thus when asked + whether her head felt all right she said, "Yes, sir." (Is + your memory good?) "Yes." (Have you been sick?) "No, sir." + (Are you worried?) "No." + + 4. This apathy cleared up too, so that by the middle of + March she was bright, active and smiled freely. With the + nurses she was rather talkative and pleased, though this + was not marked. Towards the physician only was she natural + and free. She then gave the _retrospective account_ of the + onset detailed above. When questioned about her condition + she claimed not to remember the Observation Pavilion, + although recalling vaguely going there in a carriage. She + was almost completely amnesic for a considerable part of + her stay in the Institute. She claimed it was only in + November or December that she began to know where she was + (five months after admission). In harmony with this is the + fact that she did not recall the tube- and spoon-feeding + which had to be resorted to for about four months of this + period. No ideas or visions were remembered. As to her + mutism she said, "I don't think I could speak," "I made no + effort," again "I did not care to speak." She claimed that + she remembered being pricked with a pin but that she did + not feel it. She remembered yelling when taken to the tub + (towards end of the marked stupor) and claimed she thought + she was to be drowned. + + When she went home (March 24, 1908) she got into a more + elated condition. She was talkative, conversed with + strangers on the street, said to her mother that she was + now sixteen years old and wanted "a fellow." When the + mother would not allow her to go out, she said it would be + better if they both would jump out of the window and kill + themselves. She then was sent back to the hospital. In the + first part of this period after her return, she was + somewhat elated and overtalkative, though she did not + present a flight of ideas, and was well behaved. She soon + got well, however, and was discharged, four months after + her readmission, fully recovered. + + After that, it is claimed, she was perfectly well and + worked successfully most of the time with the exception of + a short period in the spring of 1909, when she was slightly + elated. + + In 1910 she had a subsequent attack, during which she was + treated at another hospital. From the description this + again seems to have been a typical stupor (immobility, + mutism, tendency to catalepsy, rigidity). According to the + account of the onset sent by that hospital (it was obtained + from the mother), this attack began some months before + admission, with complaints of being out of sorts, not being + able to concentrate and fearing that another attack would + come on. Finally the stupor was said to have been + immediately preceded by a seizure in which the whole body + jerked. She made again an excellent recovery. + + The patient was seen about two years after this attack, and + described the development of the psychosis as follows: She + claimed she began to feel "queer," "nervous," "depressed," + got sleepless. Then (this was given spontaneously) she + suddenly thought she was dying and that her father's + picture was talking to her and calling her. "Then I lost my + speech." As after the first attack, she claimed not to have + any recollection of what went on during a considerable part + of the stupor but recalled that she began to talk after her + brother visited her. It is not clear how she was during the + period immediately following the stupor. + + She made a very natural impression and came willingly to + the hospital in response to a letter and was quite open + about giving information. + + + CASE 2.--_Caroline DeS._ Age: 21. Admitted to the + Psychiatric Institute June 10, 1909. + + _F. H._ The father died of apoplexy when patient was nine. + The mother had diabetes. A paternal uncle was queer, + visionary. + + _P. H._ The patient was always considered natural, bright, + had many friends, and was efficient. + + Some months before admission the patient's favorite + brother, who is a Catholic, became engaged to a Protestant + girl, and spoke of changing his religion. The family and + the patient were annoyed at this, and the patient is said + to have worried about it, but was otherwise quite natural + until seven days before admission. Then, at the engagement + dinner of the brother, the psychosis broke out. She refused + to sit down to the table, and then suddenly began to sing + and dance, cry and laugh and talk in a disconnected manner. + Among other things, she said "I hate her," "I love you, + papa" (father is dead), "Don't kill me." She struck her + brother. She was in a few days taken to the Observation + Pavilion. + + The patient stated after recovery that what worried her was + that the brother would marry a Protestant and that he would + leave home (favorite brother). + + At the _Observation Pavilion_ she was excited, shouted, + screamed, laughed, called out "Don't kill me," again + "Brother, brother," "You are my brother" (to doctor). + + _Under Observation:_ 1. On admission, and for two weeks, + the patient presented a marked excitement, during most of + which she was treated in the continuous bath. She tossed + about, threw the sheets off, beat her breasts and abdomen, + put her fingers into her mouth, bit the back of her hands, + waved her arms about, sometimes with peculiar gyration, + etc., at the same time shouting, singing, again praying, + laughing or crying, sometimes fighting the nurses and + resisting them. She also talked quite a little as a rule, + but there were periods when, although excited, she would + not talk or answer questions. She was very little + influenced in her talk by the environment. When on one + occasion asked if she had any trouble, she said: "No--I + don't want, somebody else gave me a book--all right I love + myself, Uncle Mike too--all right too--all right I am in + Bellevue--I love everybody except the Jews all right, all + right--give me water, give me milk, give me seltzer--white + horse uncle--Holy Father, he is killing me, I want my + mother," or "Wait a minute, say, that's a lie--oh no, Holy + water--no I didn't wash the water away--oh, she forgets, I + am sick--mother why don't you come--look at the baby, they + knocked my head against the wall--wait a minute, isn't that + terrible?--I was married--I was so--I forgot--April fool--I + kiss you seven kisses and one more--I love papa and mamma, + I like others too--I am papa's angel child--yes I confess I + love him, but I don't want to die myself." On another + occasion, when asked where she was, she said: "I am at the + ball--I am going to Heaven--don't shoot me" (affectless). + (Why are you afraid?) "Because you see--high water (in the + tub)--white horse." (What about the water?) "My name is + Caroline--if you love me, father, tickle me under my feet," + or, rolling her eyes up, "Oh, isn't that awful, that ring, + that diamond, that is the key to Heaven." + + 2. For about ten days she was somewhat different. She + became quieter and at first lay muttering unintelligibly, + saying some things about being killed, but speaking little, + often restlessly tossing about and tremulous. She had to be + tube-fed. On one day (July 1) she smiled more and talked + more, said to the physician "You have been arrested for + me--you arrested the first man that I ever--New York + State--let me see that book" (note pad). Then she went on: + "Oh, I am all apart--diamonds--they didn't know--must I + keep them clean?--what is your name?--that is another thing + I would like to know." But when asked what house she was in + she said: "This is the same Ward's Island" and then added, + "How long have I been here?--there is my picture up there + (register), who is that? (listening) it's Ida ..." She + began to sing softly. Then again she whined. "O mamma, + mamma!" When asked how long she had been here, she said: + "Since Decoration Day, when my father went in my sister's + house, nobody could catch up with me--somebody blackened + her eyes." When asked whether she was sick, she said "No, + insane." + + Although, as was stated, she said at one time, "This is the + same Ward's Island," usually questions regarding + orientation were not answered, as she gave few relevant + replies, but she repeatedly said spontaneously that she was + in "Hoboken or Bellevue," and called the nurse by the name + of a former teacher. A few days after this state had + developed she had a fever. Once this rose to 104. The + fever lasted two weeks, coming down gradually. It was + associated with a leucocytosis of 15,000 on June 29 (no + differential count) and with coated tongue. No Widal (two + examinations). No diazo (July 1). + + 3. Then while the temperature still lasted she developed a + stupor which persisted for about a year. During this time + her temperature rose to 100 without ascertainable cause. + She lay for the most part motionless, changing her position + but rarely; her expression was stolid; she retained and + drooled saliva, wet and soiled herself. She never answered + any questions; showed no interest whatever. At times she + was quite stiff and very resistive but never cataleptic. + Her extremities were cold and cyanotic. She had to be + tube-fed throughout. During this time she lost much hair. + + After some months she occasionally gazed about furtively, + or later watched everything when unaware of being observed; + at this time she also smiled occasionally at amusing + things, or perhaps said "yes" or "no" to questions, but + usually was stolid when interrogated. + + Then about nine months after admission, while in the + condition just described, she developed a lobar pneumonia. + During it she remained the same. But during convalescence + she began to speak and eat. + + 4. A period followed lasting six months during which she + was up and about, but sat or stood around a good deal. On + the other hand, she helped the nurses a little when urged. + Her face was often stolid, again she looked about. At times + (even nearly to the end) she drooled and soiled. She said + little. At no time was she resistive. On other occasions + she smiled or laughed, not always on provocation, or she + showed little playful tendencies, such as throwing a pillow + about the room, tearing leaves from the plants, taking the + doctor's arm and walking down the hall, asking him to kiss + her. At such times she often looked quite bright, keen, + alert and amused. Towards the end she would give at times + playful answers, such as "I came to-day," or "This is the + Hall of Fame." This tapered off, so that by December, 1910, + she was perfectly well. + + _Retrospectively_, the patient claimed not to remember the + upset at the dinner, or what happened afterward, although + recalling the trip to the Observation Pavilion. She denied + any memory of the journey to the hospital, but could tell + what ward she came to. How well the condition after that + was recalled, was not inquired into, except that she could + or would not explain further the utterances during the + first period. For the stupor period it is stated that she + remembered many external facts, but it is not clear in + which period they occurred. + + _Catamnestic Note._ May, 1913: She has worked efficiently, + and is said to have been perfectly well. + + + CASE 3.--_Mary F._ Age: 21. Admitted to the Psychiatric + Institute June 28, 1902. + + _F. H._ The mother died when the patient was five. The + father was living, an alcoholic and reckless man. Four + brothers and sisters died in infancy. + + _P. H._ The patient was the only surviving child. She was + brought up in a convent and orphan asylum until 11, when + her father remarried. At 12 she had to go to work, hence + she had but little education. She was bright, efficient, + well liked by her employers (in one position five years). + As to her peculiarities, she was thought to be, perhaps, a + little headstrong, and was also described as always very + exact, rather quick-tempered and inclined to be irritable + when crossed. + + She was married six months before admission and had a _baby + three weeks before admission_. The husband stated that when + the father found out she was pregnant, he spoke of killing + him. He frequently upbraided both husband and wife, though + he lived with them. Even after the child was born he + continued to be disagreeable. + + The patient was rather low spirited and quieter after her + marriage. She worried over her illegitimate pregnancy and + the scolding from her father. But nothing was thought of + all this, and it did not interfere with her activity. The + birth was normal. She had no flow, no unfavorable symptoms, + and sat up on the twelfth day. She is said to have appeared + natural mentally. + + A week before admission the family returned from the + christening, having left the patient apparently well. They + now found her sitting in her chair, limp, with closed eyes, + giving no answer to questions. Only after about twenty + minutes could she be aroused. After her father had given + her milk with whiskey in it, she claimed he had poisoned + her. In the evening she was bright and lively, singing and + dancing with the others, but in the night she woke up her + husband, seemed frightened, said somebody was in the room + and that he should get a priest as she was going to die. + The husband went to sleep again. The next forenoon the + patient claimed she had been frightened all night and + thought her father was going to kill her husband. + + On the second day, while sitting at breakfast, she groped + about for the bread plate for some time and then said she + had been blind for a short time. During the day she had + frequent spells in which she would close her eyes, become + perfectly quiet and difficult to rouse. Sometimes at the + beginning of these spells she would say "I am going." She + was then taken to her aunt and walked there, a distance of + a few blocks. She was there for two days before going to + the Observation Pavilion. In this time she is said to have + been quiet for the most part, often apparently sleeping or + staring. Once she said she was "rather dirty, filthy." Once + she tried to get out of the window, said it was a door and + that she wanted to get out and take a walk. Above all, she + had, in these two days, repeated peculiar seizures which + the aunt and the husband described as follows: When sitting + on a chair she would close her eyes, clench her fists, + pound the side of the chair, get stiff, slide on the floor, + then thrash her arms and legs about and move the head to + and fro. She frothed at the mouth. After the attack, which + lasted a few minutes, she breathed heavily for a while. + Once she wiped off the froth with a handkerchief and gave + the latter to the aunt, saying "Burn that, it is poison." + Before the attack she sometimes said that it got dark over + her eyes and that her face felt funny, again that she had a + pain in the stomach which worked towards her right + shoulder. There was no cry in the beginning of the attack, + but once she wet herself. + + After recovery the patient herself told the development of + her psychosis thus: + + There was trouble between the father and the husband, and + she was afraid of her father. On the day of the christening + she took sick: a queer feeling came over her and she + wondered whether she was going to die, "Then I seemed to + lose myself, and when I came to I found my family standing + around me." Her father gave her whiskey and she thought it + was poison. "That night I had spells of dancing and + singing, it must have been something I took, perhaps the + liquor." The same night she was frightened, thought her + father might do some harm, and had a vision of a person in + white standing at her bed. After that she had repeated + spells in which she knew nothing until "I came to again." + "It was a queer trembling." + + At the _Observation Pavilion_ she was described as in a + state of "intense mental depression," taking no interest in + things going on about her. She spoke, however; said she + wanted to die, that she had imagined her father had given + her poison, that every one was against her, and that people + were talking about her. + + 1. _On admission_ the patient had a slightly elevated + temperature, which soon subsided, full breasts but without + inflammation. Sordes were not mentioned. + + For a few days she was essentially somewhat restless, + getting out of bed, disarranging her clothes, wandering + about--all in a rather deliberate, aimless way, sometimes + vaguely resistive, again with free movements. She looked, + dazed, sometimes stared straight ahead and looked "dreamy." + Occasionally there was a tendency to close her eyes. With + the restlessness she looked at times "a little + apprehensive," or shrank away when approached. She spoke + slowly, with initial difficulty, but answered quite a + number of questions. The mental content of this period was + displayed in the following utterances: She would ask for a + priest, or say "Have I done something?" or "Do people want + something?" or, when asked why she was here, she said "I + have done damage to the city, didn't I?" (What have you + done?) "I don't know." Or she spoke of people watching her. + When asked the day, she said "Judgment Day," yet she knew + the month. Once when asked what the place was she said, + "This is the hereafter." When asked what had happened at + home, she said: "Voices told me I was to be killed." She + was not clearly oriented, called the place Bellevue, asked + "Isn't this a hospital?" yet again said, "Ward's Island, + where they work." On the day of admission she thought she + came "the day before," but knew she had come in a boat. + When asked her address, she said slowly, "Didn't I live at, + etc.," giving the address correctly. To the physician she + said, "Are you my brother?" And on another occasion, "My + God! You are Charlie" (brother). It was difficult to get + her to eat, and she had to be spoon-fed. + + 2. Then she became more preoccupied, the restlessness was + much less in evidence, it became necessary to tube-feed + her, she retained her urine, answered a few questions, and + when asked where she was, she said, "Calvary, ain't it?" + (What house?) "Heaven, ain't it?" She still called the + physician by the name of her brother. After a few days this + gave way to a more marked stupor which lasted nearly two + years. This was characterized most frequently by a complete + inactivity. She usually lay or sat motionless, sometimes + with mouth partly open, letting the flies crawl over her + face, gazing in one direction, soiling, wetting, resisting + moderately or markedly any interference, and had to be + tube-fed. But this was not the invariable state. The most + constant feature was her mutism, but even that was a few + times interrupted. Thus, when after a visit from her uncle + (towards the end of July, 1902) she tried to get out of the + window and was prevented, she swore at the nurse. Or in + August, 1902, when she got into another patient's bed and + was taken out, she resisted and said promptly: "I think it + is a damned shame I can't get into my own bed." But this + was the extent of her talk for a year and a half. Nor was + she always totally inactive. In the middle of July, 1902, + she sometimes tried to get out of bed, wandered about, got + into other patients' beds. It was on such an occasion that + the above incident happened. In August, 1902, she sometimes + tried to get out when the door was opened, and we have + seen that she tried to get out of the window, but she did + not change her placid expression at such times. Her motive + was not known. On two occasions towards the end of 1902, + when she was taken to a dance and was made to take part, + she waltzed with considerable animation but did not speak. + This was quite striking in that these incidents occurred in + a setting of marked inactivity (i.e., a condition in which + she had to be pushed to the table, pushed to the closet). + She did not soil any more, but she sometimes drooled and + had to be spoon-fed. However, on a third occasion when this + was tried, she had to be dragged around. Finally, though + her facial expression showed at times a preoccupied + staring, she more often looked around, sometimes quite + freely and often looked up promptly enough when accosted. + But there was very little evidence of any affect at any + time. We have seen that twice she swore a little when + opposed. On another occasion she slapped a patient when the + latter helped her. Twice she was seen crying a little + without apparent provocation, but she did not laugh, and + the only suggestion of pleasurable emotion was that at the + two dances mentioned she could be led into a certain + animation. Usually, even when she got less resistive + towards the end, she was essentially apathetic. + + Once in January, 1903, she could be made to write her name + but wrote her maiden name. In the end of 1903 she improved + gradually (a condition not well observed), so that by + December she answered some questions in a low tone. Even in + April, 1904, she was still described as apathetic, though + she had begun to do some work. + + 3. Then she improved markedly and began to work, looked + after herself in a natural way, spoke freely, was entirely + oriented and her mood generally presented nothing striking. + But her mental attitude was still peculiar when she was + questioned. She seemed somewhat inattentive, sulky, + sneering. Thus, when asked why she was here, she said, "You + will have to ask those who brought me here." + + She denied ever having been pregnant, said the nurses on + the ward had spoken of her having had a child and that they + had showed her a child (one was born on that ward about + August, 1903) but that it was not hers. She thought it was + wrong for the nurses to speak on the ward of her having + been pregnant. Again questioned about her marriage, she + first said she had not been married, again that she was + married "a year ago" (was in the hospital then). Again she + spoke of her husband as her "gentleman friend," claimed she + called herself Mary M. (maiden name) until a girl friend + wrote her a letter addressed to Mrs. F. From then on, she + called herself by her married name. But she thought that + probably they sometimes spoke of her marriage in fun. If + she were Mrs. F. she would be living in Mr. F.'s house. + + On June 29, when again asked about her marriage, she said + she was to have been married in December (correct date). + (Were you?) "So they say." (Do you remember it?) "In a + way." (When was the baby born?) "You will have to ask + somebody more superior to me, more experienced." Then, when + further questioned about the age of the baby, she said, + "The baby I saw in the ward was about a year old," and she + claimed not to remember ever having a baby. When asked why + she had come here she said, "Well, I don't know, perhaps + you know better, through sickness I guess," and later: + "Well, don't you ever get a cold and want doctors to + examine you?" (What kind of a place?) "This is a nice place + for sensible people who have enough knowledge to know and + realize what they come for." But she knew the name of the + place, the date, the names of persons. + + Questioned about the trouble with her father or her + husband's trouble with him, she denied it, "If he did (sc. + have any trouble), I don't remember." About her not + speaking, she said, in answer to questions, "I didn't know + what I was here for, what was the object in keeping me + here"; and to other questions about her condition, "I don't + know, those who examined me can tell you more about that." + Finally, she said in reply to the question, why she came + here, "I don't remember _unless it was through fire_," but + would not explain what she meant. + + In the beginning of July, she again said that she had no + recollection of her marriage. + + She then improved a great deal and finally appeared very + natural, gave the retrospective account noted in the + history, had a clear appreciation of the fact that she was + married and had a child. She claimed that she had + previously forgotten about her marriage and thought she was + still merely keeping company with Mr. F. She claimed not to + remember coming to the hospital, did not know what ward + she came to, who the doctor and nurses were, in fact + claimed that it was about a year before she knew where she + was. But she remembered having been tube-fed. She could not + say why she did not speak. But she appreciated that she had + been ill. + + Ten years after discharge the husband, in answer to an + inquiry, stated that she had been perfectly well and had + had no trouble at three successive childbirths. + + + CASE 4.--_Mary D._ Age: 20. Admitted to the Psychiatric + Institute September 17, 1907. + + _F. H._ The grandfather and the father of the patient were + alcoholics. The father died three years before the + patient's admission; he was killed in an accident. The + mother stated that she herself was nervous, but she made a + normal impression. + + _P. H._ The patient was described as bright at school and + efficient in her work as a dressmaker, but she was rather + quiet, inclined to stay at home and had not much + inclination to consort with the other sex. She was rather + proud. As an example of this is stated the fact that she + was always somewhat sensitive, because the family lived in + the basement of the house in which her mother was + janitress. She did not menstruate until 16. It was about + this time that her father was killed in an accident. She + was considerably upset by this, talked a good deal about + the way he was killed, but did not break down. The patient + on recovery stated that it worried her because the father + died without having any chance to get a priest. + + Six weeks before admission the patient was given a + vacation, as there was not work enough in the shop, but she + worked at home. + + Two or three weeks before admission her appetite failed + somewhat, and ten days before admission, without any + appreciable cause, she began to sleep badly, seemed + somewhat nervous, became a little "fidgety" and said she + worried because her mother had to work so hard. Later she + began to speak about people saying that the ambulance would + come for her and she heard voices saying "You will be + dead." It is not known in what emotional setting these + remarks were made. Her mother took her to a dispensary. On + the way she asked the mother where she was going and said + "I can't tell the number and I don't know where I am going. + I think I am losing my mind." She also said she could not + understand any more what she read. She was put to bed. She + then talked less, appeared stupid, and was inclined to + refuse food. + + Four days before admission she claimed that she could see + her dead father beckoning to her, again she said a certain + young man was God. She was sent to the Observation + Pavilion. On the day she went there she was reported to + have shown a slight jaundice. + + The patient, after her recovery, added to the above account + of the mother, that about two weeks before admission, for + no reason which she could state, she began to feel quiet, + and that after that her father's death began to prey on her + mind, and that later she had a vision of her father. She + claimed that in this period she had no fear but that her + head felt dizzy and her vision seemed dim. + + At the _Observation Pavilion_ the patient was described as + constrained, refusing food, mute, resistive of attention, + sometimes muttering to herself and having the appearance of + uneasiness. + + _Under Observation:_ 1. On admission the patient had a + slight jaundice, which disappeared in a few days, and the + bile test in the urine was negative on admission. She was + rather thin, but otherwise in good physical condition. Her + temperature was 99.2. + + For three months the patient was very inactive, moving very + little. She had to be dressed and undressed, when taken out + of bed. She often was markedly constrained, either lying + with her head raised from the pillow, or for long periods + of time holding her arms or hands in rather constrained + positions on her body. But there was at no time any + catalepsy when tested by moving her arms. In the beginning, + however, before she lay so persistently with her head + raised, she was found holding it up from the pillow after + her hair had been fixed. Again, she did not correct other, + rather uncomfortable, positions in which she had been left. + There was also at times a slight or occasionally a somewhat + more marked resistance in her arms and neck, but this never + amounted to a pronounced resistance. She sometimes did not + react to pin pricks, sometimes flinched a little, never + warded off the pin, indeed she would put out her tongue + repeatedly when asked to do so in order to have a pin stuck + into it. She very often wet and soiled, once even + immediately after she had been taken to the closet, on + which occasion she did not urinate. Her face was usually + dull, vacant and immobile, but sometimes, when questioned + or when something obtrusive happened, a little puzzled. + Occasionally she looked slowly about or followed people + with her eyes. There was no evidence of any affect as a + rule, but not infrequently she smiled, even quite freely at + times, when the physician came to her or on other + appropriate occasions. For example, once when a nurse came + into the ward whom she had known outside she flushed and + smiled a little. Once when the mother came to see her a few + tears appeared, the only time this occurred. + + Although for the most part immobile, when she did move, she + was distinctly slow. When asked to do certain things, she + usually did not comply, but now and then, after urging, + would show her tongue after delay, or merely open her + mouth; or she would bring the hand forward slowly when the + physician offered his hand in greeting. Once she fumbled + with her braids slowly. When out of bed, she stood about + aimlessly or sometimes walked somewhat slowly. + + She was almost entirely mute, but a few times she returned + a greeting quite promptly, or on another occasion + (September 23) she said quite promptly, when asked how she + felt, "I feel better. I took off my clothes" (correct--she + had been up and put to bed again). Again she sometimes + answered simple questions by "yes" or "no," though + sometimes in a contradictory and rather aimless manner, but + promptly enough. Once she said to her mother, "I can't, I + have to remain here." There were some other replies which + we shall presently take up. Several times it was possible + to make her write. On these occasions she wrote her name + promptly, or might write only after much delay or stopping + in the middle of a word. + + This leads us to her capacity to think, the defect of which + was perhaps most clear in her writing. Thus, though having + been told to write her name, and having written it quickly + enough, when, immediately after it, she was asked to write + her address or the name of the hospital, she had to be + urged much, and then wrote each time merely a repetition of + her name, this time much more slowly. On October 13, when + she was asked to write her name, she wrote it correctly; + then for the address she wrote the house number correctly, + but for 90th street she wrote "90theath"; and, urged again + for the address, she added "Dr. Wyeth." Again when asked to + write the word "watch" she was slow, and finally put down + "10." When on October 23 she was asked to write "Manhattan + State Hospital," she wrote "Manhatt Hhospshosh," and for + "Ward's Island" (which she was told), "Ww Iland." Then she + was asked to write "I wish to go home." She wrote "I wish + to go home, go West." Here again the first part was written + promptly. + + We now can add some of the other replies which she gave. + Once she was asked "Do you know where you are?" She + promptly said, "Yes." (Where?) No reply. On another + occasion, at the initial examination, she said she was home + or "in papa's house." Once when asked "Do you know me?" she + said "Yes." (What is my name?) "Miss D." (her name). On the + occasion on which she had stated that she had taken off her + clothes, she was asked "Where have you taken off your + clothes?" She made the irrelevant reply, "That was the girl + the one I had." + + 2. Then she improved somewhat. On January 5 she walked + about a little more, though slowly, and still looked + slightly puzzled when questioned. She spoke more readily, + counted promptly though once stopped in the middle of the + exercise. In calculation she multiplied correctly 3 7, + but for 4 9 repeated the 21, and when given 9 9 she did + not answer. A few days later, though she lay again + motionless with her head raised as before, and, as she had + sometimes done, smiled brightly when accosted, she gave few + replies, but when asked to write down the month she slowly + wrote "December." Asked to write it the second time, she + did it promptly. She also replied promptly by saying "Yes" + when asked whether Christmas, and again whether New Year's, + had passed, but did not reply to the questions how long ago + Christmas, or how long ago New Year's, had occurred. On + January 23 she was decidedly more free and prompt in her + replies, yet she still wet and soiled (in fact this did not + cease until the end of the month, when great improvement + occurred). At this time she gave quite a number of + calculations promptly, about an equal number wrongly. She + knew where she was, knew the names of a number of people + about her, but thought she had been here about two weeks + (four months), and gave the year and the date, the latter + as the 28th of January. When then told that it was + Thursday, January 23, and that she must remember it, and + asked five minutes later what she had been told, she again + said "January 28" and left out Thursday. To some questions + to which she did not know the answers, since she had an + amnesia for the time of their occurrence (the incidents of + coming here), she simply remained silent. Even on February + 7, when she was much freer, helped the nurses, and said + herself she was "smarter," she had difficulty in thinking, + said she was 17 (21), gave the date of her birth correctly, + but the current year as 1909 (1908) and still insisted she + was 17. She then did the calculations on paper, and with + considerable difficulty got correctly "22." But she could + not straighten out the discrepancy. At that time, also, she + still wrote "Hospitital," calculated even simple + multiplications with some mistakes, could not get the point + of a story, and to retention tests gave poor results. + Indeed, even seven days later, when she wrote a very + rational letter and appeared quite natural, she made some + omissions in her writing, and a few mistakes in spelling. + + However, she now improved rapidly, and by March 31 she made + a very natural impression, was frank, free, had good + insight, calculated well, etc., understood a story, + retention was good. + + She then gave the retrospective account embodied in the + history, and in addition told that she had no recollection + of going to the Observation Pavilion, the coming here, or + the first part of her stay, including presentation of the + case at a staff meeting, a physical examination and a blood + examination, and she claimed for a long time not to know + where she was, "I was in a kind of dazed condition." She + also said she could not understand the questions which were + asked her. This probably refers, however, to the second + part, i.e., the partial stupor lasting for two months. She + did not "feel like talking," the limbs "felt stiff-like." + + + CASE 5.--_Annie K._ Age: 22. Admitted to the Psychiatric + Institute January 7, 1907. + + _F. H._ The father was an alcoholic, who died when patient + was a child. A paternal aunt had a nervous breakdown, with + recovery. The mother appeared to be normal. + + _P. H._ The mother stated that the patient was a rather + delicate child. She attended school irregularly, never felt + much interest in it, and was always glad to be at home and + help the mother take care of the other children. On the + other hand, she is said to have been quite lively, rather a + tomboy, with a temper. She left school at 14; learned + dressmaking for a year, but did not get along well. Then + she took several other positions, which she held for about + a year, getting on pretty well. + + She married at 20. Her husband never supported her well and + often beat her. She had to borrow money to get along and + worried much. During pregnancy she seemed to worry more, + had crying spells, and often seemed absorbed in thought. + + Three weeks before admission she gave birth to a child. The + labor was somewhat difficult, but she had no fever. She got + up on the tenth day, and then seemed to lose all interest, + did not attend to the baby, said she was not strong enough. + She sat about, appearing depressed. The mother then took + her and the baby to her house. There she sat or walked + about, said very little. But she repeatedly came to her + mother, said she had something to tell her, or that she had + "done something," although she could never be induced to + say what. Once she came to her and said, "You are not going + to die." She often moaned. Finally, she claimed a neighbor + had been saying she was poisoning the baby. + + The patient herself gave, after recovery, the onset as + follows: When she married she knew her husband was not what + he should be, but not that he was so bad as he proved to + be. He was a gambler, did not support her, and this caused + her much worry. When she became pregnant, eight months + after marriage, this increased her worry, and throughout + the pregnancy she spoke much to a neighbor about her + worries, and said she did not know how she could manage, + pay the doctor, and the like, but she did not say much + about it to her mother (because the latter would have made + such a fuss about it, or would have said, "It serves you + right"). Then the childbirth came. This further accentuated + her worries. She felt her difficult circumstances, wondered + how she could get the necessary money, "I lay there + worrying." And she claimed she did not sleep at all. About + her statement, mentioned by the mother, that she had done + something, she said that she thought she had poisoned the + child by giving it fennel tea, and that she thought a + neighbor who visited her said she had poisoned it. She was + then put to bed again, and one night she had a vision of + her father. This frightened her. She thought this meant he + had come for her and she wanted to die. + + At the _Observation Pavilion_ she was dull, staring, + resisting attempts at passive motions. + + _Under Observation:_ 1. There was nothing noteworthy in her + physical condition, except for a rise of temperature to + 100 occasionally during the first month of her admission. + For the first four months she was often found lying in bed + with her head half raised from the pillow, or standing or + sitting about in constrained positions, immobile, + frequently she let saliva collect in her mouth. She usually + wet and sometimes soiled the bed. Sometimes, when sitting + in a constrained position, she let herself gradually slide + on the floor. She often began to feed herself when urged, + but would not finish, and had to be spoon-fed, as a rule. + She was never tube-fed. She was often quite stiff and + showed marked resistance. This was manifested either when + passive motions were tried, at which times she usually + resisted passively, i.e., she became more tense; or when + there broke through a more active aggression and she would + strike. Above all, the opposition showed itself towards the + nurses' attention; in this she also showed either a + passive, aimless opposition and stiffness, or a more active + one; but even in the latter an open show of angry affect, + or plain irritation, though present at times, was by no + means constant. When it was present, she would strike quite + aimfully; once she struck the nurse and said, "You are the + cause of it all," and once, when the nurse tried to give + her some milk, she said, in an irritated tone, "I wonder + people would not let me alone some time." Again, she bit a + patient who tried to hold her. On another occasion she + quickly jumped up and pulled the hair of a patient who + evidently disturbed her by her noisy shouting. As was + stated, she usually wet the bed, resisted being taken to + the toilet, or when taken there, would not urinate or + defecate, but would do so as soon as she was returned to + bed; or she urinated while standing. The same perverse + opposition was seen when she would refuse a glass of milk, + but grab it when it was taken away and then refuse to let + go. She often would grasp the bedclothes or other things + and hold on aimlessly. + + She rarely spoke, answered almost no questions, complied, + as a rule, not even with the simplest commands. To pin + pricks she did not react except at times by flushing. But + she did not stare, rather looked about, and was at times + easily attracted by noises or happenings about her, and + would then look in that direction not without some + interest. Often there was then an expression of + bewilderment. Her mood, however, was, as a rule, apathetic, + but at times, as stated, she showed some anger. Once she + wept, and a few times she smiled or snickered. As a rule, + this happened without appreciable cause. But once, when a + cheering remark was made, she smiled; or, when her picture + was taken (to show the peculiar constrained attitude with + the head raised from the pillow), she laughed loudly. + + Although she spoke rarely, she made a few utterances in the + first few days. Thus she suddenly said: "I want to see Mr. + N.--what I said to him was not right," or "Listen! there + are the priests calling," or "You are all faking--it is me + that done it--they are all dressing up downstairs," or "I + told you she was not able to nurse the baby," or "I have + nobody, I am lost--I want to know the truth--my mamma," or + she called her sister, "They are dead since last night." + + Even during the more stuporous state she could, a few + times, be made to write a little. Then she either wrote + very slowly and not more than a letter, or if she wrote + more, it was remarkably mixed up. Thus when asked to write + the date, she wrote, "Jane (mother's name) to me to + Chrichst," or when asked to write her name: "Annie take you + ktusto." + + As to her orientation, nothing could be made out as a rule. + At first, however, a few weeks after admission, she spoke + correctly of the month as January and spoke of the Island. + When at that time she was asked if she had a baby, she + said, in an annoyed tone, "I don't know." + + 2. In the beginning of May, i.e., four months after + entrance, her condition changed somewhat, and for two + months she presented the following state: She stood about, + or walked around slowly, usually with her arms folded. She + had a tendency to stand near the door. She had to be + assisted in dressing, pushed rather than led to her meals, + and urged to eat. For the most part, she would not answer + questions, but would either smile in a sneering way, or + just walk away, or say, "Oh, don't bother me," or "I don't + want to talk," and generally her attitude was rather sulky. + Nor was this only towards the physicians but towards the + husband, sister and child as well. When on May 17 the + sister came, she would not speak to her but said "Go away." + The baby she simply pushed away sulkily when it was brought + to her. To the husband she said on May 31, "Go away, you + stink." In the first part of this period, she presented + some bursts of elation, on one occasion turned somersaults, + indulged in a few pranks with laughter, or once, when a + knock at the door was heard, she called out "Holy gee, + cheese it, the cop." But these occurred only in the first + part of the period. On June 1 she spoke to the nurse, said, + "What is the matter with these people, they must be crazy," + asked to go home, and was then by the nurse found to be + oriented, and to know the names of people around her. But + when she was asked about the baby she would not answer, and + questioned whether she was not married, she said "I don't + know." Yet when the physician desired to talk to her, she + was just the same as before and remained so for two more + weeks. Another somewhat isolated occurrence was when on + June 18 she spoke a little to the physician, but she sat in + a constrained position when taken into the office and + answered many questions by "I don't know," namely, those + regarding her condition and feelings, the questions about + orientation, about her mother's address, and her child's + age; but when asked how long she had been married she said + correctly "Two years." + + At the beginning of July she improved quite rapidly, and on + July 5 appeared fairly free and gave a fair retrospective + account, with some urging, and it was thought that she + smiled somewhat too freely. However, on July 27, she seemed + perfectly well, had normal insight, and then gave the + second retrospective account, which, together with the + first, will now be taken up. + + _Retrospectively:_ She claimed to remember things at home, + and at both interviews said she recalled being taken to the + Observation Pavilion. While there she thought she knew + where she was, remembered that she did not talk. She had a + feeling she was going to die and said "I thought I would + die if I kept still." However, the transfer to this + hospital was vague in her mind, as was the entrance on the + ward, and she claimed not to have known for quite a while + where she was. She added that she used to wonder where she + was, how she had gotten here, and how she could get out, + and thought the questions which were asked were queer. + Individual occurrences, too, specifically inquired into + were not recollected, such as an examination in a special + room. Of the mixed-up writing at the end of the second + week, she had no recollection even when it was shown to + her. She did not recall having her picture taken (with eyes + open) two months after entrance. Yet a sudden angry + outburst ten weeks after admission was remembered. She + stated that she struck the patient because the latter + annoyed her by her shouting. She had a general recollection + of being stiff, having her head raised, and of soiling and + drooling, but could not account for it. She felt stubborn. + She also claimed not to have been hungry and not to have + felt pin pricks. + + In regard to ideas which she had, she claimed to be afraid + at first that she would be cut up. She remembered repeated + visions of her father at night, also once of her dead aunt, + who said "Come to me." She thought she was in a cemetery, + all the family were dead, the baby dead. In the beginning, + too, she sometimes heard a priest whom she had known, say + "Be good and God will look after you." + + In regard to the later period, she recalled that she got up + in May and felt cross. She did not answer because she did + not want to be bothered. She pushed the baby away because + she did not think it belonged to her, the husband because + she did not like him. (She did not think she was not + married.) She evidently remembered the visits, thought she + knew where she was, knew she stood near the door "because I + wanted to go home." Besides the idea that the baby was not + hers, she recalled none, and thought she had no + hallucinations. + + She was discharged perfectly well six months after + admission to the hospital. Soon after that, she left the + husband, once had him arrested in 1908 and sent to the + workhouse. She was again examined in 1913, and was found to + be perfectly well, and she stated she had been well since + the discharge. + +These five cases will have to suffice for the present. They were given +in full in spite of the fact that we shall leave out of our present +considerations the history of the cases and certain of the stages, and +confine ourselves to that stage of each case which is best qualified to +give us a good general survey of the essential features of the stupor +reaction. + +These phases are: stage 1 of Case 1, lasting five months; stage 3 of +Case 2, lasting one year; stage 2 of Case 3, lasting two years; stage 1 +of Case 4, lasting three months; stage 1 of Case 5, lasting four months. + +We gather from these descriptions that the essentials of the stupor +reaction are (1) more or less marked interference with activity, often +to the point of complete cessation of spontaneous and reactive motions +and speech; (2) interference with the intellectual processes; (3) +affectlessness; (4) negativism. + +_Inactivity:_ There is a complete cessation or more or less marked +diminution of all spontaneous or reactive movements. This includes such +voluntary muscle reflexes as contain a psychic component. For instance, +there is, often, an interference with swallowing (letting saliva collect +and drooling), winking, and even with the inhibitory processes used in +holding urine and feces (soiling and wetting). Often there is no +reaction to pin pricks or feinting motions. The inactivity also often +interferes with the taking of food so that spoon-feeding or tube-feeding +has to be resorted to. The patient may keep his eyes covered or stare +vacantly, the face often presenting a remarkably immobile wooden, or +stolid, expression. Complete mutism is the rule. When activity is not +totally interfered with, those movements which are present may be slow. +The patient may have to be pushed around and be able to take a few +steps, but soon relapses. More often they are of normal rapidity. Speech +then may also be slow and low, but usually shows no change except for +the fact that it is diminished in amount. Sometimes awkward positions +are assumed and retained, and there may be catalepsy. + +_Negativism:_ A common symptom is perverse resistiveness. It may consist +in a marked stiffening of the body which is assumed spontaneously or +appears only when attempts at interference are made, or there may be a +more active turning away or even a direct warding off, sometimes with +scowling or anger or even swearing and striking. Retention of urine, +which is seen at times, should, perhaps, be mentioned here. Now and then +we find that a patient is put on the toilet and cannot be induced to +urinate or defecate, while soiling and wetting occur at once on +returning to bed. + +_The intellectual processes:_ Little is known about the intellectual +processes from direct observation in these more pronounced cases, except +for the fact that in Case 5 questions or obtrusive occurrences sometimes +produced a somewhat puzzled facial expression. Moreover, the patient +retrospectively stated that she was unable to understand the questions, +which points to marked difficulty in apprehension. We also find that +occasionally there is evidence of an interference with the intellectual +processes which showed itself in what may be called "paragraphic" +writing when the patient could be induced to write. Above all, we see +that retrospectively very little is remembered of what took place during +the stupor, even of such obtrusive events as the moving from one ward to +another, tube-feeding, physical examination, the presentation at a staff +meeting, and the like. + +_Affect:_ Complete affectlessness is an integral part of the stupor +reaction. Modification of the statement will later be mentioned. The +patient is indifferent so far as his basic condition is concerned, and +it is only by certain stimuli that at times emotional reactions can be +elicitated, some tears at a visit of a relative, an appropriate smile at +a joke or a comical situation when the stupor is not too deep or an +angry reaction called forth by interference. + +_Catalepsy:_ Waxy flexibility or merely a tendency to maintain +artificial positions is a frequent but not an essential symptom. + +_Physical Condition:_ Not infrequently we find in the beginning or in +the course of the stupor an elevation of temperature to 101, 102 or +even 103. In one case we found a marked cyanosis in the extremities. +Case 2 showed marked loss of hair. Gain in weight is never observed and +marked emaciation is the rule. This we may attribute to the refusal of +food. + +A perusal of these cases, then, shows that the dominant (and well-nigh +exclusive) symptoms of the stupor are inactivity, apathy, negativism and +disturbance of the intellectual functions. Benign stupor can be defined +as a recoverable psychosis characterized by these four symptoms. The +meaning of such vague physical manifestations as the low fever is not +clear. + + +FOOTNOTES: + +[1] MacCurdy has discussed the psychological phenomenon of a dramatist +depicting a psychosis correctly in "Concerning Hamlet and Orestes." +_Journal of Abnormal Psychology_, Vol. XIII, No. 5. + +[2] Many of these states seem to be hysterical rather than +manic-depressive stupors, but so far as the unconsciousness goes, there +is probably as much psychological as symptomatic resemblance between the +two types of reaction. + +[3] Kraepelin recognizes, of course, the occurrence of stupor symptoms +or states in the course of manic-depressive psychoses. It is stupor as a +clinical entity, as a separate psychosis, that he regards as one form of +the catatonic, and therefore of the dementia prcox, reaction. + +[4] Kirby, George H.: "The Catatonic Syndrome and Its Relation to +Manic-Depressive Insanity." _Jour. of Nervous and Mental Disease_, Vol. +40, No. 11, 1913. + + + + +CHAPTER II + +THE PARTIAL STUPOR REACTIONS + + +The cases thus far considered, namely, those of marked stupor, are +fairly well known and have been studied by others. Less well known and +formulated, but even more important from a practical as well as from a +theoretical point of view, are what may be called partial stupors. + +The reader has noted that the states of deep stupor described in the +last chapter, did not end abruptly with a sudden return to health or a +sudden change to another type of psychosis. They all gradually passed +away, not by the disappearance of one symptom after another, but by the +attenuation of all. Sometimes a more or less stable condition persisted +for months, in which there was no stupor in a literal, clinical sense +but when apathy, inactivity, interference with the intellectual +functions and negativism all existed. Had these been the only states +observed in these patients, there might have been some ground for doubt +as to the diagnosis. As it was, it was clear that we were dealing with +mild stages of stupor. When a psychiatrist meets with an undeveloped +manic state, he calls it a hypomania and does not hesitate to make this +diagnosis in the absence of complete development into a florid +excitement. This procedure is not questioned, because the manic +_reaction_ as distinguished from a _mania_ is well recognized. We +believe that there is just as distinctive a _stupor reaction_ which may +be exhibited either in deep stupors or what we may term partial stupors. +Theoretically, complete apathy, inactivity, etc., make up the clinical +picture of a deep stupor. When these symptoms appear rather as +tendencies than as perfect states, a partial stupor is the product. That +partial stupors occur as well-defined psychoses, developing and +disappearing without the appearance of deep stupor, we shall attempt to +show in the following three typical cases: + + + CASE 6.--_Rose Sch._ Age: 30. Admitted to the Psychiatric + Institute August 22, 1907. + + _F. H._ Both parents were living (father 74, mother 68), as + were two brothers and two sisters. All were said to be + normal. + + _P. H._ Nothing was known of the patient's early + characteristics, except that she herself said she was slow + at learning in school and did not have much of an + education. But when well she made by no means the + impression of a weak-minded person. The husband had known + her for ten years. He married her eight years before + admission, by civil process, keeping this from his own + family because he was a Jew and she a Christian. He said + that this undoubtedly worried the patient at times and that + she often asked him when he would take her to his family. + The patient herself later also said that this used to worry + her. Finally, one and a half years before admission she + agreed, on account of the children, to accept the Hebrew + faith, and they were then married in the synagogue. But he + still did not take her to his family. + + There were four pregnancies: the first child died; of the + survivors one was 8, a second 5 years old. Finally, a year + before admission, she became again pregnant. During the + pregnancy one of the children had whooping cough and she + herself was thought to have caught it. The baby was born + three months before admission. It was a blue baby which + died two days after birth. The patient flowed heavily for + three weeks and was taken to a hospital, where she + continued to flow intermittently for some weeks more. + + Finally, three weeks before admission, a hysterectomy was + performed. Several days after this, when the sister-in-law + visited her, the patient begged her to take her home, said + the doctor wished to shoot her and to give her poison. + Later the patient confirmed this, saying that she thought + they wanted to give her saltpeter, and that she heard them + say they wanted to shoot her. + + When taken home she refused food; gazed about, was + absorbed, seemed obstinate, and several times tried to jump + out of the window. Retrospectively the patient stated that + she heard children on the street call "Katie." She thought + they meant her child, heard that it was to be taken away + from her, and a similar idea again came out later in her + psychosis, namely, that somebody was going to harm her + children. + + At the _Observation Pavilion_ she appeared stupid, rather + immobile, her attention difficult to attract. + + _Under Observation:_ On admission the patient appeared + sober, impassive, moved very little, was markedly + cataleptic, though not resistive. On the other hand, her + eyes were wide open and she looked about freely, following + the movements of those around her not unnaturally. When + questioned, she looked at the questioner rather intently, + and was apt to breathe a little more rapidly, and made some + ineffectual lip motions but no reply. To simple commands + she made slow and inadequate responses. She flinched when + pricked with a pin, but made no attempt at protecting + herself. She had to be spoon-fed. The catalepsy persisted + only for two days. + + After this she continued to show a marked reduction of + activity, moved very little, said nothing spontaneously, + had at first to be spoon-fed (later ate naturally enough). + But she never soiled herself and went to the closet of her + own accord. + + Emotionally she seemed dormant for the most part, though + for the first few days she appeared somewhat puzzled, and + one night when a patient screamed she seemed afraid and + did not sleep, whereas other nights she slept well. She + answered only after repeated questions and in a low tone. + Very often, though her attention was attracted easily + enough, her answers were remarkably shallow and also showed + a striking off-hand profession of incapacity or lack of + knowledge. This was often without any admission of + depression or concern about her incapacity. She would + usually say "What?" or "Hm?" or repeat the question, but + most often would say, "I don't know," this even to very + simple questions. For instance, when asked, "What is your + name?" she answered, "My name? I don't know myself" (but + she did give her husband's name), or when asked to write + her name, she said, "I don't know how to write," or "Call + Annie, she will write my name." When requested to read or + write (even when asked for single letters), she would make + such statements as "I can't read." However, she finally + named some objects in pictures. This condition was + characteristic of her for two weeks. + + Then her condition changed a little. She spoke a little + more freely but was similarly vague. The following + interview of September 9, is characteristic: When asked how + she was, she said, "Belle." (Are you sick?) "No." (Is your + head all right?) "Yes." (Is your memory all right?) "Yes." + (Do you know everything?) "Yes." (Understand everything?) + "Yes." (Are you mixed up?) "No." (Do you feel sick?) "No." + But when asked where she was, how long she had been here, + what the name of the place was, what was the occupation of + those about her, she said, "I don't know." (How did you + come here?) "I couldn't tell how I came up here." (What are + you here for?) "I am walking around and sitting on + benches," but finally, when again asked what she was here + for, she said, "To get cured." She now gave and wrote her + name and address correctly when requested, also gave the + names of her children. Yet when asked about the age of the + girl, said, "I don't know, my head is upside down." When an + attempt was made to make her repeat the name of the + hospital, or the date, or the name of the examiner, she did + so all right, but even if this was done repeatedly and she + was asked a few minutes later, she would say "I couldn't + say," or "I forget things," or "I have a short memory," or + she would give it very imperfectly, as "Manhattan Island," + or "Rhode Island" for "Manhattan State Hospital, Ward's + Island." (How is your memory?) "All right." But when at + this point the difficulty was pointed out, she cried. + (Why?) "Because I forget so easily." All this was while her + general activity was much reduced, and she seemed to take + very little interest in her surroundings. + + Then she improved somewhat, asked the husband some + questions about home, and on one occasion cried much and + clung to him and did not want to let him go without taking + her. She also began to work quite well, but still said very + little spontaneously. During this period when asked + questions, she spoke freely enough, but seemed somewhat + embarrassed. What was still quite marked were striking + discrepancies in giving dates, and her utter inability to + straighten them out when attention was called to them, as + well as to her inability to supply such simple data as the + ages of her children. Her capacity was later not gone into + fully but it was certainly less defective on recovery than + at this time. She was rather shallow in giving a + retrospective account during this period. Even later, when + she had developed a clear insight and made, in respect to + her activity and behavior, a natural impression, she was + not able to give much information about her psychosis, + although she apparently tried to do so. + + She was discharged recovered four months after admission, + her weight having risen from 93 lbs. on admission to 133 + lbs. on discharge. For the first two weeks of her stay in + the hospital, her temperature varied between 99 and 100. + + _Retrospectively:_ She said in answer to questions about + her inactivity and difficulty in answering that she did not + feel like talking, felt mixed up, could not remember well, + did not want to write. + + Before she was quite well she knew of her entrance to the + Observation Pavilion and her transfer to Ward's Island, of + which she could give some details, but thought she had been + in the Observation Pavilion two weeks instead of three days + and in the admission ward one month instead of a few hours. + As to the precipitating cause of the attack, she spoke of + her flowing so much after childbirth and of her operation. + + She was seen again in March, 1913, when she seemed quite + normal mentally and claimed that she had been well ever + since leaving the hospital. + +With the exception of negativism, which appears only in the anamnesis, +all the cardinal stupor symptoms are found in this history. Particularly +noteworthy is her intellectual deficiency which seemed to be made up of +a real incapacity plus a remarkable disinclination for any mental effort +whatever. It is important to note that her attitude towards this +disability was usually one of indifference and that, in general, there +was no show of affect whatever. Freedom of speech was the last thing for +her to regain. + + + CASE 7.--_Mary C._ Age 26. Single. Admitted to the + Psychiatric Institute April 7, 1907. + + _F. H._ The father had repeated attacks of insanity, from + which he recovered, but he died in an attack at the age of + 60. A sister also had a psychosis, from which she + recovered. + + _P. H._ The patient was rather quiet and easily worried. + When 14 she had some dizzy spells, with momentary loss of + consciousness. After that time she had no such attacks, + except after a tooth extraction when about 24. + + The patient came to the United States six months before + admission. She went to live with a cousin who died a week + after she arrived at his house. She worried and said that + she brought bad luck. Then she took a position, where she + was well liked, but she was not particularly efficient. In + this situation she often felt homesick and lonely. + + Two weeks before admission an uncle died, which affected + her considerably. She spoke of his leaving three children, + and would not go to the funeral. Then she thought she was + going to die. She felt dizzy, weak, walked with a stooped + position, was sleepless. In the midst of this she suddenly + felt frightened and walked into her mistress' room, to + whom she complained that some one was talking outside but + could not tell what was said. She heard shooting. + Retrospectively, after recovery the patient said that at + that time she suddenly got "mixed up," and that her "memory + got bad." + + She was taken to a general hospital, where she thought + there was a fire, and screamed "Fire!" She was soon + transferred to the _Observation Pavilion_, where she + appeared dazed, moving slowly, yet showing a certain + restlessness. She spoke of "the boat" being shut up so that + no one could go out. Again, she said "The boat went down + and all the people keep turning up." Retrospectively the + patient stated about this condition that she remembered + going to the general hospital but not her stay at the + Observation Pavilion. (The trip to the Manhattan State + Hospital was again clearer to her.) About the ideas she had + at the time, she remembered only that the room seemed to go + around, and that after she had come to the Manhattan State + Hospital and was clearer, she thought she was in Belfast, + was on a ship, and that people were drowning. + + _Under Observation:_ On admission she had a temperature of + 100, a coated tongue, suffused conjunctiv. There were + herpes of the lower lip, a general appearance of weariness + and exhaustion, a flushed face, trace of albumen in the + urine, which was absent on the third day, no leucocytosis, + but 41 per cent. lymphocytes. + + Then and henceforth she was inactive and very slow in all + her movements; she never stirred spontaneously, and had to + be pushed to the toilet and to the table; she ate slowly. + She did not speak spontaneously, and her replies were very + slow in coming. She had to be urged considerably before she + would speak and, as a rule, she did not answer. On one + occasion she was for a day totally inactive and looked + duller. That day and on a few other occasions she wet the + bed. There was at times an appearance of dull bewilderment. + When, soon after admission, asked whether she felt cheerful + or downhearted, she said "downhearted," but this was the + only time. Often she answered "I don't know," when asked + whether she was worried, and she could never say what she + was worried about. Again she directly denied worry. + Sometimes she smiled appropriately, and repeatedly, when + asked how she felt, said, "I feel better." In answer to + questions as to how her head was, she replied several + times, "My memory is gone," also "I can't take in my + surroundings," or "I don't know where I am," or "I cannot + realize where I am." Again, she spoke of being dizzy and + once said it was as though the room went round. Sometimes + she knew where she was or knew names, again said "I + forget," but she always was approximately oriented as to + time. There were no special ideas expressed and no + hallucinations, except in the very beginning when she still + thought at night, when she heard the boats on the East + River, that people were being drowned. She later, as stated + above, said she thought she was on a boat and people were + being drowned. + + By June, i.e., two months after admission, she began + rhythmical swaying of the body, twisting of the fingers, or + pulling out some of her hair. She ascribed this behavior + simply to "nervousness." + + On July 16, after a visit from her cousin, who said to her + that if she worked she would soon get better, she began + spontaneously to occupy herself somewhat. She became more + active, said she felt stronger and brighter, and that her + memory was better. By the beginning of August she was + fairly free, but still spoke in a rather low voice, + although answering well. Her capacity to calculate also + remained poor. When asked about the more inactive state, + she said she had been afraid to stir. (What afraid of?) "I + didn't know where to go or what to do." Further, she + recalled that she had had a numb feeling in her tongue, + could not speak quickly, and that her mind had felt + confused and "she could not take in things." Further review + with her of the earlier period of her psychosis showed that + there was a blank for external events and most of the + internal events during this time. + + She made a perfect recovery and was discharged August 7, + 1907, four months after admission. + +This case, although very like the last, differs from it in two +particulars. For one day her symptoms were sufficiently marked to +suggest a deep stupor. Secondly, her intellectual incapacity was not so +marked (always approximately oriented for time) and with this there was +some subjective appreciation of her defect. Apparently, however, this +insight did not cause her any worry. The affectlessness was equally +prominent in both of the foregoing cases, the fact that Mary C. (Case 7) +once admitted feeling downhearted in response to leading questions, +having little significance in the face of her expression, actions and +usual denial of worry. It is interesting to note that, during the bulk +of her psychosis, her only complaints were of mental hebetude and +dizziness. Possibly the latter was merely an expression of her +subjective confusion. + + + CASE 8.--_Henrietta H._ Age: 22. Admitted to the + Psychiatric Institute March 6, 1903. + + _F. H._ The father stated that both parents were living and + well, also eight brothers and sisters. + + _P. H._ The patient came to this country when she was a + baby. She was bright at school and industrious. From the + age of 17 on, she worked in a drygoods store and gave + satisfaction. About her mental make-up no data were + available, except for the statement that she always made a + natural impression. + + When 21 (February, 1902), without known cause, she broke + down and was sent to the Manhattan State Hospital, but was + not observed in the Institute ward. She remained in the + hospital for three months. It was claimed that the attack + came on suddenly two days before she was sent away. She + suddenly appeared anxious, said something had happened and + became excited. This lasted for about a week, and then she + was, as the description says, "depressed and cataleptic." + She remained in this condition for about a month, during + which time there was a slight rise of temperature. Then she + improved gradually and was discharged three months after + admission. After recovery from the present attack the + patient stated that during the first sickness she had + visions of dead friends. + + She was perfectly well in the interval. + + Six days before admission she suddenly became excited, + refused to eat, and began to talk, repeating phrases over + and over. Then she became elated and excited. + + After recovery the patient described the onset of her + psychosis as follows: Six days before admission, after + having been perfectly well and without any known cause, she + was feverish and vomited, but slept well. Next day she felt + nervous, and her thoughts were clear. She constantly + thought of dead friends, heard them talking, when she tried + to do anything the voices said, "Don't do that." She also + thought somebody wanted to harm her people. Soon she + started singing and felt happy. + + Then she was sent to the _Observation Pavilion_, where she + appeared to be in the same condition which was observed in + the Institute. + + _Under Observation:_ 1. On admission she was in good + physical condition, except for her skin seeming greasy. She + presented for nine days the following picture: She was + essentially elated, laughing, singing, jumping out of bed, + good-natured and tractable, and very talkative. Her + productions showed a good deal of sameness and a certain + lack of progression. She spoke at times in a rather + monotonous voice, but again often in very theatrical tones, + with much, rather slow, gesturing. The following are very + representative samples: + + "I have been suffering from my own blood, my own blood sent + all away from home. I just came from Bellevue. I left here + last May (correct) a healthy girl. A sister is a sister--I + wonder why shorthand is shorthand, a stenographer is a + stenographer (seeing stenographer write)--a kind brother, + Bill H.--why H. his wife is a sister-in-law to us, she has + four children--four beautiful children--sister-in-laws and + brother-in-laws--telephone ringing (telephone did + ring)--dear Lord, such a remembrance--remembrance was + remembrance, truth was truth--honesty is honesty--policy is + policy--if she married him, she is my sister-in-law and he + is my brother-in-law--Max knows me--she changed her name to + Mrs. R.--two children who are Rosie and Maud, if names were + given, names should not be mistaken--they are Julia, + Lillian--Rosie and Maud--why should wonders wonder and + wonders cease to wonder, why should blunders blunder and + blunders still blunder; sleep is one dream and dream means + sleep--if move is moving, why not move?" When she + accidentally heard the word wine, she said "Guilty wine is + not in our house--wine is red and women are women, and + women and wine and wine and women and wine and song." + Again, "You are not Mr. Kratzberger, Mr. Steinberger, Mr. + Einberger--you are not Mr. Horrid or Mr. Storrid--perhaps + you are Mr. Johnson or Mr. Thompson--no, you are Dr. C." + (correct). + + She was quite clear about her environment. + + Although the mood was throughout one of elation, on the + ninth day in the forenoon she cried at times, wanted to see + her mother, and spoke in a depressed strain (content not + known). A few hours after that she suddenly became quiet. + + 2. Then for four days (March 14-17) she was markedly + inactive, though at times got out of bed. She looked about + in a bewildered manner, did not speak spontaneously, but + could with urging be induced to make some replies. She did + this now fairly promptly, now quite slowly. Questions were + apt to bring on the bewilderment. Thus, when asked where + she was, she merely looked more bewildered, finally said + "Bellevue--I don't know," and questioned who the doctor was + whom she had called by name in her manic state, she said, + with some bewilderment, "Your face looks familiar." (Where + have you seen me?) "In New York." She claimed to feel all + right. There was no real affect. She made the statement + that at home she heard voices saying "You will be killed." + + 3. Henceforth this bewilderment ceased, and for 16 or 17 + days she was essentially inactive for the most part, for a + short time with a tendency to catalepsy and some + resistiveness, and at that time lying with eyes partly + closed. As a rule she said nothing spontaneously, but + replied to some questions, usually with marked retardation, + again more promptly. She constantly denied feeling sad or + worried, repeatedly said she felt "better," only on one + occasion did she cry a little. When asked to calculate she + sometimes did it very slowly, again fairly promptly. The + simple calculations were usually done without error, the + others with some mistakes. As to her orientation the few + answers obtained showed that at times she knew the name of + the place and the day, again she gave wrong answers + (Bellevue). Once asked on March 23 for the day, she said + April. She wrote her name promptly on one occasion, again + a sentence slowly but without mistakes. Once during the + period she sang at night. Once she suddenly ran down the + hall but quickly lapsed into the dull condition. + + On April 4, at the end of this period, she suddenly + laughed, again ran down the hall, said she had done nothing + to be kept on Ward's Island. But she quickly lapsed again + into the dull state. Later, on the same day, when the + doctor was near, she said, in a natural tone, "Thank God, + the truth is coming out." (What do you mean?) "That I have + been trusting in a false name and that Miss S. (the nurse) + should not nurse me." Then she got suddenly duller, + calculated slowly and with some mistakes, 317=41, 419=56, + and when asked to write Manhattan State Hospital she wrote + (not very slowly) "Mannahaton Hotspalne." + + 4. Next day it was noted that she was more stuporous, and + she remained so for two weeks, now showing a decided + tendency to catalepsy and more resistance than before, + though not marked, except in the jaw. She lay often with + head raised, sometimes with eyes partly open, or staring in + a dull, dreamy way, neither soiling nor drooling, however; + a few times she looked up when spoken to sharply. There was + no spontaneous speech. Usually she did not answer at all, + but a few times a short low response was obtained. Once she + wrote slowly a simple addition, put down on paper. When, on + one occasion, asked how she felt, she, as before, said, "I + feel better." + + 5. Then, with the exception of a day at the end of the + month, when the more stuporous state was again in evidence, + she returned to her former condition without catalepsy or + resistiveness and without staring, but essentially with + inactivity or slowness. She now even dressed herself, + answered slowly though not consistently, but she again + denied feeling troubled or sad, "I feel better." + + On July 7 she got brighter but was still rather slow. She + then even began to do some work. She again denied feeling + sad. + + In a few weeks, while having a temperature of 102 with + vomiting and diarrhea, she suddenly got freer. She then + said, in answer to questions, that she did not speak + because she was not sure whether it would be right, again + because she seemed to lose her speech. She did not move + because she was tired, had a numb feeling. She said she + had not been sad, "but I had different thoughts," "saw + shadows on the walls of animals, living people and dead + people." She was not frightened, "I just looked at them." + People moved so quickly that she thought everything was + moved by electricity. She thought her head had been all + right. + + After a few days she relapsed into a duller state again, + but then got quite free and natural in her behavior. On + August 28 she gave a _retrospective_ account of her + psychosis, a part of which has been embodied in the + history. She had insight in so far as she knew she had been + mentally ill. She claimed to remember the Observation + Pavilion and her coming to the hospital, also the incidents + during the manic state, when she heard cannon and thought a + war was on, and voices she could not recognize nor + understand. Then she became stupid, although neither sad + nor happy. + + Then, she claimed, she got stupid, but neither sad nor + happy. She claimed to have known all along where she was, + but felt mixed up at times, her thoughts wandered and she + felt confused about the people. She thought she was in + everybody's way, thought others wanted to get ahead of her, + did not speak because she did not know if it were right or + wrong, felt she might cause disturbance if she answered. + (It is not clear whether she had complete insight into the + morbid nature of these statements.) She also claimed again + that all along she "saw shadows on the wall," "scenes from + Heaven and Earth," "shadows of dead friends laid out for + burial." She had insight into the hallucinatory nature of + these visions. Sometimes she thought she was dead also. She + claimed that she began to feel better when these shadows + stopped appearing in June (the actual time of her + improvement). + + She was discharged recovered a month later, after having + been sent to another ward. + +In this case, then, we find that the two months of stupor were ushered +in by a brief state in which, in addition to the usual inactivity, there +was a certain bewilderment, increased by questions, while the +orientation which in the preceding manic state had been good became +seriously interfered with. The psychosis bordered on deep stupor for +brief periods when the inactivity seemed to be complete or she lay in +bed with her head raised from the pillow. On the other hand, there were +occasional sudden spells of free activity even with a certain elation. +She could often be persuaded to answer questions or to write, the +slowness of this spoken or written speech varying considerably. Her +replies revealed the fact that she was essentially affectless and that +her intellectual processes were interfered with, even to the extent of +paragraphic writing. We have, therefore, here again features similar to +those of the preceding cases. In addition we must add as important that +this patient said retrospectively that she thought she was dead, that +she saw "shadows from Heaven and Earth," "shadows of dead friends laid +out for burial," all this without any fear. We shall see later that this +is a typical stupor content. + +We will here include state 3 of Anna G. (See Chapter I, Case 1) who +after the pronounced stupor was for two months merely dull, somewhat +slowed and markedly apathetic. Although her orientation was not +seriously affected, there was considerable interference with her +intellectual processes, as shown in her wrong answers or her lack of +answers when more difficult questions were asked. + +A similar picture was presented in state 2 of Mary D. (See Chapter I, +Case 4.) Here, to be sure, there were more marked stupor features in +that the patient wet and soiled, in addition to occasional spells when +she lay with her head raised. But she spoke and acted fairly freely +(even while soiling). By her replies she showed a considerable +intellectual inefficiency, although, like Anna G., her orientation was +not seriously disturbed. Here again there was complete affectlessness. + +This gives us, therefore, five states which may be analyzed for the +symptoms of partial stupor. The pictures of all five are unusually +consistent. There is inactivity, marked but not complete; poverty of +affect without perfect apathy; and a marked interference with the +intellectual processes. The last can be studied better than in the deep +stupors because these partial cases are more or less accessible to +examination. There is a tendency for the patient to think much of death +either in the onset or during the psychosis. Negativism seems much less +prominent than in the deep stupors. + +A natural criticism is that these cases merely had retarded depressions. +Although this topic will be discussed fully in a later chapter, two +differential characteristics should be mentioned now. First, depression +is a highly emotional state in which the sadness of the patient is as +evident from his facial and vocal expression as from what he says, while +these stupor reactions are by observation and confession states of +indifference. Secondly, there is no such disturbance of the intellectual +processes in depression as is here chronicled. Let the retardation once +be overcome so that the will is exercised and no real defect is +demonstrable. In our experience the cases of apparent depression with +intellectual incapacity are found on closer study to be really stupors +as other symptoms show. + + + + +CHAPTER III + +SUICIDAL CASES + + +An important "catatonic" symptom is a tendency to sudden, impulsive, +unexplainable acts. Such actions occur occasionally in benign stupors +and, since we attempt an understanding of the reaction as a whole, an +effort should be made to study these phenomena as well. The cases chosen +showed persistent, quite affectless, yet very impulsive attempts at +self-injury. They characterized the first of the three cases throughout, +were present in one stage (the second) of the second patient, while in +the last for one day there was behavior which can be similarly +interpreted. + +Mention has been made of the prominence, approaching universality, of +the death idea in stupor. This is a subject to be discussed in length +presently, but for the present we may say that there may be a delusion +of death with dramatization of that state or a mere abandonment of the +mental activities of life. It is but a step from corpse-like behavior to +suicidal attempts, psychologically speaking, yet this transition +necessarily modifies the clinical picture, since one necessitates +inactivity and the other activity. Secondarily, other atypical clinical +features appear, as will be seen. + + + CASE 9.--_Pearl F._ Age: 24. Admitted to the Psychiatric + Institute July 26, 1913. + + _F. H._ A paternal aunt was insane. Both parents died long + ago; the mother when the patient was a baby; the father + when she was a girl. She came to this country when 17. In + this country she had generally been a domestic. An older + brother and sister were also in America. + + _P. H._ She was described as sociable, good-natured, bright + enough, not inclined to be depressed. She had little + education. There was no former attack. + + Four months before admission, the patient did not + menstruate but was said not to have worried about this. A + month later she began to show symptoms. She said she did + not want to live, had done something wrong but could not or + would not say what it was. Again she said a young man was + going to sue her, a young Jewish fellow whom she had seen + only a few times. She talked of turning on the gas. She + also complained that people were looking at her and that + the food was poisoned. + + The patient after recovery gave the following version of + the onset: She had a position on 99th St. for 2 years. + She liked the people there and often went to see them + later. Her next position was in the Bronx. She was there + for nine months. In the same house lived "Harry." After the + work she used to talk to him in the yard and, after she + left, she used to think of him and long for him. But she + denied, with a very natural attitude, that she worried + about him at the beginning of her psychosis. After the + position in the Bronx she went to one on 96th St., where + she was for four months. In the same house was a girl whom + she liked and who was lively. When she left, the patient + left too. This was a month before the psychosis began. When + she left there, she got word that her employer on 99th St. + had developed consumption and had to go out West, but did + not worry over this news, she claimed. She looked for + another position and had one for two weeks, but felt + lonely, did not care to live. Then her sister took her to + her home. She thought people were looking at her and were + making remarks because she was not working. During this + time she had a dream one night in which her dead mother + appeared to her (in ordinary street clothes) and said to + her that she (the patient) "was going away." She woke up + frightened. She was worried, thought she had not prayed + enough for her mother, and asked her sister to pray also + and to give money to the poor. She did not recall, or at + any rate denied, speaking of the young man suing her. + + She was then taken to a _private sanatorium_, where she was + for two months preceding her admission to this hospital. + There she was described as quiet, mute, tube-fed, + resistive. + + When well, the patient said that in this sanatorium she was + first spoon-fed, cup-fed, later tube-fed, "I used to be + scared of them, they used to put a spoon way down my throat + and I had no appetite--I did not like them around me, they + were mean to me. They used to let me stand without clothes, + used to spite me." "If I did not want to dress myself, they + used to hit me." "I used to feel lonesome for home and I + imagined my people were there and that my sister passed the + place without stopping." She was afraid of the nurses, + thinking they wanted to kill her. + + At the _Observation Pavilion_ the patient was described as + dull, but brightening up under examination. She made few + spontaneous remarks, but in answer to questions said she + was melancholy, tired of life, because she was in love with + a Gentile fellow who refused to marry her. She also said "I + get peculiar thoughts that I am going to die." + + _Under Observation:_ The patient's condition lasted for + about two years. Much of the time she lay in bed, often + with the covers pulled over her, sometimes with her legs + drawn up, again in a more natural, comfortable position, or + she sat up with her head bowed. She obeyed almost no + commands. For months she soiled and wet herself, but never + drooled. For a time she refused food consistently, lost + flesh and had to be tube-fed. For the most part she said + very little and, when one accosted her, she was apt to turn + away. A few times, when further urged, she swore at the + examiner. There was also persistent marked resistance + towards any interference, sometimes merely passive or quite + often, especially at first, with wriggling or severe + scratching of her own body. There was often with this + evidence of irritation or she moaned. Again she was + described as quite affectless. One of the most striking + features throughout a large part of the course were her + suicidal attempts. She would try to strike her head against + the iron bedpost, throw herself out of bed, throw herself + about generally, try to strangle herself with the sheets, + try to pull out her tongue, all of which seemed to be done + with great impulsiveness. Almost her only utterances had to + do with death. She said she wanted to die, wanted to drop + dead, did not want to live, wanted to kill herself, that + she did not eat because she wanted to die. When once she + was found tossing about and was asked whether she worried, + she said "I know I am going to die." (You mean you will be + killed?) "I don't care." + + There were a few episodes which still have to be mentioned. + Quite early in the course of the stupor, when she was + restless, scratching herself and moaning, she once spoke + quite freely. She said "Give me that fellow (Harry), I + don't care, I can't help it. I must have him, even if it + costs me my life." "I would feel happy if I could get him. + O God, I love him--I will never get him even if I drop + dead, I know I won't get him, the darling" (cries). (What + if you did get him?) "I know I would lose him again." Then + with shame she claimed she had had sexual relations with + him (when well, denied). At the same interview, when the + doctor sneezed, she said "Gesundheit." In June, 1914, she + was seen smiling at times. But the first was the only + episode when she spoke more freely, and the two occasions + the only ones when she showed a frank affect. + + The improvement commenced in April, 1915. Although still + very inactive, she sometimes began to laugh and sing and + talk a little to other patients. She also answered a few + questions on April 22, 1915. Thus, when asked whether she + wanted to go home, she said "No, I want to stay here." (Do + you like it here?) "Yes" (smiles), "I can't get no other + place; I have got to like it here." She smiled freely. To + orientation questions, she knew the place, month, but not + the year. + + She continued inactive and above all diffident, but + improved steadily and, when examined by the writer on + November 15, she made a very natural impression and gave + the retrospective account of the onset embodied in the + history. She was quite frank, thanked the doctor for the + interest he took in her case, and said for example, "You + know I never thought I would get well. I quite gave up--I + am very glad I am well now." + + When questioned about her stay here, the patient evidently + remembered much. She was able to say which wards she had + been in and approximately how long she had been in each + one. She claimed that at first it "seemed strange." "I did + not eat, I did not want to eat, I used to tell them to + poison me and that I wanted to die, I was _disgusted_, I + thought I would never go home." She also says she felt + _angry_, wanted to kill herself. She bit and scratched + "because I was nervous." She remembered talking about + Harry, "I said I was in love with him, I thought I wanted + to die because I could not have him." She also talked of + having been _stubborn_. Sometimes she felt like running to + the river. She also claimed she imagined people were false + to her. + + In one of the wards she said she thought people were there + on her account, were waiting for her death. She did not + care for a time whether she died or not. She knew she tried + to choke herself occasionally. Asked how she behaved, she + first said she was quiet. (Were you not restless?) "I used + to get tired and have backache and roll around in bed." She + also felt like running away sometimes, wanted to get out of + bed and wanted to walk about. (What about going to the + river?) "I used to say that." She claimed not to have been + mixed up at any time and to remember everything. Remarkable + is the fact that she claimed she _did not worry at all_, + "_I felt I was lost and would not worry._ I used to worry + at home and at Dr. M.'s (the private sanatorium) but not + here. Here I never worried, I did not care where I went." + She said she did not talk because she was bashful in the + presence of doctors, sometimes she felt afraid of them, + afraid they would kill her, put poison in her food when + they fed her. "When my people came, I said I did not want + to live, wanted to kill myself. I used to cry." Again asked + why she did not talk, she admitted she really did not know. + Once she said she was bashful because she soiled her bed. + She did not want to go to the closet because she was afraid + of the nurse. She denied hearing voices. + +In addition to the activity incidental to her attempts at self-injury, +this patient showed an unusual degree of resistiveness and with this +some affect, for she appeared to be irritated and at times moaned. Still +more unusual were the appearances of delusions not associated with +death but with a vivid form of life, namely, a love affair. Occasionally +she spoke of her imaginary lover "Harry." Another atypical feature was a +fair memory for the period when she was in stupor. She claimed to +remember much of her movements and this claim was substantiated by her +answers to questions after recovery. + + + CASE 10.--_Margaret C._ Age: 23. Single. Admitted to the + Psychiatric Institute November 13, 1913. + + _F. H._ Heredity was absolutely denied. The mother is + living and made a natural impression. The father died at + 65, nine months before patient's admission, of cardio-renal + disease. Two brothers and one sister died of acute + diseases. One sister died in childbirth. Three brothers and + one sister were said to be well. + + _P. H._ The patient was bright and passed successfully + through high school. For seven years prior to the psychosis + she worked for the same company as clerk. She was described + as efficient, conscientious, systematic, though sometimes + upset by her work; as lively, talkative, cheerful, with + somewhat of a temper and easily hurt, also as quite + religious. She was more attached to her mother than to her + father, but still more to her older sister, whose death + precipitated her psychosis. She never had any love affair + and was said not to have cared for men. Two months before + admission, when her favorite sister was confined, the + patient was quite worried about her, but relieved when she + heard good news. A few hours later, however, the sister + died suddenly. When the patient learned of the sister's + death, she screamed, and screamed several times at the + funeral. She did not cry, said she could not. After this + she slept poorly, seemed nervous, went to church more, but + there was no other change. She continued to work and, + according to the employer, worked well. + + Nine days before admission she would not get out of bed in + the morning, said little and refused food. A few days later + she was induced to take a walk, but she seemed to have no + interest in anything. When she talked at all it was about + her sister and of wanting to go to a convent. When asked + to do anything she said she would if it were God's will. + She did not menstruate after her sister's death. When + practically recovered, the patient attributed her breakdown + to this tragedy. She added to the description above given + that, soon after losing her sister, she had a fright at + home. "It was the house in which my father died and one day + when I was in bed I thought somebody came in." But she + denied a vision and could not further explain. + + At the _Observation Pavilion_ she was very inactive, so + that she had to be fed and cared for in every way, mute, + often covering her head with a sheet, turning away when + questioned and resistive when the physical examination was + attempted. But at times she smiled or laughed. + + _Under Observation:_ 1. For two months the patient was + generally inactive, sometimes lying in bed with her eyes + tightly closed, or with her face covered by the sheets or + buried in the pillow; or she sat inactive, staring, or with + eyes closed, or her head buried in her arms. On one visit + she had to be brought into the examining room in a wheel + chair and lifted into another seat. A few times she was + observed holding herself very tense with her head pressed + against the end of the bed. But this inactivity was often + interrupted by her going quickly into various rooms to + kneel down, though she was never heard praying. Or she ran + down the hall for no obvious reason. Or, again, she was + found lying on the floor face down. She ate very poorly and + had to be tube-fed a considerable part of the time. When + this was done, she sometimes resisted severely, as she did + in fact most nursing attentions. Thus she soon began to + struggle when her hair was combed. She also resisted being + taken to the toilet or being brought back. She did not soil + or drool, however, but sometimes seemed to be in + considerable distress before she finally literally ran to + the closet. This resistance just spoken of consisted + chiefly in making herself stiff and tense. Sometimes at the + feeding she pulled up the cover when preparations were made + and held to it tightly. Quite striking was the fact that + with such resistance she sometimes, though by no means + always, laughed loudly, as she did occasionally when she + was talked to, or even without any external stimulation. + This laughter always was one of genuine merriment and quite + contagious, and by no means shallow or silly. + + Usually the patient was totally mute. The exceptions + occurred mostly when her resistance was called forth. Thus + one day when fed she said, "I wish you people would have + more to do," or on another occasion, when she had resisted + being brought into the examining room, she said, "I will + get out of here if I break a leg." But once when the nurse + accidentally tickled her, she said, "Since I am ticklish, I + must be jealous--I should worry." She also answered very + few questions and such responses as she made were chiefly + expressions of resentment. Thus, when one kept urging her, + she finally would say "stop," or after much urging "I am + going to hurt you pretty quick." Sometimes she said "Go + away," or "Let me alone." She was just as silent with the + mother and the priest as with the physicians. On one + occasion she told the nurse that the priest had told her to + talk to the doctors, but that she had nothing to say. + Sometimes she did not even look at the visitors, but turned + away from them, as she did from the physicians, but at one + visit from a priest, though she scarcely said anything, she + held on to him when he was about to depart and would not + let him go. Throughout this period, since scarcely any + answers were given, nothing was known about her + orientation, except when on admission she gave a few + answers. She then thought she was at the Observation + Pavilion, seemed unable to tell even that the physician was + a doctor, but knew the date. When asked how she came to + Ward's Island, she said "By ambulance." The physical + condition presented nothing of note, except for a certain + sluggishness of the skin with marked comedones. + + 2. By _January_, 1914, the picture changed somewhat and she + then presented the following state for an entire year: The + mutism persisted and indeed became even more absolute, and + she began to wet and soil constantly. This commenced as + what seemed to be an act of spite as a part of her + resistiveness, for the first time she soiled she seemed to + do it deliberately when the nurses insisted that she allow + them to put on a dress. Later this explanation no longer + held. Tube-feeding too was for the most part necessary, the + resistiveness continuing as before. But the inactivity was + broken into much more than before by constant impulsive + attempts to hurt herself in every conceivable way--by + bumping her head against the wall, putting her head under + the hot water faucet, trying to pound the leg of the + bedstead on her foot, striking herself, pinching her + eyelids, pulling out her hair, trying to pick her radial + artery, throwing herself out of bed, knocking her head + against the bed rail, etc. This was done in silence but + with what appeared a great determination that occasionally + showed itself in her face. She also sometimes scowled and + frowned. With the difficulty in feeding her and the + constant impulsive excitement in which bruises could not + always be avoided (once an extensive cellulitis developed + in the arm which had to be lanced), the patient got weak, + emaciated and exhausted; much of her hair fell out, + although some she pulled out. It should be stated that + during this entire impulsive state she could not be taken + care of in the Institute ward, but was sent to a special + ward in the Manhattan State Hospital, where suicidal + patients are under constant watch. These impulsive attempts + at self-injury lessened only towards the end of the period. + Her laughter, which had been such a prominent trait, + disappeared almost entirely during this entire phase. With + all this, the general resistiveness, as has been stated, + remained towards feeding or any other interference. It was + only in the beginning associated with laughter as in the + previous stage. + + Although there were, as a rule, no spontaneous remarks and + no replies, she on one occasion said spontaneously, + probably referring to her unsuccessful attempts to kill + herself: "I can't do it, I have no will." During the same + period she once said: "I don't want to eat, I don't want to + get well, I want to do penance and die." + + By _January_, 1915 (i.e., a year after the second phase had + commenced), she began to dress herself and eat, and also + became clean. But she remained for the most part very + inactive, sitting stolidly about all day and still without + interest in her environment. The impulsive attempts at + killing herself disappeared. Although she remained for + months to come still inactive, she gradually began to talk + a little, began to play a little on the piano, but said + little to any one. + + By _August_, 1915, she still was inactive, shy, standing + about, or sitting picking her fingers, occasionally going + to the piano, but evidently unable to finish anything. She + had to be coaxed to come to the examining room and talked + in a low tone. Often she commenced vaguely to speak and + then stopped and could not be made to repeat what she had + been saying. Affectively she was remarkably frank, + sometimes a little surly, or she showed a slight empty + uneasiness. She could, however, be made to laugh heartily + at times, or did so spontaneously on very slight + provocation. + + Some of her utterances were in harmony with her apparent + indifference. It was difficult to get her to say how she + felt even when thorough inquiries were made. Once she said, + when asked about worrying, "I don't worry," or again "I get + angry sometimes," or "I used to worry about my health, I + don't now," or, when asked what her plans were, she said + directly: "I don't care what happens." Again she said "I + guess I am disagreeable," or "I guess I am a crank." + Another interesting indication of her state was expressed + in her repeated statement, "I don't know what I want." But + she was oriented in a way, though not sure of her data. She + would give most of her answers with a questioning + inflection, "This is the Manhattan State Hospital, isn't + it?" or she would say, "I don't know exactly where I am, + it's Ward's Island, isn't it?" and in the same way she gave + the day, date and year correctly. But she did not know the + names of the physicians. At that time she could give many + data about her family correctly, but was slow, even if + correct, in calculation, and, though she got the gist of a + test story, she left out some important details. + + A retrospective account at that time showed she was + uncertain about the Observation Pavilion, that she was not + certain how she came to Ward's Island, "On a boat, I + believe." It was clear that she did not remember the + admission ward, about the Institute ward (in which she had + been for the first two and a half months and in which she + was again examined); she said it was familiar to her, but + she was not certain that she had been in it. About the + physician who saw most of her in these first two and a half + months, she said that his voice seemed familiar, and she + asked him whether he had tube-fed her (she had been + tube-fed by him many times), but she again said, "No, you + are not the one," and described as the man who had fed her + the one who did it on the second ward where she was for a + year. But she knew that she had been sent to the second + ward, because she constantly tried to injure herself. These + injuries she recalled but was unable to say why she + attempted them, "I suppose I didn't know what I was doing." + She claimed she heard voices and had "all sorts" of + imaginations, but could not be gotten to tell about them. + When it was difficult for her to give an answer, she was + apt to keep silent and then could be prodded without much + success. + + In _October_, 1915, there was further improvement, inasmuch + as she began to converse some with other patients, played + the piano and seemed able to carry a piece through. She was + put in the occupation class and did quite well. At the + interview with the physician she was still apt to laugh + boisterously at slight provocation. Even now she had great + difficulty in describing her condition and at the + examination was often still quite vague. Thus, when asked + how she felt, she said, "I do know I feel + ridiculous--sometimes I feel kind of angry--I don't + know--they say I am crazy but I am not, but I am hungry--I + don't know whether I am or not, I don't know what I can do + well," etc. This is quite characteristic. When asked + whether she was worried, she said: "I don't know, am I + worried?--yes, a little sometimes, I am to-day--I am so + untidy--don't know what is the matter with me." Again: + "Sometimes I lose my speech--I can't say what I feel, I + don't know what it was." Later, half to herself: "I don't + know what is the matter with me--I don't care anyway." + + In _December_, 1915, there was still further improvement, + and on the ward and in superficial conversation she made, + towards the end of the month, in many ways a natural + impression, though the laughter before described was still + somewhat in evidence. It usually came not without occasion, + but was, as a rule, quite out of proportion to the + stimulus. She again said she could not explain why she + tried to injure herself, claimed she did not feel it, and + even claimed she did not remember doing it in the Institute + but only in the second ward. + + The defect in thinking which still remained is very + difficult to formulate. She was now entirely oriented, no + longer with any hesitation about the correctness of her + information. She subtracted 7 from 100 very quickly and + could from memory write a long poem, but there was a + certain vagueness about her which partly may have been due + to a still existing indifference. This vagueness consisted + chiefly in a difficulty of attention or in her capacity to + grasp fully what was wanted. It is best illustrated by a + few examples: After she had been asked about the _onset_ of + her sickness and she had said that what was on her mind + then were prayers for the salvation of her relatives, she + was asked exactly when it was that she thought of this; she + answered "Now?" (What period were we talking of, the + present or past?) "The present." (What did I ask you?) + "About this period of my sickness." (Which one?) "What + sickness?" She said herself at this point, "I am rather + stupid" (quite placidly). Or again she said she did not + know why she pounded her head, but finally said, "To get + better and go home." (Do you think if you pounded your head + against the wall you would go home sooner?) "I don't + know--maybe." (How would it help you?) "You mean to go to + the city?" (Yes.) "I don't know." Again when asked how her + mind worked, she said, "Pretty quickly sometimes--I don't + know." (As good as it used to?) "No, I don't think so." + (What is the difference?) This had to be repeated several + times, at which she said, "There is no difference." (What + did I ask you?) "The difference." (The difference between + what?) "You did not say." Equally striking was the fact + that when she was jokingly told "If it snows to-night, we + shall have a black Christmas," she did not grasp the + absurdity at once, but in a rather puzzled way asked, + "Why?" + + She was then discharged on parole, two years and one month + after admission. Soon after discharge her menstruation, + which had been absent throughout her psychosis, returned. + On her discharge she had regained her normal weight, and + during the two subsequent months gained fifteen pounds. + + She then recovered completely, so that three months after + discharge she made a very natural impression. She said, on + looking back over her state with impulsive excitement, that + she constantly had the idea that she wanted to punish + herself, but that _she did not know why_, and did not think + she was sad or worried. + +Considering only the second phase of the psychosis, this deep stupor +showed many interruptions, due not merely to her suicidal efforts but +also to her resistiveness. The condition, too, was not so completely +affectless as one expects a deep stupor to be. In the first stage there +was much sudden laughter, reminding one of dementia prcox (except for +its never being shallow or silly) and this persisted into the first part +of the second phase. The actual attempts at self-injury brought out +emotion, for with them she scowled and frowned as well as showing +considerable energy. + +To these may be added the following case. It is not unlike the ordinary +stupor in the fact that there was intense inactivity and mutism with +great tenseness. The remarkable trait was, however, that for a whole day +she forcibly held her breath until she got blue in the face. The case in +detail is as follows: + + + CASE 11.--_Rosie K._ Age: 18. Admitted to the Psychiatric + Institute January 24, 1907. + + _F. H._ Both parents were living. The father was a loafer. + Nine brothers and sisters were said to be well, with the + exceptions of one brother who had an irritable temper, and + of a markedly inferior sister. + + _P. H._ The patient was a Galician Hebrew, a shirtwaist + operator. Not much was known about her make-up, but it is + certain that she was a bright girl. The patient herself + said after recovery that her father was nagging her + constantly with complaints that she was not making enough + money, although he himself did not work and she contributed + much to the support of her family. She disliked him very + much and claimed that all her relatives worried her, except + her mother. + + Nine weeks before admission a messenger came into the shop + where she worked and said, "Rosie, your father is dead" + (the message was intended for a fellow worker). In spite of + the fact that the matter was explained, she was upset and + nervous enough to be taken home. Though she continued to + work for over two weeks, she worried over many trivial + matters and talked much about this. She also said that + everything looked queer at her home and complained of + having difficulty in concentrating her mind. Finally she + became elated and talkative. Nothing is known of any + special ideas. + + At the _Observation Pavilion_ she appeared to be typically + manic. + + Then she was sent to an institution where she remained for + six weeks. The report from there stated that she was for + ten days "elated, excited, talkative, with flight of + ideas." Then her condition suddenly changed to a marked + reduction of activity, in which she neither spoke + spontaneously nor answered questions. She "appeared to + sleep," but was said to have talked to her people. When + interfered with, she was resistive and sometimes let + herself fall out of bed. On the other hand, she + occasionally wandered about at night. It should be added + that during the stupor an alveolar abscess developed which + discharged pus. It was washed out and healed. + + Then she was sent to the Manhattan State Hospital and + admitted to the service of the Psychiatric Institute. + + _Under Observation:_ 1. On the first day she lay in bed + with cyanotic extremities, weak pulse, grunting, moaning + and not responding in any way when examined. After this the + moaning and grunting ceased and she was essentially + indifferent, and for the most part kept her eyes closed. + Often she wet and soiled herself. She was resistive to any + care or examination. She would not eat, as a rule, but + again gulped down milk offered her. For a considerable time + she had to be tube-fed. During the early part of this + stupor she once took a paper from the doctor, examined it, + and then gave it back without saying anything, or again she + peered around silently, or asked to go home, or again, on a + few occasions, answered a question or two or spoke some + unintelligible words. Orientation could not be established. + + 2. After a few weeks she became more rigid, a condition + which continued for six months. She let saliva collect in + her mouth, and drooled. She had to be tube-fed. She lay + very rigid, with very pronounced general tension, with her + lips puckered, hands clenched, sometimes holding her eyes + tightly closed, and often with marked perspiration. For one + day she held her breath until she was blue in the face. On + the same day she was extremely rigid, so that she could be + raised by her head with only her heels resting on the bed. + Her eyes were tightly shut and she was in profuse + perspiration. Sometimes she interrupted this by a deep + breath, only again to resume the forcible holding of her + breath. On another day towards the end of the period, while + quite stiff, she kept grunting and screaming "murder." The + soiling continued. She never spoke. + + _Physical condition during the stupor:_ At first she had a + coated tongue, foul breath and a fetid diarrhea. The latter + was treated with high colonic flushing and mild diet. Urine + normal--gynecologically normal. General neurological and + physical examination not possible. At the same time she had + for two weeks a temperature which often reached 100 or a + little above, a weak, irregular but not rapid pulse, a + leucocytosis of 17,500 and 80% hemoglobin. When she began + to refuse food and before she was tube-fed regularly, she + twice had syncopal attacks and lost considerable flesh + which was gradually regained under tube-feeding. After the + diarrhea she was habitually constipated. Cyanosis of the + extremities seemed to have been present only at first. + + 3. Six months after admission she began to make very free + facial movements--winking, raising the eyebrows--and soon + developed an excitement with marked elation. She had to be + kept in the continuous bath, talked continuously, whistled, + sang, was markedly erotic towards the physician, careless + in exposing herself and often obscene in her talk. Most of + her productions were determined by the environment. She was + therefore quite distractible, very alert; sometimes she was + meddlesome, again irritable, irascible. The following + illustrates her productions: "Send for my husband, S.--He + had one sister as big as that. She likes candy.... My + father is underneath and my mother is on top because she is + fat and he is skinny.... Wait till the sun shines, + Nellie--we will be happy, Nellie--don't you sigh, + sweetheart, you and I--wait till the sun shines by and + by.... Come in (as noise is heard)--I bet that is my + husband--my name is Regina K. (mother's name)--my mother's + name is the same--I got a little sister named Regina--she + is my husband." When she heard the word pain, she said, + "Who says paint, Pauline used paint, I used paint," etc. + + Towards the end of August she had pneumonia, which did not + change her condition. + + By October she was well, having gradually settled down. She + had good insight. + + _Retrospectively:_ She laid very little stress on the false + report of the father's death. She claimed to remember being + at the Observation Pavilion, but to recall very little of + the other hospital. Unfortunately an inquiry was not made + regarding her memory during the stupor period under + observation with the exception of the fact that she said + she wanted to die and therefore refused food. + + She was seen in March, 1913, appeared perfectly well, and + stated she had been well during the entire interval. + +If this forced holding of the breath had been the only anomaly, one +would, perhaps, not be justified in drawing any conclusions as to its +significance. But the deep stupor was interrupted again for a day by +grunting and screaming of "murder." This is certainly indicative of a +compulsive death idea and retrospectively she spoke of having refused +food in order to die. The latter seems to indicate some connection +between her negativism and death. Consequently, even if we regard the +breath holding as resistiveness, it would still be related to her idea +of dissolution. Her negativism went beyond ordinary limits in that it +affected the expression of the face. + +When we consider these three cases together, we see that what would +otherwise have been deep stupors with profound inactivity, were modified +by activity in two directions: suicidal and resistive. Presuming that +the symptoms of stupor are all interrelated, we can see a reason why the +affect should also have been altered. When one is modified, this should +influence the other. When the activity is increased, the emotional +concomitants of impulsive acts tend to break through as well. Hence the +changes observed in these cases in facial expression and tone of voice. +It is noteworthy, too, that all three showed a tendency for laughter to +appear, as if, the emotions once stirred, it was possible for them to be +exhibited in other than unpleasant forms. So, too, it was possible for +ideas unrelated to the stupor picture, such as those of lovers, to occur +sporadically. Finally, since activity must imply some contact with +environment, the first of these cases at least showed less interference +with the intelligence than is usual. In general, one may conclude that +any aberration from the pure type of stupor tends to allow other +impurities to appear. + + + + +CHAPTER IV + +THE INTERFERENCES WITH THE INTELLECTUAL PROCESSES + + +This is one of the most interesting and important of the stupor +symptoms. We are accustomed to think of the functional psychoses having +symptoms to do with emotions and ideas in the main, and, conversely, +that disorientation, etc., observed in such cases is merely the result +of distraction, poor attention or coperation. But in stupor the deficit +in understanding, incapacity to solve simple problems and failure of +memory seem deep-rooted and fundamental symptoms. So far is this true +that Bleuler[5] looks on "schizophrenic" cases with this symptom of +"Benommenheit" as organic in etiology. It may be said at the outset that +we do not share this view for many reasons. One at least may now be +stated as it seems to be final. In benign stupor purely mental stimuli +may change the whole clinical picture abruptly and with this produce a +change in the intellectual functioning such as we never see in organic +dementias or clouded states. We find it more satisfactory to attempt a +correlation of this with the other symptoms on a purely functional +basis, as will be explained later. + +For the study of the interferences with the intellectual processes +during stupor reaction, we have two sources of information: The first is +derived from the account which the patient is able to give in regard to +what he remembers as having taken place around him or in his mind during +the stupor period; the second is the direct observation of partial +stupor reactions. + + +1. Information Derived from the Patient's Retrospective Account + +We will start with the cases of marked stupor mentioned in Chapter I. +Anna G.'s (Case 1) psychosis commenced at home, and under observation +lasted with great intensity for five months. She remembered only vaguely +the carriage going to the Observation Pavilion, had no recollection of +the latter, nor of her transfer to the Manhattan State Hospital and of +most of the stay at the Institute ward, including the tube- or +spoon-feeding which had to be carried on for four months. She also +claimed that she did not know where she was until four or five months +after admission. She was amnesic for her delusions and hallucinations. +Of Caroline DeS. (Case 2) we have no information. Of Mary F. (Case 3), +whose stupor began at home and under observation lasted two years, we +find that she had no recollection of coming to the hospital, what ward +she came to, who the doctor and nurses were (with whom she became +acquainted later), in fact she claimed that for about a year she did +not know where she was. But she remembered having been tube-fed (this +took place over a long period). Mary D.'s (Case 4) stupor also commenced +at home, and under observation lasted for three months. She had no +recollection of going to the Observation Pavilion, of the transfer to +Manhattan State Hospital, and of a considerable part of her stay here, +including such obtrusive facts as a presentation before a staff meeting, +an extensive physical and a blood examination, and she claimed not to +have known for a long time where she was. Annie K.'s (Case 5) stupor +commenced at home. Although she recalled the last days there and some +ideas and events at the Observation Pavilion, the memory of the journey +to Ward's Island was vague, as was that of entrance to the ward, and she +claimed not to have known where she was for quite a while. Specific +occurrences, such as the taking of her picture (with open eyes two +months after admission), an examination in a special room, her own +mixed-up writing (end of second week) were not remembered. But it is +quite interesting that an angry outburst of another patient within this +same period, which was evidently not recorded, is clearly remembered. + +We shall later show that when the patient comes out of a stupor the +condition may be such that, for a time at least, retrospective accounts +are difficult to obtain. It must also be remembered that not +infrequently the more marked stupors may be followed by milder states, +and it is important, if we wish to determine how much is remembered, +not to confuse the two states or not to let the patient confuse them. +For example, Mary D. (Case 4), who showed two separate phases, while she +claimed not to know of many external facts, also added that she could +not understand the questions which were asked. From observation in other +cases it seems that in marked stupor any such recollection about the +patient's own mental processes would be quite inconsistent. We have to +assume, therefore, that this remark referred in reality to the second +milder phase, for which, as we shall see, it is indeed quite +characteristic. It is not necessary to burden the reader with other +cases, all of which consistently gave such accounts. + +We see, then, that in the marked stupor the intellectual processes are +regularly interfered with, as evidenced by almost complete amnesia for +external events and internal thoughts. In other words, this would +indicate that the minds of these patients were blank. Inasmuch as direct +observation during the stupor adduces little proof of mentation, we may +assume that such mental processes as may exist in deepest stupor are of +a primitive, larval order. + +Before we examine more carefully the milder grades of stupor, it will be +necessary to say a few words about the retrospective account which the +patient gives of intellectual difficulties during the incubation period +of the psychosis. As a matter of fact, we find that these accounts are +remarkably uniform. While some patients, to be sure, speak of a more or +less sudden lack of interest or ambition which came over them, others of +them speak plainly of a sudden mental loss. Mary. C. (Case 7) claimed +she suddenly got mixed up and lost her memory. Laura A. spoke at any +rate of suddenly having felt dazed and stunned. Mary D. (Case 4) said +she felt she was losing her mind and that she could not understand what +she was reading. Maggie H. (Case 14) began to say that her head was +getting queer. We see from this that the interferences with the +intellectual processes may in the beginning be quite sudden. + +In some instances a more detailed retrospective account was taken, which +may throw some light upon the interferences with the intellectual +processes with which we are now concerned. Emma K., whose case need not +be taken up in detail, had a typical marked stupor which lasted for nine +months, preceded by a bewildered, restless, resistive state for five +days. She was in the Institute ward for the first four months, including +the five days above mentioned; later in another ward. When asked what +was the first ward which she remembered, she mentioned the one after the +Institute ward, and when asked who the first physician was, she +mentioned the one in charge of the second ward. However, when taken to +the Institute ward, she said it looked familiar, and was able to point +to the bed in which she lay, though somewhat tentatively. The same +rousing of memory occurred when the first physician, who saw her daily, +was pointed out to her. She remembered having seen him, and then even +recalled the fact that he had thrown a light into her eyes, but +remembered nothing else. This observation would seem to show that with +some often repeated or very marked mental stimuli (throwing electric +light into her eyes) a vague impression may be left, so that it may at +least be possible to bring about a recollection with assistance, whereas +spontaneous memory is impossible. In another instance, the patient was +confronted with a physician who had seen a good deal of her. She said +that he looked familiar to her, but she was unable to say where she had +seen him. Here then again evidence that a certain vague impression was +made by a repeated stimulus. + +Another feature should here be mentioned, namely, that isolated facts +may be remembered when the rest is blank. We have seen above that Annie +K. (Case 5), while very vague about most occurrences, recalled a sudden +angry outburst in detail. Another patient, though the period of the +stupor was a blank, recalled some visits of her mother. At these times, +as she claimed, she thought she was to be electrocuted and told her +mother so, "Then it would drop out of my mind again." These facts are +very interesting. We can scarcely account for such phenomena in any +other way than by assuming that certain influences may temporarily lift +the patient out of the deepest stupor. In spite of the fact that stupors +often last for one or two years almost without change, a fact which +would argue that the stupor reaction is a remarkably set, stable state, +we see in sudden episodes of elation that this is not the case, and +other experiences point in the same direction. A similar observation was +made on a case of typical stupor with marked reduction of activity and +dullness. A rather cumbersome electrical apparatus (for the purpose of +getting a good light for pupil examination) was brought to her bedside. +Whereas before, she had been totally unresponsive, she suddenly wakened +up, asked whether "those things" would blow up the place, and whether +she was to be electrocuted. During this anxious state she responded +promptly to commands, but after a short time relapsed into her totally +inactive condition. We have, of course, similar experiences when we try +to get stuporous patients to eat, who, after much coaxing may, for a +short time, be made to feed themselves, only to relapse into the state +of inactivity. + +Such variations are paralleled, as we shall later show, by a suddenly +pronounced deepening of the thinking disorder. We have already seen that +the onset may be quite sudden. All this indicates that, in spite of a +certain stability, sudden changes are not uncommon. Finally, we know +that, in spite of the fact that stupor is an essentially affectless +reaction, certain influences may produce smiles or tears, or, above all, +angry outbursts, which again can hardly be interpreted otherwise than by +assuming that those influences have temporarily produced a change in the +clinical picture, in the sense of lifting the patient out of the depth +of the stupor. All these facts suggest that inconsistencies in +recollection are correlated with changes in the clinical picture. + +As is to be expected, the cases with partial stupors remember much more +of what externally and internally happened during their psychoses. Rose +Sch. (Case 6), who had a partial stupor during which she answered +questions but showed a great difficulty in thinking, said +retrospectively that she felt mixed up and could not remember. Although +she recalled with details the Observation Pavilion and her transfer, she +was not clear about their time relations (how long in the Observation +Pavilion, how long in the first ward). Mary C. (Case 7), whose activity +was not entirely interfered with and who showed some thinking disorder, +said retrospectively that she could not take in things. Henrietta H. +(Case 8), who had a partial stupor, claimed to have known all along +where she was, but that she felt mixed up, that her thoughts wandered +and that she felt confused about people. In the cases where a partial +stupor was preceded by a marked one, such as in phase 2 of Anna G. (Case +1) and phase 2 of Mary D. (Case 4), we have no retrospective account +regarding the partial stupor, because emphasis in the analysis was +naturally laid on the period comprising the most marked disorder. +However, we can gather from the few cases at our disposal that the +patients retrospectively lay stress chiefly on their inability to +understand the situation. + +We finally have to consider the group of suicidal cases. We have +information only in regard to two cases, namely, Margaret C. (Case 10) +and Pearl F. (Case 9). In both of these, we find that a good many things +that happened during the period under consideration were remembered, as +were also the patients' own actions. In Rosie K. (Case 11) we have at +least the evidence that she remembered her own impulses, namely, that +she refused food because she wanted to die. In other words, in these +partial stupors with impulsive suicidal tendencies the interference with +the intellectual processes seems to be moderate, and memory for external +events not markedly affected. + + +2. Information Derived from Direct Observation + +The evidence can best be presented by considering the details of some +cases. + +Rose Sch. (Case 6) was remarkable, in connection with the present +problem, in her unusually poor answers. She either merely repeated the +questions, or made irrelevant superficial replies, or said she did not +know, this even with very simple questions. When better, too, though not +quite well, she showed striking discrepancies in time relations and +incapacity to correct them. It would seem that in this case there was +something more than an acute interference with the intellectual +processes, such as we are here discussing. As a matter of fact, we have +the statement in the history that the patient herself said she was slow +at learning in school and had not much of an education. A congenital +intellectual defect and the attitude which it creates may, however, as +my experience has repeatedly shown me, very greatly exaggerate an acute +thinking disorder. The case, therefore, while it shows us an +unquestionably acute interference with the intellectual processes, does +not give us useful information about its nature. More information can be +gathered from Mary D. (Case 4). Even toward the end of her marked stupor +some replies were obtained chiefly by making her write. When asked to +write Manhattan State Hospital, she wrote Manhatt Hhospshosh, and for +Ward's Island, Ww. Iland. Again, instead of writing 90th Street, she +wrote 90theath Street. These are plainly reactions of the path of least +resistance or, in these instances, of perseveration. Of the same nature +are some of her other replies in writing or speaking. After she had been +asked to write her name, she was requested to add her address, or the +name of the hospital; she merely repeated the name. Similarly, when +asked whether she knew the examiner, she said "Yes," but when urged to +give his name, she gave her own. In the partial stupor at a time when +she knew where she was, knew the names of some people about her, the +year and approximately the date, she made mistakes in calculation and +could not get the point of a test story. Moreover, she failed in +retention tests without there being any evidence of anything like a +marked fundamental retention disorder, such as we find in Korsakoff +psychosis. It seems that these results are best termed defects in +attention, which chiefly interfere with the apprehension of more +difficult tasks. As we shall see later, this seems to be rather +characteristic of these cases. Another point which should be mentioned +is the fact that her reaction to questions which she was unable to +answer (such as matters which referred to her amnesic periods) was +peculiar, inasmuch as she did not only not try to think them out, but +seemed indifferent to her incapacity, simply leaving the question +unanswered. This too, as we shall see later, is characteristic. Laura +A., at a time when she could be made to reply, merely repeated the +question, again a reaction of least resistance. The same patient +sometimes asked, "Where am I?" Mary C. (Case 7) made similar queries. +Although she was at times approximately oriented, she would say, "I +don't know where I am," or "I can't realize where I am," or more +pointedly, "I can't take in my surroundings." She often did not answer +and sometimes seemed bewildered by the questions. Henrietta H. (Case 8) +again showed some defect of orientation and mistakes in calculation, and +above all, marked mistakes in writing (for Manhattan State +Hospital--Manhaton Hotspal). A special feature here is that this +occurred immediately after she had been quite talkative, but suddenly +had relapsed into a dull state. Anna G. (Case 1), during the third phase +of her psychosis, showed the following: Although she was approximately +oriented and answered promptly simple questions; e.g., about orientation +or simple calculation, she, like these other patients, simply remained +silent when more difficult intellectual tasks were required of her +(more difficult calculations); or when she was asked how long she had +been here (which involved data that could not be available to her, owing +to her amnesia); or when questions were put to her regarding her +feelings or the condition she had passed through. On the other hand, she +sometimes gave appropriate replies in the words "yes" or "no," but it +was difficult to say whether these answers did not also represent the +path of least resistance. + +We will finally take up the last phase of Margaret C. (Case 10). +Although she was entirely oriented, there was a certain vagueness about +her answers which is difficult to formulate. She was telling about the +onset of her sickness and said that at that time her mind was taken up +with prayers about the salvation of her relatives. She was asked exactly +when it was that she thought of this and she answered "Now?" (What +period are we talking about?) "The present." (What did I ask you?) +"About this period of my sickness." (Which one?) "What sickness?" She +said herself at this point, "I am rather stupid." Again when asked how +her mind worked, she said, "Pretty quickly sometimes--I don't know." (As +good as it used to?) "No, I don't think so." (What is the difference?) +"There is no difference." (What did I ask you?) "The difference." (The +difference between what?) "You did not say." In this the shallowness of +her comprehension and thinking is well shown, and it seems here again +perhaps justifiable to formulate the main defect as one of attention, +which prevents completion of a complicated process of comprehension. A +feature of further interest in this case is that automatic intellectual +processes, such as those necessary for the writing of a long poem from +memory, were not interfered with. + + +Summary + +In the most pronounced stupor we have evidently a more or less complete +standstill in thinking processes. Practically no impressions are +registered and consequently nothing is remembered except events that +occurred in some short periods when some affective stimulus, or a brief +burst of elation, lifts the patient temporarily out of the deep stupor. +It is impossible to say whether the statement of a complete standstill +has to be qualified. In some stupors repeated environmental stimuli +sometimes make at least a vague impression, so that while spontaneous +recollection is impossible a feeling of familiarity is present when the +patient is again confronted with this environment. This might be an +exception to the dictum of complete mental vacuity, or it may be that +there are somewhat less pronounced stupor reactions. When more is +perceived, there is often a retrospective statement of having felt mixed +up, being unable to take in things, or, directly under observation, the +patient may say, "I cannot realize where I am," "I cannot take in my +surroundings." In harmony with this is the fact that questions often +produce a certain bewilderment. In quite pronounced states in which +some replies can still be obtained, we find that the intellectual +processes may be interfered with to the extent of a paragraphia, i.e., a +remarkably mixed-up writing in which perseveration (one form of +following the path of least resistance) plays a prominent part. This +same principle is also seen in such reactions as the repetition of the +question or the senseless repetition of a former answer. These phenomena +remind us of what we see in epileptic confusions, in epileptic +deterioration and in arteriosclerotic dementia. + +In milder cases difficulties in orientation may be more or less marked; +or there may be incapacity to think out problems, although the +orientation is perfect. The more automatic mental processes may run +smoothly (memory and calculation may be excellent) and there may yet be +a certain shallowness in thinking, a defect of attention (a purely +descriptive term) which is most obvious in the patient's inability to +grasp clearly the drift of what is going on or the meaning of +complicated questions. I am inclined to think that poor results in +retention tests are entirely due to this attention disorder, for we have +no evidence of any fundamental retention defect such as we find in the +totally different organic stupors. From a practical point of view it is +important at this place to call attention to the fact that such mild +changes are particularly seen in end stages. Even when pronounced +negativistic tendencies do not play a prominent rle, the patient is +then apt to be silent chiefly as a result of the residual disorder in +the intellectual processes. Still more striking are the conditions which +are on a somewhat higher level and in which the shallowness of the +responses, due to the residual disorder of attention, together with the +last traces of the affectlessness, are apt to create the impression of a +dementia. In such cases the opinion is often held that the patient has +reached a defect stage from which recovery is impossible, whereas a +thorough knowledge of these end stages teaches us that they are not only +recoverable but quite typical for the terminal phases of stupor. + +Considering these data, especially those gathered in the end stages, it +would appear that there is no tendency in this intellectual disorder +associated with the stupor reaction for any special side of mental +activity to be most prominently affected. It looks rather as if it were +a question of a general diminution of the capacity to make a mental +effort which in its different intensities accounts for the symptoms. + + +FOOTNOTES: + +[5] See Chapter XV. + + + + +CHAPTER V + +THE IDEATIONAL CONTENT OF THE STUPOR + + +_Brief survey of the ideas associated with stupor:_ Having thus +described the formal manifestations of the various stupor reactions, it +will now be interesting to see what ideas seem to be associated with +these reactions. It is, of course, impossible to obtain during a +considerable part of the stupor any statement of the patients' thoughts. +We therefore have to depend on their utterances during periods when the +inactivity temporarily ceases, or on the retrospective account which the +patient gives after the stupor has completely disappeared; and as we +shall see, we also may obtain considerable information by studying the +ideas which occur in the period preceding the stupor. These last may be +autogenous delusions or thoughts about actual events which precipitated +the psychosis. + +It is not likely that many observers have a very clear conception about +what sort of ideas to expect. We have, as a rule, not been in the habit +of paying much attention to the content of delusions, hallucinations, +and the like. So far as we could judge, therefore, the ideas expressed +might be expected to be fairly multiform, and it was distinctly +interesting to us when we found a marked tendency for the trends of +ideas to remain within a certain small compass.[6] It was possible, to +state this at once, to show that in by far the majority of cases the +same set of ideas returned, and that these ideas had among themselves a +definite inner relationship, being concerned with thoughts of "death." +In isolated instances other ideas were found as well, and they will have +to be discussed later. For the present we shall take up more habitual +content. + +In addition to the eleven cases already described, it may be well to +cite four others which present material now of interest to us. + + + CASE 12.--_Charlotte W._ Age: 30. Admitted to the + Psychiatric Institute October 21, 1905. + + _F. H._ The father was alcoholic and quick-tempered; he + died when the patient was a child. The mother was alcoholic + and was insane at 40 (a state of excitement from which she + recovered). A brother had an attack of insanity in 1915. A + maternal uncle died insane. + + _P. H._ The patient was described as jolly, having many + friends. She got on well in school and was efficient at her + work. + + She was married at 23 and got on well with her husband. The + latter stated, however, that she masturbated during the + first year of her married life. The first child was born + without trouble. + + _First Attack at 25:_ Two or three days after giving birth + to a second child, her mother burst into the room + intoxicated. The patient immediately became much + frightened, nervous, and developed a depressive condition + with crying, slowness and inability to do things. During + this state she spoke of being bad and told her husband + that a man had tried to have intercourse with her before + marriage. This attack lasted six months and ended with + recovery. + + When 29, a year before her admission, she had an abortion + performed, and four months later another. Her husband was + against this, but she persisted in her intention. Seven + months before admission she went to the priest, confessed + and was reproved. It is not clear how she took this + reproof, but at any rate no symptoms appeared until three + weeks later, after burglars had broken into a nearby + church. Then she became unduly frightened, would not stay + at home, said she was afraid the burglars would come again + and kill "some one in the house." The patient herself + stated later, during a faultfinding period, that at that + time she was afraid somebody would take her honor away, and + that she thought burglars had taken her "wedding dress." + "Then," she added, "I thought I would run away and lead a + bad life, but I did not want to bring disgrace to the + family." + + The general condition which she presented at this time is + described as one of apprehensiveness when at home. For this + reason she was for five weeks (it is not clear exactly at + what period) sent to her sister, where she was better. + About a month before the patient was admitted, the husband + moved, whereupon she got depressed, complained of inability + to apply herself to work, became slow and inactive, and + blamed herself for having had the abortion performed. She + began to speak of suicide and was committed because she + bought carbolic acid. She later said that while in the + _Observation Pavilion_ she imagined her children were cut + up. + + _Under Observation_ the condition was as follows: + + 1. For the first three days the patient, though for the + most part not showing any marked mood reaction, was + inclined at times to cry, and at such times complained + essentially that this was a terrible place for a person who + was not insane. + + 2. On the fourth day the condition changed, and it will be + advisable to describe her state in the form of abstracts of + each day. + + On _October 24_ the patient began to be preoccupied and to + answer slowly. A few days later she became distinctly dull, + walked about in an indifferent way or lay in bed immobile. + Twice on _October 27_ she said in a low tone and with + slight distress, "Give me one more chance, let me go to + him." But she would not answer questions. At times she + lapsed into complete immobility, lying on her back and + staring at the ceiling. When the husband came in the + afternoon, she clung to him and said: "Say good-by forever, + O my God, save me." Again, very slowly with long pauses and + with moaning, she said: "You are going to put me in a big + hole where I will stay for the rest of my life." _On + October 28_ she was found with depressed expression and + spoke in a rather low tone, but not with decided slowness + as had been the case on the day before. She pleaded about + having her soul saved; "Don't kill me"; "Make me true to my + husband"; once, "I have confessed to the wrong man the + shame of my life." Later she said she did not tell the + truth about her life before marriage. Again she wanted to + be saved from the electric chair. At times she showed a + tendency to stare into space and to leave questions + unanswered. + + 3. From now on a more definite stupor occurred, which is + also best described in summaries of the individual notes. + + _Oct. 29._ Lies in bed with fixed gaze, pointing upward + with her finger and is very resistive towards any + interference. She has to be catheterized. + + _Oct. 30._ Can be spoon-fed but is still catheterized. + During the morning she knelt by the bed and would not + answer. At the visit she was found in a rather natural + position, smiling as the physician approached, saying "I + don't know how long I have been here." Then she looked out + of the window fixedly. At first she did not answer, but, + when the physician asked whether she knew his name, she + laughed and said, "I know your name--I know my name." Then + she would not answer any more questions but remained + immobile, with fixed gaze. When her going home was + mentioned, however, she flushed and tears ran down her + cheek, though no change in the fixedness of her attitude or + in her facial expression was seen. + + _Nov. 1._ Lies flat on her back with her hands elevated. + She is markedly resistive. + + _Nov. 2._ Free from muscular tension and more responsive. + When asked whether she felt like talking, she said in a + whining tone, "No, go away--I have to go through enough." + Then she spoke of not knowing how long the nights and days + were, of not having known which way she was going. When + asked who the physician was she whimpered and said, "You + came to tell me what was right." She called him "Christ" + and another physician "Jim" (husband's name), though, later + in the interview, she gave their correct names. When asked + about the name of another physician, she said: "He looks + like my cousin, he was here, they all came the first night. + I did not take notice who it was till I went through these + spirits, then I knew it was right."--She paused and added: + "My God--mother it was; she is here on Earth, somewhere in + a convent--Sister C. (who actually is in a convent) she was + here, too, I could hear her." She said they all came to try + to save her. When asked whether she had been asleep, she + said: "No, I wasn't asleep, I was mesmerized, but I am + awake now--sometimes I thought I was dead." (When?) "The + time I was going to Heaven." Again: "I went to Heaven in + spirit, I came back again--the wedding ring kept me on + Earth--I will have to be crucified now." (Tell me about + it.) "Jim will have to pick my eyes out--I think it is him. + Oh, it is my little girl." (Who told you?) "The spirits + told me." Again: "Little birds my children--I can't see + them any more--I must stay here till I die." (Why?) "The + spirits told me--till I pick every one of my eyes out and + my brains too." When asked what day it was, she said, "It + must be Good Friday." (Why?) "Because God told me I must + die on the cross as he did." When asked why she had not + spoken the day before, she said that "Jesus Christ in + Heaven" had told her she should not tell anything, "till + all of you had gone, then I could go home with him, because + that is the way we came in and it was Jim too all the + time." Finally she said crossly, "Go away now, you are all + trying to keep me from Jim" (crying). + + _Nov. 3._ Knelt by bed during the night. This morning lies + in bed staring, resistive, again she is markedly + cataleptic. She has to be spoon-fed, and is totally + unresponsive. In the afternoon she was found staring and + resistive. Presently she said with tears: "I am waiting to + be put on the cross." + + _Nov. 4._ Still has to be catheterized. She sits up, + staring, with expressionless face, but when asked how she + felt she responded and said feebly: "I don't know how I + feel or how I look or how long I have been here or + anything." (What is wrong?) "Oh, I only want to go to a + convent the rest of my days." (Why?) "Oh, I have only said + wrong things, I thought I would be better dead, I could not + do anything right." Later she again began to stare. + + _Nov. 5._ During the night she is said to have been + restless and wanted to go to church. To-day she is found + staring, but not resistive. When questioned she sometimes + does not answer. She said to the physician, "I should have + gone up to Heaven to you and not brought me down here." She + called the physician "Uncle James." Again she said, "I want + to go up to see Jim." Sometimes she looks indifferent, + again somewhat bewildered. + + _Nov. 6._ She eats better, catheterizing is no longer + necessary. She is found lying in bed, rigid, staring, + resistive, does not answer at first, later appears somewhat + distressed, says "I want to go and see Jim." (Where?) "In + Heaven." She gave the name of the place and of the + physician, also the date. + + _Nov. 8._ In the forenoon, after she had presented a rather + immobile expression and had answered a few orientation + questions correctly, she suddenly beckoned into space, then + shook her fist in a threatening manner. When later asked + about this, she said: "Jim was down there and I wanted to + get him in." (And?) "You was up here first." (And?) "I + thought we was going down down, up up--the boat-- --you + came in here for--to lock Jim out so we wouldn't let him + in." Later she said, when asked whether anything worried + her, "Yes, you are taking Jim's place." + + _Nov. 9._ During the night she is reported to have varied + between stiffness with mutism and a more relaxed state. + Once, the nurse found her with tears, saying "I want to go + down the hall to my sister--to the river," and a short time + later with fright: "Is that my mother?" Again she said: "Oh + dear, I wish this boat would stop--stop it--where are we + going?" In the forenoon she was quiet and unresponsive. In + the afternoon she said in a somewhat perplexed way, "We + were in a ship and we were 'most drowned." (When was that?) + "Day before yesterday it must have been"--Again she said in + the same manner: "It was like water. I was going down. I + could hear a lot of things." She claimed this happened + "to-day." "I saw all the people in here, it was all full + of water," "I have been lying here a long time--do you + remember the time I was under the ground and it seemed full + of water and every one got drowned and a sharp thing struck + me?" "I was out in a ship and I went down there in a + coffin." When asked whether she had been frightened at such + times, she said: "No, I didn't seem to be, I just lay + there." She also said: "the water rushed in," and when + asked why she put up her arms, she said, "I did it to save + the ship." + + _Nov. 10._ She is still fairly free. She said that when she + was on the ship things looked changed, "the picture over + there looked like a saint, the beds looked queer." (How do + things look now?) "All right." (The picture too?) "The same + as when I was going down into a dark hole." When asked + later in the day where she was, she said, "In the Pope's + house, Uncle Edward is it?" but after a short time she + added, "It is Ward's Island, isn't it?" + + _Nov. 11._ Inactive, inaccessible, but for the most part + not rigid. + + _Nov. 14._ Varies between mutism with resistance and more + relaxed inactivity. To-day lies in a position repeatedly + assumed by her, namely, on her stomach with head raised, + resistive towards any interference, immobile face, totally + inaccessible. + + _Nov. 15._ Freer. She said: "One day I was in a coffin, + that's the day I went to Heaven." She also said she used to + see "the crucifix hanging there" (on the ceiling)--"not now + but when I was going to Heaven." (When was that?) "Over in + that bed" (her former bed). Later she added, "The place + changed so ... things used to be coming up and down + (dreamily)--that was the day I was coming up on the ship or + going down." She is quite oriented. + + _Nov. 17._ Usually stands about with immobile face, + preoccupied, but she eats voluntarily. + + _Nov. 24._ When the husband and sister came a few days ago + she said she was glad to see them, embraced them, cried and + is said to have spoken quite freely. To-day she speaks more + freely than usually. When asked why she had answered so + little, she said she could not bring herself to say + anything, though she added spontaneously, "I knew what was + said to me." When shown a picture of her cataleptic + attitude with hands raised, she said dreamily, "I guess + that must have been the day I went to Heaven, everything + seemed strange, things seemed to be going up and down." + (Did you know where you were?) "I guess that was the day I + thought I was on the ship." When the sister spoke to her, + she seemed depressed and said, "If only I had not done + those things I might be saved, if I had only gone to church + more." + + _Dec. 3._ Seems depressed. She weeps some, says she is sad, + "There seems to be something over my heart, so I can't see + my little girls." Again: "I should have told you about it + first--I should not have bought it"--(refers to buying + carbolic acid). She wrote a natural letter but very slowly. + + 4. There followed then a state lasting for six months, + during which the patient was rather inactive, preoccupied, + even a little tense at times. Sometimes she did not answer, + again at the same interview spoke quite promptly. For the + most part the affect was reduced, at other times she + appeared a little uneasy, bewildered, or again depressed. + She said that sometimes a mist seemed to be over her. Now + and then spoke of things looking queer and she asked, when + the room was cleaned, "Why do they move things about?" and + she added irrelevantly: "I thought the robbers broke into + my house and stole my wedding dress and my children's + dresses" (refers to the condition during the onset of her + psychosis). In the beginning of this state, when asked + about the stupor, she spoke again of the "ship" and about + going "down, down," but also said that on one occasion she + heard beautiful music, was waiting for the last trumpet and + was afraid to move. Moreover, she had some ideas referring + to the actual situation which were akin to those in the + more marked stupor period. Although she admitted she was + better, she said on December 8 that she still had queer + ideas at times, "I sometimes think the doctor is Uncle Jim" + (long dead). She also spoke of other patients looking like + dead relatives, and added, "Are all the spirits that are + dead over here?" "We never die here, the spirits are here." + But after that date no such ideas recurred, in fact this + whole period seems to have been remarkably barren of + delusions. Exceptionally isolated ones were noted. Thus, on + January 28 it is mentioned that she stated she sometimes + felt so lonely, and as though people were against her; and + on February 13 she said she felt as though the chair knew + what she was talking about. It is also mentioned in January + that she wept at times, but this seems not to have been a + leading feature at all. In March, when asked why she was + not more active and cheerful, her lips began to quiver and + she said, "Oh, I thought my children would be cut up in + Bellevue." "I don't know why I feel that way about them." + She sometimes cried when her friends left her. + + 5. Then followed a week of a rather faultfinding, + self-assertive state, during which she demanded to be + allowed to go home, saying indignantly that she was not a + wicked woman, had done nothing to be kept a prisoner here; + she wanted justice because another patient had called her + crazy. But in this period also she said that after the + robbery (at home) she felt afraid that her honor would be + taken away. When told that her husband had been with her, + she said "Yes, but I was afraid they would get into a + fight." (You mean you were afraid the other man would kill + him?) "No, he is not dead." She further talked of a + disagreement she had at that time with her husband, and + that she felt then like running away and leading a bad + life, but thought of the children. With tears she added: "I + would not do anything that is wrong. I have my children to + live for." Quite remarkable was the fact that she then told + of various erotic experiences in her life, though with a + distinctly moral attitude and minimizing them. + + 6. On _June 16_ another state was initiated with peculiar + ideas, the setting of which is not known, as she told them + only to the nurses. She said that she was not Mrs. W. but + the Queen of England, again that she was an actress, or + again the wife of a wealthy Mr. B., and that she was going + to have a baby. But at night she is said to have been + agitated and afraid she was to be executed. She asked to be + allowed to go to bed again, then stopped talking, and + remained in this mute condition for about a week. She often + left her bed and went back again, remained much with a + perplexed expression. On one occasion she put tinsel in her + hair saying it was a golden crown. + + 7. At the end of that time she became freer and more + natural, and remained so for three weeks. She occupied + herself somewhat. When asked what had happened in the + condition preceding, said she thought she was a queen or + was to be a queen. + + 8. Towards the end of this period she had again three more + absorbed days, but when examined on the third of these days + got rather talkative and somewhat drifting in her talk on + superficial topics. + + 9. Two days later she began to sing at night, kissed + everybody, said it was the anniversary of her meeting her + husband, again cried a little, and on the following morning + began to sing love songs, with a rather ecstatic mood, and + at times stood in an attitude of adoration with her hands + raised. This passed over to a more elated state, during + which she smiled a good deal, often quite coquettishly; she + sang love songs softly; on one occasion put a mosquito + netting over her head like a bridal veil; or she held her + fingers in the shape of a ring over a flower pinned to her + breast. But even during this state she said little, only + once spoke of waiting for her wedding ring, and again, when + asked why she had been singing, said "I was singing to the + man I love." (Why are you so happy?) "Because I am with + you" (coquettishly). + + This, however, represented the end of the psychosis. She + improved rapidly. At first she smiled rather readily, but + soon began to occupy herself and made a perfect recovery. + + She gave a rather shallow retrospective account about the + last phase: at first she said it was natural for people to + feel happy at times, and that she did not talk more because + the inclination was not there. The only point she added + later was that she held her fingers in the shape of a ring + because she was thinking of her wedding ring. + + She was discharged on _October 11_. + + The patient was seen again in _September, 1915_. She then + stated that she had been perfectly well until 1912, when + she had a breakdown after childbirth. (A childbirth in 1910 + had led to no disorder.) The attack lasted six months. She + slept poorly, lost weight, and felt weak, depressed, "my + strength seemed all gone." In _July, 1915_, following again + a childbirth, she was for about six weeks "despondent, weak + and tired out." + + At the interview she made a very natural, frank impression, + and displayed excellent insight. + + + CASE 13.--_Johanna S._ Age: 47. Admitted to the Psychiatric + Institute January 23, 1904. + + _F. H._ It was claimed that there was no insanity in the + family. + + _P. H._ The patient was said to have been bright and rather + quick-tempered. She came to the United States from Ireland + at the age of 20, worked as a servant, was well liked, and + retained her position well. + + She was married at 24. After a second confinement, at the + age of 26, the patient had her first attack of manic + excitement, from which she recovered in four months. She + had, subsequently, at the ages of 28, 30, 32, 35, 43, and + 45, other attacks of the same nature, each one lasting + about four months. No precipitating cause was known for any + of them. Only one of the attacks, the fifth, (none were + well observed) seems to have shown features different from + an elated excitement with irritability. At the end of this + attack she was said to have been "dull" for a month. + + Her husband died four years before the present admission, + evidently soon after her sixth attack. + + The present attack: + + About two months before admission the patient began, + without appreciable cause, to be sleepless, complained of + headaches and appeared downhearted and sad. She sat about. + + After a week she would not get out of bed and remained in + bed until she was sent to the Observation Pavilion, getting + up only to go to the closet. She said very little and would + not eat much. About a month before admission she began to + say that she did not want to live, begged her daughter to + throw her out of the window. About two weeks before + admission she began to insist that she heard the voice of + her brother (living in Ireland) calling her. She got out of + bed to look for him. + + At the _Observation Pavilion_ she was described as slow, + looking about in an apprehensive manner, bewildered, dazed, + saying "I am dead--there is poison in it (not clear in + what)--I am dead, you are dead." + + _Under Observation:_ 1. On admission the patient had a + coated tongue, foul breath, constipation, lively knee-jerks + and a pulse of 110. She appeared dull, inactive, lay in bed + with her eyes closed. She would open them when urged but + appeared drowsy and her face was strikingly immobile. At + times she moaned a little. She could be made to respond in + various ways such as shaking her head, or making some + motions as though to indicate that she could not give any + explanations. All movements were slow. She also responded + to a few questions by "I don't know." + + Two days after admission the condition was not essentially + different except that she was a little uneasy when urged to + speak, corrugated her forehead, said "Everything is dark," + again "I am very sick," or she turned away her head. + + On the fourth day, i.e., January 26, the picture altered, + inasmuch as she was much more responsive. She was found + sitting up in bed and, at times, a little uneasy. She was + slow in her movements and answers, speaking in a whisper + and sometimes a little fretfully. The answers, though slow, + were, however, by no means given in the shortest possible + manner, but with variations, e.g., from "I don't know," to + "I could not tell you," or "I can't tell that either." She + said herself that everything had "been so dark--it is light + now, but it gets so dark sometimes." She denied knowing + where she was, even in what city, also denied knowing the + month, adding to the latter answer "the nurse can tell + you." She could not tell where she had been before coming + to the hospital, or how she came. Finally, she also claimed + not to know her age, her birthday or the date of her + marriage; but she gave the current year correctly, the + place where she went to school, the names of some of her + teachers, and the year of her arrival in the United States. + She also stated in answer to questions that she came to the + hospital "to get well." She repeatedly said "I am so sick," + or "I am so stupid," or "My mind is mixed up, twisted," or + "My mind is not so good," or "I am so tired." What could be + obtained of a content was as follows: When she spoke of + being "twisted," she said, "I got all kinds of medicine." + (How does it affect you?) "Through my head and it made me + hot inside." Again, when asked whether anybody had done + anything to her, she said "No, I have done wrong myself, by + speaking bad of my neighbors." She claimed to hear voices + "all over," but could not tell what they said. When, in the + evening of that day, the nurse asked her why she did not + talk more, she said, "God damn it, I am all twisted, my + brain is mixed up, my system is all upset, the doctor made + me stupid with questions, and the medicine I have taken + made me all stupid and I am inhaling gas now." Then she + again settled into a dull state and was found by the + physician with immobile expression, slow motions and mute. + + 2. For about ten days, i.e., from January 27 to February 8, + her condition was of a more pronounced character. For the + most part she lay in bed with often quite immobile face and + with eyes closed, or she looked about in a bewildered + manner. She was very inactive, presented a marked + resistance in her arms and jaw when passive motions were + attempted, or, again, exhibited decided catalepsy. She had + to be tube-fed. Once on the 27th of January, when the nurse + tried to feed her, she pushed her away and said, "I am + dead--I am not home." Sometimes she turned her hands about + with slow tremulous movements, looking at them in a + bewildered manner. + + She usually was mute, except on the few occasions to be + mentioned later, as well as on February 3, when she was + generally a little more responsive. At that time she could + be made to open her eyes, and then replied to a few + questions slowly and in a low tone; others were left + unanswered. (To the questions where she was and how long + she had been here, she replied with "I don't know," but to + questions about who the physician and the nurse were, by + saying "You are a doctor," and "she is a nurse.") + + In the general setting just described there occurred at + various times changes in behavior which were as follows: On + the evening of the 27th of January she got out of bed and + walked about with slow restlessness, saying: "They say I am + going to be cut up." On February 1, she was seen for a time + making peculiar slow swimming motions with her hands. Again + on the 3d of February she got out of bed, walked about + slowly, with peculiar steps, as though avoiding stepping on + something. Next day (the 4th) she sat up in bed--again made + at times her peculiar slow swimming motions. She presented + at the same time a peculiar dazed bewildered uneasiness + and, when questioned what was the matter, said: "I am--I + am--at the bottom of the deep--deep water--oh--oh--the + deep--deep--dark water." And when further urged she added + with the same manner, "I can't swim--I don't know--but the + place"--She did not finish but later again muttered "the + deep--deep--dark water." (Do you really think you are in + the water?) "I don't know--my head is so bad." + + For the following five days this behavior was repeated + from time to time, when she would sit up and with + bewildered uneasiness make slow swimming motions and mutter + when questioned, "I am in the deep, dark water." + + Some other emotional responses in reaction to external + events must still be mentioned. They were rare. On February + 1 the patient's daughter came while she was lying + motionless in bed. She slowly extended her hands, tried to + speak, and then her eyes filled with tears. Again, at the + end of the interview of February 3, after she had made a + few replies, she settled down to her usual inactivity and, + when further urged to answer, her eyes filled with tears. + + 3. From about February 9 to February 24 the condition again + presented a different aspect, inasmuch as while there was + still a marked reduction of activity, she showed this to a + decidedly lesser degree. Moreover, there was no + bewilderment at any time. No resistance, but cataleptic + tendencies were still seen occasionally. There was at no + time the peculiar dazed uneasiness and slow restlessness + associated with the idea of being in the deep, dark water. + + She now dressed herself very slowly, ate slowly but of her + own accord, and spoke, though her voice was consistently + slow, in a low tone and her words were few. + + At the beginning of this period on February 9, when asked + how she was, she said "I--I am sick." To the questions as + to where she was, how long she had been here and how she + had been taken sick, she replied by saying "I don't know." + But she knew she was in a hospital, had been here before + "many times." (Correct.) She was then again asked for the + name of the hospital, but replied "I don't know." So the + physician pointed out of the window and asked her what it + was that she could see there (the East River). She replied, + "It is the dark water. Sometimes I go there and don't come + back again--and--something throws me up and I come back." + (What has been the matter with you?) "I have been sick all + this time." Again, "I can't tell--I am not a good woman--I + am very sick." (Why do you say you are not a good woman?) + "Oh, I did not do things right." + + At a later interview, during the same period, she knew the + doctor's name, knew she had seen him at Ward's Island, + knew she was in a hospital, but somehow could not connect + the present place with Ward's Island. She said she didn't + know, when asked where she was, and when questioned about + the season, said, after a pause "Summer" (February 15). + + We have seen above that she once spoke of not having been a + good woman. She repeated this on February 10, said "I have + done lots of harm, I have been a bad woman all my life." + Again: "I had bad thoughts." (What kind?) "I have forgotten + all about them." It should be added that at this interview + she also said, "My mind is better now." + + On February 25 there was a sudden change. She laughed when + a funny remark was made on the ward. Later, when the + physician came to her, she still lay in bed inactive and + had to be urged considerably at first, but presently began + to laugh good-naturedly and quite freely commented on the + funny remark she had heard earlier in the morning, and on + peculiarities of some patients. She spoke quite freely and + without constraint. But it was striking how little account + of the condition she had gone through could be obtained + from her. She either turned the questions off by flippant + remarks, or said she did not know. The only information + obtained was that she had been sick since Christmas, felt + like a dummy, that she had lost track of time, and did not + know how she had felt during that period. When asked why + she had not spoken, she said, "I couldn't, I had a jumping + toothache," or she said, "Ask the nurse, she put it down in + the book." Or again she said, "Did you ever get drunk? That + is the way I felt. I felt like dead." + + She soon developed a lobar pneumonia and died. + +The following typical case of partial stupor is quoted as an example of +delusions appearing only during the onset. + + + CASE 14.--_Maggie H._ Age: 26. Admitted to the Psychiatric + Institute February 8, 1905. + + _F. H._ The father died when 33. The mother was living. + Psychopathic tendencies were denied. + + _P. H._ The husband and brother stated that the patient + was natural, capable, rather jolly. She married about a + year before admission and shortly became pregnant. During + the pregnancy she was rather nervous and had various + forebodings, among which were that the child might be born + deformed, or that she would die in childbirth. + + The baby was born three weeks before admission. The patient + seemed much worried immediately after the childbirth, + fretted about not having enough milk, was quite concerned + about her husband and did not want him to leave her side. + The brother stated that about this time the patient heard + that the husband was out of work. She worried about this + and told her sister so. She also began to say that her head + was getting queer. On the fifth day after childbirth, a + change came over the patient. She cried and said she was + going to die. She also spoke of poison in the food and + accused the husband of unfaithfulness. The next day she + became silent, "did not seem to want to have anything to do + with anybody," lay in bed, had a tendency to pull the + covers over her head and scarcely ever spoke. But during + this period she continued to look after the baby + faithfully. Sometimes she clung to her husband, saying she + was afraid he was going to die. + + After recovery the patient said that while she was at home + she thought she saw bodies lying about. + + At the _Observation Pavilion_ she was quiet and apathetic, + indifferent to environment and could not be induced to + speak. She soiled, refused food, and was resistive when + anything was done to her. + + _Under Observation:_ 1. On admission the patient was fairly + well nourished but looked rather anemic and weak. The + temperature was normal, the pulse a little irregular but of + normal frequency, the tongue coated. She lay inactive but + looked about, and the facial expression sometimes changed + as she did this. Any interference met with intense + resistance. There was no catalepsy. In contradistinction to + this inactivity and resistance, natural, free motions were + observed at times, as, for example, when she arranged her + pillows. She did not speak and could not be made to answer. + + For the rest of the first week she made no attempt to + speak, except once when she seemed to attempt to return a + "good morning," or on another occasion, when the nurse + tried to feed her, she said, in quite a natural tone, "I + can feed myself." The resistance to interference remained + in a variable degree, and was at times quite strong. It was + largely passive, though not infrequently associated with a + scowl, or she moved away when approached. She sometimes + looked dull and stared, again she looked determined, + "disdainful," or scowled; or she looked about watching + others, sometimes only out of the corners of her eyes. She + had to be spoon-fed at times, again she ate naturally when + the food was brought. Repeatedly, when taken out of bed, + though she resisted at first, she dressed with natural free + motions. She always retracted promptly from pin pricks. + + Towards the end of the week she even complied at times with + a request to do some work, but on the same day she would + remain passive, with a look of disdain, or resist intensely + when interfered with, e.g., when an attempt was made to + make her sit down. She never soiled and never showed any + catalepsy. + + 2. Then the condition changed, inasmuch as the marked + resistance ceased entirely, and the mutism gave way first + to slow and low answers, and later to much freer speech, + though the inactivity improved only gradually. Thus at the + examination on February 19, though she was quite inactive, + she answered some questions, albeit in whispers and + briefly. This was the case when questioned about the year, + month and date, which she gave correctly, but she merely + shook her head when asked how long she had been here, why + she was here, what was the matter with her. Once she smiled + appropriately. Later she became freer in speech, with a + more natural tone, although her answers continued to be + short. Not infrequently, when asked to calculate or to + write, she would not coperate, saying "This has nothing to + do with my getting well," or (later) "What has that got to + do with my going home?" or she would simply say she did not + want to. Improvement in her listlessness and inactivity was + more gradual. + + The prevailing affective state was indefinite. She denied + repeatedly that she was depressed, though later she + admitted once being downhearted, yet it seems that even + then her mood was not so much one of sadness as of a slight + resentment. On one occasion, however, she showed some tears + when asked about the baby. She repeatedly expressed the + wish to go home, but not in a pleading, rather in a + resentful, way, saying she would never be better here, that + the questions which were asked had nothing to do with her + going home, that she would be all right if she went home. + She never admitted that she had ever been sick enough to be + taken to a hospital, though she quite appreciated that + there had been something the matter with her head at home + and in the hospital. She stated, in answer to questions, + that she had a peculiar feeling in the head which she could + not explain, that she could not remember so well as + formerly. Once she said, "I hear so much around here that + my head gets so full." + + When towards the end she was questioned about her + condition, i.e., the reason for her resistance, her mutism, + and her refusal of food, she said that then she "wanted to + be left alone"; that she did not eat "because she did not + want food," and she also spoke of not having had any + interest. + + She was discharged on April 29, i.e., about ten weeks after + admission before she had become entirely free. + +The last case is interesting in that a depressive onset to a deep stupor +was observed in the Institute. It was characterized by constant +repetitions of a request to be killed. + + + CASE 15.--_Meta S._ Age: 16. Admitted to the Psychiatric + Institute June 26, 1902. + + _F. H._ The father was dead, and the mother living abroad. + Not much could be learned about them and the immediate + family. + + _P. H._ An aunt who gave the anamnesis had known the + patient only since she came to the United States, a year + before admission. After her arrival the patient at once + went to work as a servant. It was claimed that her employer + liked her, but that she was rather slow about the work. The + only trouble known was that she sometimes complained of + indigestion. She went to see her aunt about once every two + weeks. + + Three weeks before admission, when the patient visited her + aunt, she seemed quieter than usual. Further, she spoke + about sending money home on the _Kaiser Wilhelm der + Grosse_, which was thought peculiar because she had no + money, and on a walk through a cemetery said "I would like + to be here too." At the time this did not impress the aunt + as very peculiar. The patient continued to work until nine + days before admission. The employer then sent for the aunt + and said the patient had been very quiet for about two + weeks, and that she now had become more abnormal. She + suddenly had begun to cry, said the police had come, + claimed, without foundation, that she had "stolen," and + kept repeating "I have done it, I will not do it again." + The aunt took her home with her. There she was quite + dejected, cried, spoke of killing herself (wanted to jump + out of the window, wanted to get a knife). On the whole, + she said very little, but when the aunt pressed her to say + why she was so worried, she said she had allowed men to + kiss her and had taken money from them. It is claimed that + she never menstruated. + + After recovery the patient herself described the onset as + follows: Ever since she came to this country she had been + homesick, and felt especially lonesome for some months + before admission. She knew, however, of no precipitating + cause, in spite of what she had said to the aunt and what + she said at first under observation. She consistently + denied that anything had happened with young men. A short + time before she left her place (she left it nine days + before admission) she could not work, began to accuse + herself of being a bad girl and of having stolen. Then she + was taken to the aunt's house. There she wanted to die. + + _Under Observation:_ 1. On admission the patient appeared + depressed, sat with downcast expression, looking up rarely. + She spoke in a low tone and slowly. But, in spite of delay, + she answered all questions, knew where she was and gave an + account of the place where she had worked. When questioned + about trouble with men, she claimed that a man who lived in + the same house where she worked had tried to make her "lie + on the bed," but that she refused; that later a man had + assaulted her and had after that repeatedly come to her + room when she was alone. Yet when asked whether she worried + about this, she denied it. + + 2. For eight days her condition was sometimes one of marked + reduction of activity, with preoccupation. She sat in a + dejected attitude, and had to be urged to do anything. + Sometimes she was very slow in greeting and slow in + answering, and said very little. But whenever spoken to she + was apt to cry and this might lead to such distress that + the reduction of activity was no longer to be seen. Thus on + June 28, when greeted, she began to cry and say, "Oh, what + have I done!--Oh, just cut my head off--Oh, please what + have I done--I have given my hand." (Tell me the whole + story.) Imploringly and with hands clasped: "No, I can't do + it--just cut my head off, please, please." (Why can you not + tell me?) "Oh, what have I done!" The imploring to cut her + head off was then several times repeated, and she could not + be made to answer orientation questions. On June 29 she + became agitated spontaneously and cried loudly, saying, + "Oh, let me go home and die with my father." She was then + put to bed, and when seen she could not be made to answer + orientation questions. But when asked whether she had seen + the physician before, she said, "I saw you yesterday." She + could not be made, however, to say how long she had been + here, "I think a"--not finishing the sentence. Although she + would not answer further, she presently began to say "Oh, + cut my head off--oh, where is my papa and mamma?" When told + that her people were in Germany and that she could go back + to them, she said "I haven't any money to pay it." Then she + wanted to know if she was to pay for her board and bed and + said she could not do it. + + Again, on July 1, although she had been quite preoccupied, + inactive and silent, she began to say when greeted, "Oh, + please cut my head off." But she then answered some + questions, said she had not worked enough. On questioning, + she explained it was not that the work had been too much, + but that she had been nervous, had tried to work as much as + the servant next door, but could do only half as much, "Oh, + I ought to have worked." + + Repeatedly on other occasions she begged, with distress, to + have her head cut off or to be killed. Frequently there + were statements of self-blame: she ought to have worked + more, was lazy or "I am not worthy"; or she said she had + lied and stolen; or again, "I have not paid for these beds + and I cannot," or "I am a bad girl." + + 3. For a month she presented a more marked reduction of + activity. She sat about with a dejected look, often gazed + in a preoccupied manner, or she stood or walked around + slowly. Sometimes she had to be spoon-fed. At other times + she ate slowly. Toward the latter part of this period, a + distinct tendency to catalepsy appeared. During this + period, too, as a rule (though not always), she would cry + when spoken to. A few times she would make some ineffectual + motions when questioned, but she scarcely ever spoke. + + 4. Then followed a period again lasting about one month in + which the picture was at times one of still greater + inactivity. She would retain uncomfortable positions, allow + flies to crawl over her face. She presented resistance in + the jaws, did not react to pin pricks. She sometimes sat + with eyes closed or, with an immobile face, the eyes stared + with little blinking. The catalepsy was more decided. She + often would not swallow solid food but swallowed fluid. + Again she held her saliva, sometimes drooled. Once she held + her urine and had to be catheterized. When spoken to she + once smiled at a joke, sometimes there was no response, but + as a rule there were tears or flushing of the face. On the + physical side, there were marked dermatographia and, for a + time, towards the end of the period, profuse sweating. + Throughout the stupor proper her temperature was between + 99 and 100 as a rule. + + 5. The period which followed and which lasted about two + months was characterized, like the one just described, by + marked stupor symptoms, associated, however, with more + resistance, while the crying practically disappeared. On + the other hand, a number of plainly angry reactions were + seen and, towards the end, smiling and laughing. She lay in + bed, on her back, staring, allowing the flies to crawl over + her face; retained uncomfortable positions without + correcting them, and her arms often showed a decided + tendency to catalepsy. Sometimes she soiled. She constantly + held saliva in her mouth, though she did not often drool. + She was totally mute, did not respond in any way except in + the manner to be presently indicated. She had to be + tube-fed a good part of the time, was quite resistive when + an attempt was made to open her mouth. When attended to by + the nurse, she was apt to make herself stiff. But as a + rule, she was not resistive to passive motions when tested. + On a few occasions she had, as was stated, marked angry + outbursts. Thus on one occasion when her temperature was + taken she angrily pushed the nurse away and then struggled + vigorously. On another occasion, when the bed-pan was put + under her, she threw it away angrily and struck the nurse; + once she did the same with the feeding tube. She struck a + patient, on another occasion, when the latter came to her + bed. On two occasions she suddenly threw herself headlong + on the floor. Towards the end of the period, when the + blood-pressure was taken, she smiled and then laughed out + loud. She could be made to smile again later. + + 6. The last period, before the more definite improvement, + lasted about a month. She was inactive and slow, ate slowly + (feeding no longer necessary), and was mute. But she did + not stare, was no longer resistive, no longer held saliva. + She appeared indifferent, but could be made to smile quite + readily when spoken to. On one occasion she laughed out + loud when a comical toy was shown her, again was amused at + a party. In the beginning of the period she was once seen + to cry a little when sitting by herself, and at the same + time wept a little when spoken to, but this was now + isolated. Towards the end of the period she spoke a little, + asked for paper and pencil and wrote: "Dear Mother.--I only + take up the pencil in order to write you a few lines. We + are all cheerful and in good health and hope that you are + the same and we congratulate you on your birthday 19th of + December that I have not written to you for a long time + were in the same ..." (Translated.) This was written very + slowly. + + On the day after this letter she was distinctly freer, + talked a little to the nurse and then improved rapidly. A + week after this, January 16, she is described as quite free + in her talk and activity, but when asked about the + psychosis she merely shrugged her shoulders. However, mere + extensive retrospective accounts were taken later. + + The retrospective accounts were obtained on January 24 and + March 13. As these two accounts do not seem to be + fundamentally different for the period of the psychosis, + they may here for the sake of brevity be combined. + + She remembered clearly going to the Observation Pavilion, + and feeling frightened, as she did not know where she was + going and what they were going to do with her. She knew + when she was in the Observation Pavilion and had a good + recollection of the place, also of the transfer to the + hospital, the ward she came to, who spoke to her, etc. She + did not know what the place was until the doctor told her a + day or two after admission. Unfortunately definite + incidents were inquired into only for the first part + (July). But she remembered those clearly. She also claimed + to remember all visits which were made to her by her + friends, but it was not specifically determined whether + there was a period of less clear recollection or not. + However, she remembered the tube-feeding, which occurred + only during the more marked stupor. Her desire to be + killed, to have her head cut off, she recalled but claimed + not to know why she wanted to be killed. However, she + remembered worrying about being bad, about the fact that + she could not "pay for the beds," etc. + + Her mutism and refusal of food she was unable to account + for. She could not talk, her "tongue would not move." As + regards ideas during the more stuporous period, she claimed + that (when quite inactive) she heard voices but did not + recall what they said. But she remembered having dreams at + that time "of fire," "of her dead father and of home." + +In a survey of thirty-six consecutive cases of definite stupor, literal +death ideas were found in all but one case. They seem to be commonest +during the period immediately preceding the stupor, as all but five of +these cases spoke of death while the psychosis was incubating. From this +we may deduce that the stupor reaction is consequent on ideas of death, +or, to put it more guardedly, that death ideas and stupor are +consecutive phenomena in the same fundamental process. Two-thirds of +these patients interrupted the stupor symptoms to speak of death or +attempt suicide, which would lead us to suppose that this intimate +relationship still continued. One-quarter gave a retrospective account +of delusions of being dead, being in Heaven, and so on. From this we may +suspect that in many cases there may be a thought content, although the +patient's mind may seem to be a complete blank. It is important to note +that when a retrospective account is gained, the delusions are +practically always of death or something akin to it, such as being in +prison, feeling paralyzed, stiff, and so on. + +In the one case of the thirty-six who presented no literal death ideas, +the psychosis was characterized essentially by apathy and mild +confusion, a larval stupor reaction. It began with a fear of fire, +smelling smoke and a conviction that her house would burn down. It is +surely not straining interpretation to suggest that this phobia was +analogous to a death fear. When one considers the incompleteness of +anamneses not taken _ad hoc_ (for these are largely old cases) and that +the rule in stupor is silence, the consistence with which this content +appears is striking. + +To exemplify the form in which these delusional thoughts occur we may +cite the following: Henrietta H. (Case 8) said, retrospectively, that +she thought she was dead, that she saw shadows of dead friends laid out +for burial, that she saw scenes from Heaven and earth. Annie K. (Case 5) +claimed to have had the belief that she was going to die, and to have +had visions of her dead father and dead aunt, who were calling her. She +also thought that all the family were dead and that she was in a +cemetery. Rosie K. (Case 11) said she had the idea that she wanted to +die and that she refused food for that purpose, and during the stupor +she sometimes held her breath until she was cyanotic. Mary F. (Case 3), +before her stupor became profound, spoke of the hereafter, of being in +Calvary and in Heaven. In this case, as well as in the above-mentioned +Henrietta H., we find, therefore, associated with "death" the closely +related idea of Heaven. Whether Calvary merely referred to the cemetery +(Mt. Calvary Cemetery) or leads over to the motif of crucifixion, cannot +be decided. It is, however, clear that this latter motif may be +associated with that of death, as is shown in Charlotte W. (Case 12), +who, during intervals when the inactivity lifted, spoke of having been +dead, of spirits having told her that she must die, of having gone to +Heaven, of God having told her that she must die on the cross like +Christ. But this patient also showed in a second subperiod of her stupor +another content. She said: "It was like water. I was going down." Or +again, she spoke of having gone "under the ground"; "I went down, down +in a coffin." She spoke of having gone down "into a dark hole," "down, +down, up, up"; again, of having been "on a ship." We shall see in the +further course of our study that this type of content occurs not at all +infrequently. + +_The internal relationship among the different ideas associated with +stupor:_ Before we go any further it may be advisable to examine the +meaning of such ideas when they arise in other settings than those of +the psychoses. If we consider these ideas of death, Heaven, of going +under ground, being in water, in a boat, etc., we are impressed with the +similarity which they bear to certain mythological motifs. This is, of +course, not the place to enter into this topic more than briefly. We are +here concerned with a clinical study, and therefore, among other tasks, +with the interrelationship of symptoms, but for that purpose it is +necessary to point out how these ideas seen in stupor can be shown to +have, not only a connection amongst each other, when viewed as +deep-seated human strivings, but also are closely related to, or +identical with, ideas found in mythology. + +To one's conscious mind death may be not only the dreaded enemy who ends +life, but also the friend who brings relief from all conflict, strife +and effort. Death may, therefore, well express a shrinking from +adaptation and reality, and as such may symbolize one of the most +deep-seated yearnings of the human soul. But from time immemorial man +has associated with this yearning another one, one which, without the +adaptation to reality being made, yet includes a certain attempt at +objectivation, the desire for rebirth. We need not enter further into +possible symbols for death _per se_, but it is quite necessary to speak +briefly of the symbolic forms in which the striving for rebirth has ever +found expression. The reader will find a large material collected in +various writings on mythology, for the psychological interpretation of +which reference may be made to Jung's "Wandlungen und Symbole der +Libido" and Rank's "Mythos von der Geburt des Helden." From them it +appears how old are the symbols for rebirth, and how they deal chiefly +with water and earth, and the idea of being surrounded by and enclosed +in a small space. Thus we find a sinking into the water of the sea, +enclosure in something which swims on or in the water, such as a casket, +or a basket, or a fish, or a boat; again, we find descent into the +earth. The striving for rebirth might be assumed to have adopted these +expressions or symbols on account of the concrete way in which the human +mind knows birth to take place. The tendency for concrete expression of +abstract notions causes the desire for another existence to appear, +first as a rebirth fantasy and then as a return to the mother's body. +One thinks of Job's cry, "Naked came I from my mother's womb and naked +shall I return thither," as an example of the literal comparison of +death with birth. We need only refer to the myths of Moses and the older +one of Osiris, and the many myths of the birth of the hero, to call to +the mind of the reader the examples which mythology furnishes. There is +probably not one of the ideas expressed by these patients which cannot +be duplicated in myths. We have, therefore, a right to speak of these +ideas as "primitive," and to see in them, not only deep-seated strivings +of the human soul, but to recognize in them an essential inner +relationship. It is especially this last fact to which at this point we +wish to call attention: that without any obvious connection the +fantasies of our forefathers recur in the delusions of our stupor cases. +We presume that in each case they represent a fulfillment of a primitive +human demand. In one of our cases a vision of Heaven and a conscious +longing to be there was followed by a stupor. On recovery the patient +compared her condition to that of a butterfly just hatched from a +cocoon. No clearer simile of mental rebirth could be given. + +_Brief survey of the ideas associated with the states preceding the +stupor:_ If we now return to the study of the further occurrence of such +ideas in the cases described, we find motifs, similar to those seen in +the stupor, in the period which immediately precedes the more definite +stupor reaction. Indeed we find the ideas there with greater regularity. +In Meta S. (Case 15) the stupor followed upon six days with reduced +activity and crying, with self-accusation, but also with entreaties to +be allowed to go home and die with her father. At the very onset of her +breakdown, the desire for death had also occurred. Anna G. (Case 1) +expressed a wish to be with her dead father, and, at the visit of a +cousin, she had a vision of the latter's dead mother. A second attack of +this same patient began with the idea that the dead father was calling +her. Maggie H. (Case 14) saw dead bodies, and during outbursts of +greater anxiousness, she thought her husband was going to die. In +Caroline De S. (Case 2) the psychosis began with a coarse excitement, +with statements about being killed, with entreaties to be shot, with the +idea of going to Heaven, again with frequent calling out that she loved +her father (who was dead since her ninth year), while immediately before +the stupor the condition passed into a muttering state in which she +spoke of being killed. Mary D. (Case 4) began by worrying over the +father's death (dead four years before), had visions of the latter +beckoning, and she heard voices saying, "You will be dead." Mary F. +(Case 3) had a vision of "a person in white," and thought she was going +to die. In Henrietta H. (Case 8) the stupor was preceded by nine days of +elation, with ideas of shooting and of war, but this had commenced with +hearing voices of dead friends, and with ideas that somebody wanted to +kill her family. In the case of Annie K. (Case 5) we find before the +stupor a state of worry, with reduction of activity, and then a vision +of the dead father coming for her. In Charlotte W. (Case 12) the stupor +was preceded by a state of preoccupation, with distress and entreaties +to be saved, partly from being put into a big hole, partly from the +electric chair. + +We see, therefore, in the introductory phase of the stupor in almost +every case ideas of death, and in one case an idea belonging to the +rebirth motif, namely, of being put into a dark hole. In well-observed +cases apparently we do not find the stupor reaction without either +coincident or preceding ideas of death. + +_Relation of death and rebirth ideas with affect:_ In order to +investigate the relation of these ideas to the affective condition +associated with them, it will be necessary to study not only the +abstract ideational content but the special formulation in which the +content appears. In looking over the enumeration of the ideas given +above, it is very clear that these formulations differed considerably +from each other. A priori we would say that it is, psychologically, a +very different matter whether a person expresses a desire to die, or has +the idea that he will die or is dead, or says he will be killed. We +associate the first with sadness, the last with fear, while our daily +experience does not give us so much information about the delusion of +being dead. A vivid expectation of death is usually accompanied by +either fear or resignation. + +In studying the ideas which we obtained from the patients by +retrospective account after the psychosis or from a retrospective +account during freer intervals, it is, of course, difficult, especially +in the former case, to say whether they have persisted for any length of +time. Probably in most instances this was not the case, and we must +remember in this connection that in a considerable number of cases the +patients recalled no ideas whatever. + +Of the five cases which we may consider as types, Henrietta H. (Case 8) +and Mary F. (Case 3) formulated their ideas simply as _accepted facts_ +during the stupor. The former thought she was dead, saw dead friends +laid out for burial, and scenes from Heaven and earth. The latter spoke, +during the stupor, of being in "Calvary," "the hereafter," or "Heaven." +We have seen that these stupors were essentially affectless reactions +and we can therefore say that, so far as these two cases are concerned, +the ideas thus formulated were not associated with any affect. + +Annie K. (Case 5) was a little different. During the stupor she made a +few utterances about priests and "all being dead," and retrospectively +she said that she had thought she was in the cemetery, was going to die, +that she had repeated visions of her dead father and once of a dead aunt +calling her; that she had thought her family were dead, again that the +baby (who was born just before the psychosis) was dead. The formulation +is therefore less one of fact than of something prospective, something +which is coming--the _going_ to die. Correlated, perhaps, with this +anticipation were slight modifications of the usual apathy. The patient +often had an expression of bewilderment. She was also more in contact +with her environment than many stuporous patients are, for, not +infrequently, she would look at what was going on about her. Her apathy +was also broken into in a marked degree by her active resistiveness, +which was sometimes accompanied by plain anger. It seems that a prospect +of death may occur in other instances in a totally affectless state. We +have recently seen it in a partial stupor during which the patient spoke +and had this persistent idea in a setting of complete apathy. We see +here also, as in one of the former cases, the idea of other members of +the family being dead. + +More difficult and deserving more discussion are the two remaining +cases, Rosie K. (Case 11) and Charlotte W. (Case 12). Rosie K. showed a +peculiar condition. She said, retrospectively, that during the stupor +she had the desire to die and that for this purpose she refused food. +Moreover, she was repeatedly seen to hold her breath with great +insistence, though without affect. This is worth noting. We are in the +habit in psychiatry to say in a case like this that "there is no +affect," and yet there is evidently a considerable "push" behind the +action. We shall later have to mention in detail a patient whom we +regard as belonging in the group of stupor reactions, and who for a time +made insistent, impulsive and most determined suicidal attempts, yet +with a peculiar blank affectless facial expression and with shouting +which was more like that of a huckster than one in despair. Here also, +then, there was a great deal of "push," yet not associated with that +which we call in psychiatry an affect. In both instances we see acts +which we are in the habit of calling for this very reason "impulsive." +Evidently this is an important psychological problem which leads +directly into the psychology of affects and deserves further study. For +the present it is enough to say that with a different formulation--that +of wishing to die--there is here not, as in other psychoses, a definite +affect, such as sadness or despair, but no affect, though there may be a +good deal of "push" or impulsiveness. + +The case of Charlotte W. (Case 12) is a complicated one, for she had +short stupor periods with inactivity, catalepsy, resistiveness, etc., +which were interrupted with freer spells. A careful analysis of her +history has been instructive and justifies a detailed and lengthy +discussion. For the purpose in hand it is necessary to separate the +ideas which she expressed only in the freer periods (during which some +affect was at times seen) into those which referred retrospectively to +the stupor phase and those which referred to the freer periods +themselves. + +We find that the time during which more marked stupor symptoms appeared +may be divided into two subperiods. This is not possible in regard to +the manifestations belonging to the general reaction, which seem to have +undergone no decided change, but only in regard to the form of the +delusions. In this we find there was a first phase in which ideas of +death and Heaven (and crucifixion) occurred, and a second phase in which +ideas were present which belonged essentially to the motif of rebirth +but which were also associated with ideas of Heaven. + +About the first subperiod she said: "I was mesmerized," or "I thought I +was dead," or "God told me I must die on the cross as He did," or "I +went to Heaven in spirit." About the second subperiod she said +retrospectively: "We were on a ship and we were 'most drowned." "It was +like water, I was going down, down." She said she saw the people of the +hospital and "it was all full of water"; or again, "I went under the +ground and it was full of water and every one got drowned and a sharp +thing struck me"; or "I was out on a ship and I went down in a coffin." +She claimed she put up her arms to save the ship. Again she spoke of +having gone into a dark hole. She also said: "One day I was in a +coffin--that was the day I went to Heaven." "They used to be coming up +and down, that was the day I was coming up in a ship or going down." And +when shown her picture in a cataleptic attitude, she said: "That must +have been when I went to Heaven--everything seemed strange, things +seemed to go up and down--I guess that was the day I thought I was on +the ship." Finally she also said: "Once I heard beautiful music--I was +waiting for the last trumpet--I was afraid to move." + +We see, therefore, that most of the ideas which she thus spoke of +retrospectively as having been in her mind during this stupor, and which +belonged both to the death and the rebirth motifs were formulated as +facts (as in the cases of Henrietta H. and Mary F. above mentioned). It +was, moreover, a condition which was accepted without protest. Here +again an affect was not associated with these ideas, and when the +patient was asked whether she had not been frightened, she said herself, +"No, I just lay there." The idea that God told her she would have to die +on the cross like Christ, is, in the religious form, like the beckoning +of the father with Henrietta H. The only exception to the claim that the +ideas were formulated as facts and accepted as inevitable seems to be +the statement that she held up her arms to save the ship. This would +seem to be, in contradistinction to the rest, a formulation as a more +dangerous situation. However, this was isolated and we can do no more +than to determine main tendencies. We must expect, especially in such +variable conditions as we see in this patient, to find occasional +inconsistencies. + +In summing up we may say, therefore, that so far as the stupor itself +is concerned, the ideas are formulated as a rule:-- + + 1. As accepted facts (being dead, being in a ship, etc.). + + 2. As accepted prospects (going to die). + + 3. As the wish to die. + +In the first two types the ideas are not associated with affect; in the +third, though not associated with affect, they are combined with +"impulsive" suicidal attempts. + +In order not to tear apart the analysis of Charlotte W. (Case 12) too +much, we may begin our study of the intervals and the conditions +preceding the stupors with the ideas which this patient produced when +the stupor lifted somewhat. We shall see that the ideas are closely +related to those mentioned above but formulated differently. + +It will be remembered that Charlotte W. had freer intervals when she +responded and was less constrained generally, and that it was in these +that the ideas above mentioned were gathered. Since they were spoken of +in the past tense, we regarded them as not belonging to the actual +situation but to the more stuporous period. It seems tempting now to see +whether the ideas which are expressed in the present tense are different +in character, the general aim being to discover whether any tendencies +can be found in regard to the types and formulations of delusions +associated with different clinical pictures. We see that on November 2 +the patient, when speaking much more freely than before, said she had +felt that she was mesmerized, was dead, and that she had gone to Heaven, +ideas which we have taken up above as belonging to the stupor period. In +addition to speaking much more freely in these intervals, she showed at +times some affect. Thus to the physician whom she called Christ, she +said, with tears, "You came to tell me what was right," or again with +tears, "I will have to be crucified," or she spoke in a depressed manner +about her children, "I can't see them any more," "I must stay here till +I die," and she spoke of having to stay here till she picked her eyes +and her brains out; or she claimed her husband or her children had to +pick them out. Once she exclaimed crossly and with tears, "You are +trying to keep me from Jim" (husband). Another idea was not plainly +associated with affect. She said she had come back from Heaven, "The +wedding ring kept me on Earth." What strikes one about these +formulations is that they are, on the one hand, sometimes associated +with an affect, and that, on the other hand, they refer much more to her +actual life, her marriage, her husband, her children. At least this +seems to be a definite tendency. A similar tendency may be seen later: +On November 4, while generally stuporous, this suddenly lifted for a +short time, and with feeble voice she uttered some depressive ideas. She +said she wanted to go to a convent, that it would be better if she were +dead, that she could not do anything right. On November 5 and 6 she +said she wanted to go to Jim in Heaven (in contradistinction to the +retrospective statements that she had gone to Heaven), and on the 8th, +when she had the idea of being in a boat, she said with some anger that +she had wanted to get her husband into the boat, but that the doctor +kept him out and took his place. + +Later there were at times ideas expressed which referred to the actual +situation or essentially depressive ideas in a depressive setting. Thus +on December 3 she appeared sad, retarded, and spoke of not being able to +see her children and that she had done wrong in buying carbolic acid +(her suicidal attempt). So far as this case is concerned, therefore, we +do find a distinct tendency for the ideas which refer to the more +stuporous condition to differ from those which refer to the actual +situation in the freer intervals, a difference which we may formulate by +saying that, though primitive ideas are expressed, the tendency seems to +be to connect them more with actual life, or that the primitive +character is lost and the ideas take on a more depressive character with +a depressive affect. A few words should be added in regard to the +peculiar ideas that she or her husband or her child had to pick out her +eyes (or her brain). It is probable that this idea belongs to the motif +of sacrifice (the _Opfer motiv_ of Jung) into which we need not enter +further, except to say that in this instance it was plainly connected, +like some of the other ideas just spoken of, with the real situation of +her life (husband, children). + +It will now be necessary to examine the earlier state of Charlotte W. +The condition preceding the stupor set in with pre-occupation, slow talk +and slight distress. During the time she asked to be given one more +chance, she said to the husband she would not see him again. Then +followed a day when she was very slow and with moaning said she was +going to be put into a dark hole. Again on the next, when speaking more +freely, she begged to be saved from the electric chair, and also said, +"Don't kill me, make me true to my husband," etc. [Again the connection +with real life!] We see here the idea of death and especially an idea +pertaining to the rebirth motif in a setting of distress and slowness, +as an introduction to the stupor which had in it both of these motifs. +We must leave it undecided whether it is accidental or not that the +distress was associated with more slowness (i.e., more marked stupor +traits) when she spoke of the dark hole than when she spoke of the +electric chair or death. But what interests us is that distress and +reduction of activity (not sadness and reduction of activity, which +seems as a rule to have a different content) are here associated with +ideas seen in stupor but formulated as prospective dangers. We know from +experience that we often find associated with the fear of dying +considerable freedom of action, and we see at times in involution states +conditions with freedom of motion and marked anxiety, whereas the ideas +seem to belong to the motif of rebirth; e.g., the fear of being boiled +in a tank.[A] + +In this connection, however, two other cases should be taken up which +show a condition which reminds one somewhat of that we have just +discussed, but in which the rebirth motif appeared, not as prospective, +but, as in the stupor, as an actual situation. At the same time this +situation was not passively accepted but conceived as a dangerous +situation. The significant phenomenon in both these conditions was that +there was not anxiety with freedom of action but a bewildered uneasiness +with marked reduction of activity. + +The first case is that of Johanna S., whose history has been given in +this chapter. It will be observed that in the fourth period the patient +presented two days of typical stupor with the idea that she was dead. We +are familiar with this. But this was followed by several days of +bewildered uneasiness and slow restlessness, with ideas that she was at +the bottom of the deep, dark water and for a time she made attempts at +stepping out of the water or swimming motions. All of this was in a +general setting of reduction of activity with bewildered uneasiness. In +the ideas about being at the bottom of the deep, dark water, we +recognize again the rebirth motif, yet the situation is not accepted +but attempts are made by the patient to save herself, i.e., the attitude +is one in which the situation is taken to be one of danger. It is +interesting in this connection that immediately following this state +there was one day of ordinary retardation with sadness and ideas of +being bad and sick. That is, when the element of anxiety, the +uneasiness, disappeared and sadness supervened, the rebirth ideas were +no longer present. + +In Mary C. (See Chapter II, Case 7) we have, unfortunately, not a direct +observation, but we have, at any rate, a description from the +Observation Pavilion which seems so plain that we should be justified in +using it here. The condition we refer to is described as a dazed +uneasiness, with ideas of being shut up in a ship, of the ship being +closed up so that no one could get out, of the boat having gone down, of +the people turning up. We should add here that the condition was not +followed by a typical stupor. Essentially it was a retardation, in which +only on one occasion was a definite akinesis observed. During this phase +she soiled her bed. Perhaps the persistent complaint of inability to +take in the environment belonged also more to the retardation of stupor +than to that of depression. We have again, therefore, in this initial +phase, a similar situation, namely, ideas belonging essentially to the +rebirth motif, formulated as of a threatening character if not as +actually dangerous. + +We can say, therefore, that what characterizes these three cases, and +brings them together, is the fact that all three had ideas belonging to +the rebirth motif, but formulated as dangerous situations. Associated +with this there was not a typical anxiety with the relative freedom of +activity belonging to this state, but an anxiety or distress or +uneasiness with traits of stupor reaction, namely, slow movements, lack +of contact with the environment, and a dazed facial expression. It would +seem that these facts could scarcely be accidental but that they must +have a deeper significance. As a discussion of this belongs, however, +more into the psychological part of this study, we shall defer it for +the present, and be satisfied with pointing out here the clinical facts +of observation. + +In brief, then, our findings as to the ideational content of the benign +stupor are as follows: From the utterances during the incubation period +of the psychosis, from the ideas expressed in interruptions of the deep +stupor, as well as from the memories of recovered patients, we find an +extraordinary paucity and uniformity of autistic thoughts. They are +concerned with death, often as a plain delusion of being no longer +alive, or with the closely related fancy of rebirth. The rule is a +setting of apathy for these ideas, but when they are formulated so as to +connect them with the real life and problems of the patient, or when +rebirth is represented as a dangerous situation, some affect, usually +one of distress, may appear. + + +FOOTNOTES: + +[6] Kirby, _loc. cit._, pointed out that stupor showed resemblance to +feigned death in animals, that the reaction suggested a shrinking from +life and that ideas of death were common. + +[A] We may mention that since this study was made we risked a prediction +of stupor, which events justified, in the case of a patient who showed +expectation of death without affect. Such opportunities are rare, +however, since we usually do not see these cases till the stupor +symptoms are manifest. It would be unsafe to dogmatize on the basis of +such meager material. + + + + +CHAPTER VI + +AFFECT + + +The most constant and significant symptom in the stupor reaction is the +change in affect. This extends from mere quietness in the mildest phases +of the disease through the stage of indifference where apathy replaces +the normal reactions of the personality, to the final condition of +complete inactivity in the vegetative stupor where all mental life seems +to have ceased. It seems as though there were, as a pathognomonic sign +of the morbid process, a lack of energy and loss of the normal _lan +vital_. + +We may say, in fact, that the establishment of a specific type of +emotional change is justification for classifying all milder stupor +reactions with the deep stupors. In other words, our reason for the +enlargement of the stupor group to include all apathetic reactions +(except those of dementia prcox) is the belief that this dulling of the +emotional response is as specific a type of emotional change as is +anxiety, depression or elation. Perhaps it would be more accurate to say +that this clinical group is founded on the symptom complex which is +built around apathy. There is never any resemblance between apathy and +the mood of elation or anxiety. A discrimination from depression is the +only differentiation worth discussion. + +The first point that should be made is that there is a difference +between marked depression and the mood of stupor. In the former we get a +retardation with a feeling of blocking, rather than of an absence of +energy. The expression of the patient is one of dejection, not of +vacancy, which bespeaks a mood of sadness, even when the patient is so +retarded as to be mute and therefore incapable of describing his +emotions. Running through all the stages of stupor, however, there is an +emptiness, an indifference that is in striking contrast to the positive +pain that is felt or expressed by the depressed patient. It may be +objected, of course, that this apathy really represents the final stage +in the emotional blocking of the depressed individual, but the +development of stupor and recovery from it shows an entirely different +type of process. A deep depression recovers by changing the point of +view from a feeling of unworthiness and self-blame to one of normality. +The stuporous case, on the other hand, evidences merely less and less +indifference, and more and more interest in his environment and in +himself as he gets well. + +The associated symptoms are no less dissimilar. The difficulty in +thinking which troubles the depressed patient is slight in proportion to +his emotional gloom, and he feels himself to be much more incompetent +intellectually than examination proves him to be. On the other hand, in +the stupor reaction we find that the thinking disorder runs hand in +hand with the apathy and that the intellectual capacity of the patient +is really markedly interfered with, as can be shown by more or less +objective tests. A mere slowing of thought processes accompanied by +subjective feeling of effort is the limit reached in true depression, +while it is merely the beginning of the intellectual disorder in stupor, +for one meets with retardation symptoms only in the partial stupors. The +slowing in these cases seems to represent an early stage of the +intellectual disturbance which reaches its acme in the mental vacuity +and complete incompetence of the deep stupor, just as slow movements in +the partial stupors seem to represent a diluted inactivity reaction. +This actual thinking disorder is not present in those forms of +manic-depressive insanity which are characterized by elation, anxiety or +depression but is seen only in stupors, occasionally in absorbed manic +states (manic stupor) and sometimes in perplexity states. The +psychological mechanisms of this last group are probably analogous to +those of stupor, but this is not the place for a discussion of this +topic. + +Another associated symptom whose manifestations differ in depression and +stupor is that of unreality. In the former there is frequently a feeling +of unreality that is purely subjective, whereas the stupor case does not +usually complain of this but does exhibit a difficulty in grasping the +nature of his environment, which the typical depressive case never has. + +The occurrence of other mood reactions than apathy in the same patient +is also characteristic. Manic states (usually hypomanic) frequently +occur during the phase of recovery from the stupor. This is an unusual, +although not unknown, phenomenon in recovery from severe retarded +depressions. The circular cases who swing from depression to elation +usually show the milder types of depressive reaction which would never +be confused with stupor. On the other hand, deep stupors very frequently +are terminated by manic reactions, and if not by such means, recovery +seems to occur merely in virtue of a gradual attenuation of the stupor +symptoms. Rarely do we see a change to depression or anxiety heralding +improvement. This tendency of the stupor reaction to remain pure or +change to hypomania is a peculiarity which seems to put stupor in a +class by itself among the manic-depressive reactions, as all the other +mood reactions frequently change from one to the other. + +Although apathy is the central pathognomonic symptom of stupor +conditions, there are other mood anomalies to be noted. One of these is +the tendency for inconsistency in, as well as reduction of, the +expression of emotion. For instance, in the states where one would +expect anxiety during the onset of stupor or in its interruptions, +manifestation of this anxiety is often reduced to an expression of dazed +bewilderment. In the anxiety states associated with stupor one does not +meet with the restlessness and expressions of fear which would be +expected. Quite similarly, when a manic tendency is present, it occurs +either in little bursts of isolated symptoms of elation (such as smiling +or episodic pranks), or some of the evidences of elation which we would +expect are missing. For instance, Johanna S. (Case 13) terminated her +stupor with a hypomanic state which was natural except for her always +wearing an expressionless face. Sometimes laughter occurs alone and +gives the impression of a shallow affect, raising a suspicion of +dementia prcox. In fact, such evidences of affect as do appear in the +course of the stupor are apt to be isolated, queer and "dissociated." It +does not seem as if the whole personality reacted in the emotion as it +does in the other forms of manic-depressive insanity. For example, we +may think of the resistiveness which is so frequently present when the +patient seems in other respects to be psychically dead. One may recall +the case of Meta S. (Case 15), who, otherwise inert, was occasionally +seen with tears or smiles. Anna G. (Case 1), too, was often seen smiling +or weeping. It was noted once of Charlotte W. (Case 12) that she ceased +answering questions and remained immobile with fixed gaze, but when some +mention was made of her going home she flushed and tears ran down her +cheeks, although no change in the fixedness of her attitude or facial +expression was seen. When Johanna S. was visited by her daughter and was +lying motionless in bed, she slowly extended her hands, apparently tried +to speak, and then her eyes filled with tears. Two days later, at the +end of an interview when she had made a few replies, she settled down +into her usual inactivity and, when further urged to answer, her eyes +filled with tears. Similarly, too, in fairly deep stupor pin pricking +may result in flushing, in tears or an increased pulse rate without the +patient giving any other evidence of the stimulus being felt. These +examples seem to show a larval effort at normal human response which, +failing of complete expression, appeared as single isolated features of +emotion suggesting true dissociation. We should also in this connection +bear in mind the impulsive suicidal acts which occur either as +unexpectedly as the impulsiveness in a true dementia prcox patient, or +in a setting of coarse animal-like excitement that seems quite unrelated +to the personality. One is reminded of the patient who made suicidal +attempts during the period when she shouted like a huckster, giving no +evidence whatever by her expression or the tone of her voice of feeling +anxiety, sorrow or any other normal emotion. + +All these queer and larval affective reactions remind one strongly of +dementia prcox. The resemblance of the benign stupor to certain +dementia prcox types is not merely a matter of identity with catatonic +features (catalepsy, negativism). In these anomalous mood reactions it +seems as if there were a definite dissociation of affect, and so there +is. How then can we differentiate these emotional symptoms from the +"dissociation of affect" which is regarded as a cardinal symptom of +dementia prcox? The answer is that this term is used too loosely as +applied to the latter psychosis. It is a particular type of dissociation +which is significant of the schizophrenic reaction, for in it there is +an acceptance of what should be painful ideas evidenced either by +incomplete manifestations of anxiety or depression or actually by +smiling. We never see in dementia prcox the reverse--a painful +interpretation of what would normally be pleasant. It is the pleasurable +interpretation of what is really unpleasant that gives the impression of +queerness in the mood of these deteriorating or chronic cases. In +stupor, on the other hand, although this dissociation takes place, the +mood is never inappropriate, merely incomplete in that all the +components or the full expression of the normal reaction are not seen. + +Our description of the mood reactions in stupor would be incomplete if +we omitted to mention the occasional appearance of an emotional attitude +not unlike that seen in many cases of involution melancholia, which +reminds one in turn of the reactions of a spoiled child. The commonest +of these manifestations is resistiveness that may occur when an +examination is attempted, feeding is suggested, or a sanitary routine +insisted upon. One also meets with resentfulness. One patient, who +frequently showed this reaction, explained it retrospectively by saying +that she wanted to be left alone. Quite analogous to this is sulkiness +that occasionally appears. Then we have, particularly as recovery +begins, other childish tricks, such as flippancy in answering questions +or the playing of pranks. Such tendencies naturally lead over to frank +hypomanic behavior. + +Finally, a peculiar characteristic of the stupor apathy must be +mentioned. This is its tendency to interruptions, when the patient may +return to life, as it were, for a few moments and then relapse. Such +episodes occur mainly in milder cases or towards the end of long, deep +stupors. It is interesting that the occasion for such reappearance of +affect is frequently obvious. We usually observe them in response to +some special stimulus, particularly something that seems to revive a +normal interest. Visits of relatives are particularly common as such +stimuli, in fact recovery can often be traced to the appearance of a +husband, mother or daughter. It is also important to recognize that with +this revived interest, other clinical changes may be manifest, that the +thinking disorder may, for instance, be temporarily lifted. Helen M., +for example, when visited by her mother was so far awakened as to take +note of her environment, and remembered these visits after recovery like +oases in the blank emptiness of her stupor. She further remembered that +definite ideas were at such a time in her mind that ordinarily was +vacant. She then had delusions of being electrocuted. + +In summary, then, we may say that the _sine qua non_ of the stupor +reaction is apathy in all gradations, and that this apathy is as +distinct a mood change as is elation, sorrow or anxiety. Incidental to +this loss of affect there is a dissociation of emotional response +whereby isolated expressions of mood appear without the harmonious +coperation of the whole personality which seems to be dead. Thirdly, +there tends to be associated with the stupor reaction a tendency to +childish behavior. Finally, the apathy and accompanying stupor symptoms +may be suddenly and momentarily interrupted. An explanation of these +apparently anomalous phenomena will be attempted in the chapter on +Psychology of the Stupor Reaction. + + + + +CHAPTER VII + +INACTIVITY, NEGATIVISM AND CATALEPSY + + +1. INACTIVITY. We must now turn our attention to the other cardinal +symptoms of the stupor reaction, and quite the most important one of +these is the inactivity. It is convenient to include under this heading +both the reduction of bodily movement and the diminution or absence of +speech. This inactivity is, of course, related to the apathy which we +have just been discussing, in fact it is one of the evidences of the +loss of emotion. We presume that a patient is apathetic when there is no +expression in the face and when he does not respond to external stimuli, +whether these be physical or verbal, by movement or by word. + +Bodily inactivity is present in all degrees, and in some forty +consecutive cases was recognizable in every one. In its most extreme +form there is complete flaccidity of all the voluntary muscles, and +relaxation of some sphincters. As a result of the latter we see wetting, +soiling and drooling. Even those reflexes which are only partially under +voluntary control, like those of blinking and swallowing, may be in +abeyance; for instance, saliva may collect in the mouth because it is +not swallowed, and tube-feeding is frequently necessary on account of +the failure of the patient to swallow anything that is put into his +mouth. The eyes may remain open for such long periods of time that the +conjunctiva and sclera may become quite dry and ulcerate. In these +extreme cases there is, of course, no response to verbal commands. What +is more striking, no reaction appears to pin pricks, so that it seems as +if consciousness of pain were lost. + +This deep torpor does not usually persist indefinitely. The commonest +evidence of some form of consciousness persisting is probably to be seen +in blinking when the eye is threatened or the sclera or cornea actually +touched. A very large number of patients, when otherwise quite inactive, +showed considerable response in their muscular resistiveness, the +phenomena of which will be discussed shortly. The relaxation of the +sphincters is apt to persist even after control of the rest of the body +is exercised to the point of permitting the patient to stand or walk +about. + +The first phase of obvious conscious control is seen in those patients +who will retain a sitting posture in bed or in a chair. The next stage +is reached where the stuporous case can be stood upon his feet but +cannot be induced to walk. The next degree is that of walking only when +pushed or commanded. Finally spontaneous movement is observed in which +the inactivity is evidenced merely by a great slowness. + +No correlation can be established between restrictions of speech and +motion other than that present in the extremes. With complete inactivity +there is almost always consistent mutism, and perfect freedom of speech +does not, as a rule, appear until the movements are free. In between +these extremes all variations are possible, even the deepest stupors are +occasionally interrupted by one or two words; for instance, a patient +may remain comatose, as it were, and absolutely mute for six months, +then to every one's surprise say one or two words and relapse into a +year of silence. Again one sees cases where movements have become fairly +free and yet the patient says nothing. This is another example of that +inconsistency in reaction which we have already noted in connection with +the mood or affect. + +In so far as inactivity is merely an expression of apathy, its causation +will be considered in connection with the psychology of the stupor +reaction as a whole. In so far as there may be specific factors, +however, it may be of interest to consider what information the patients +themselves give us from time to time as to what determined their +inactivity. It is really surprising how frequently something can be +gained either from careful notes taken during the stupor or from the +retrospective accounts of the psychotic experiences. Of course when one +considers the degree of amnesia which is usually present and the extent +of the intellectual defect in general, it becomes obvious that one +cannot think of getting anything like a complete explanation of the +behavior of any given case. Nevertheless this material is quite +suggestive in the mass; it gives one some idea of the mental state as a +whole. + +Among 40 cases, 27 offered some explanation either during or following +the psychosis. Of these, 20 spoke of feeling dead, numb or drugged, or +feeling as if paralyzed or having lockjaw. This group, just half of all +the cases, apparently ascribed their disability to something which +seemed physical. One might call them somatopsychic cases. The other 7 +gave more allopsychic explanations: 3 attributed their inactivity to +outside influence; 3 more said they were afraid (one of these because +she imagined herself to be in prison), which is analogous to the outside +influence; the 7th case thought she would injure people if she moved. + +The following are some examples of the statements of the somatopsychic +group: Laura A.: "I can't move," and retrospectively, "My arms were +stiff." Bridget B. claimed retrospectively that she felt dead or +drugged, that her limbs were lifeless, she felt as if she had lockjaw. +Johanna B. remembered being pricked with a pin on several occasions but +claimed that she did not feel the pain at any time. This suggests a +definitely hysterical mechanism. Anna L. (Case 16) said retrospectively +that she felt as if she were dead, although walking around, and also +that she thought she was a ghost and not supposed to speak. Anna M. said +she had tried to speak but everything stuck in her throat. Alice R. said +that she had no energy, did not want to talk. Meta S. (Case 15) claimed +that while stuporous her tongue would not move. Isabella M. in +intervals claimed that during the stuporous periods she felt as if dead +and said retrospectively when the whole psychosis was over that it was +"an effort to speak." Johanna S. (Case 13), while stuporous when pressed +with questions would say: "I can't think," "I don't know," "I am +twisted." When food was offered her she protested, "I am dead." +Charlotte W. (Case 12), in reviewing her case, said: "I was mesmerized," +"I thought I was dead." Anna G. (Case 1), in retrospect said: "I don't +think I could speak," again "I made no effort," or "I did not care to +speak." Henrietta H. (Case 8) said, "I lost speech." She claimed that +she did not move because she was tired and had a numb feeling. Mary C. +(Case 7) said that her tongue had been thick and that she felt dull. +Rose Sch. (Case 6) said during the psychosis that her head was upside +down and retrospectively that she had been mixed up, could not remember +well, did not feel like talking. Mary D. (Case 4) said that she had been +dazed, that she had not felt like talking, and that her limbs "were +stiff like." We should probably also include here as a delusion of death +the statement of Annie K. (Case 5) who wanted to die and thought she +would do so if she kept still enough. + +It is rather striking that among all the forty cases only one spoke of +being sick--"I am so sick." Only one evaded questions with "that was my +illness." One would expect a priori that these patients would offer some +vague explanations or make complaints of weakness. If these stupors +were purely physical in origin, one would expect such explanations as +weakness or illness to be offered in accounting for the inactivity. That +there is a rather definite type of explanation offered is, we think, +distinctly suggestive. If one tries to correlate and group the death +ideas, one sees that they are all delusions of death or of loss of +energy or complaints of hysterical symptoms that look like sham death. +If the lack of energy complained of be looked upon as lifelessness, one +can conceive of these explanations being variations of one theme, +namely, that of death. In the last chapter it has been shown that a +delusion of dying, being dead, or having been dead is extremely frequent +in the stupor group. It would seem only natural then to regard the +inactivity, in so far as it may be specifically determined, as an +expression of some such delusion. + +Psychiatrists are more or less aware of there being typical ideational +contents in the different manic-depressive psychoses. For instance, +every one is familiar with ideas of wickedness and inadequacy in +depression, ideas of violence in anxiety, or expansive and erotic +fancies in manic states. Quite similarly we have seen that death is a +dominant topic in a stupor. Now in addition to these typical ideas we +often hear expressed what we might term non-specific delusions, ideas +that seem to have nothing to do with a peculiar type of reaction which +the patient presents. It is therefore not surprising to find that +inactivity is not consistently ascribed to death or a related delusion. + +For instance, Henrietta B. had much talk of higher powers that were +controlling her, also said that it was fear which kept her quiet. +Josephine G. said retrospectively that she had thought she would injure +people if she moved and that if she opened her eyes she would murder the +people around her. Johanna B. was afraid to talk because she fancied she +was in prison. Laura A.: During her stupor was more vague, saying, "I +can't move, they won't let me be," without betraying any suggestion of +whom "they" might be. Finally Mary C. (Case 7) was still more +indefinite, ascribing her immobility merely to fear. When one considers, +however, that these five were the only ones who gave any atypical +explanation of their inactivity among the thirty-seven cases, the +preponderance of the death idea becomes striking. + +2. NEGATIVISM. The next of the cardinal symptoms to be considered is +negativism. This term, which is often loosely used, we would define as +perversity of behavior which seems to express antagonism to the +environment or to the wishes of those about the patient. Naturally it is +only in the minor stupors that we see it in well-developed form as +active opposition and cantankerousness. For example, Harriett C., who +stood about until her feet became edematous, would spit out food when it +was placed in her mouth but would eat if she were left alone with the +food. Josephine G., in a milder state, would turn her back on people. +When more inactive once rolled out of bed and lay on the floor. At this +time also she tried to keep people out of her room. Rarely, patients may +have angry outbursts, as did Annie K. (Case 5) who would strike at the +nurses. + +Very often the failure to swallow and anomalous habits of excretion seem +to be negativistic in their nature. One thinks at once of the necessity +for tube-feeding, which is so common even when patients seem otherwise +fairly active. Naturally this form of treatment is necessary only when +the patient refuses to swallow. Quite frequently a refusal to urinate is +met with so that catheterization is necessary, or a patient may never +use the toilet when led to it, but will defecate or urinate so soon as +he leaves it. These latter, like some other perversities, suggest +reactions of a petulant, spoiled child. + +By far the commonest manifestation is muscular resistiveness, often +spoken of as "resistiveness." It was present in thirty-two out of +thirty-seven of our cases. Usually it takes the form of a contraction of +the whole system of voluntary muscles when the patient is touched or the +bed approached. Often it appears only when any passive movement of the +limb is attempted. All muscles of the limb then stiffen, making the +member rigid. Sometimes the negativism is expressed by quite isolated +symptoms, such as stiffness in the jaw muscles alone. One patient showed +no opposition except by holding her urine for two days. Another kept her +eyes constantly directed to the floor. The reaction of another showed +no irregularity except for stiffness in the neck and arms and wetting +herself once after she had been taken to the toilet. One displayed +merely a slight stiffness in her arms. An interesting case was that of +Annie G. (Case 1) who kept one leg sticking out of bed. If this were +pushed in, she would protrude the other. Mary F. (Case 3) sometimes +expressed her antagonism to the environment by slapping other patients. +She spoke only twice in a year and a half, and each time it was when +interfered with. By far the commonest cause of muscular movement in +these inactive cases is resistiveness, and as a rule the inactivity is +interrupted only by negativistic symptoms. + +If we look for some explanation or correlation of these symptoms, we +find that chance references to conduct seem to point in the same +direction, namely, to the desire to be left alone. This resentment +against interference again reminds us of the reactions of a spoiled +child. For instance, Laura A., in manic spells during which she was +still constrained and drooled, said, "I don't want to have my face +washed." In the intervals she showed an intense muscular resistiveness. +Mary G. used to say, "Leave me alone," and covered her head or buried it +in the pillows. Maggie H. (Case 14) said in retrospect that she had +wanted to be left alone. Similarly Alice R. thought she did not want to +talk. Emma K. thought that she was in prison and apparently resented +this. Henrietta B. combined in her behavior tendencies both to +compliance and opposition. When her arms were raised they retained the +new position for a minute. Then she dropped them and said, "Stop +mesmerizing me." But then she put them up again of her own accord, and +when she had done this presented intense resistiveness to any movement. +Later she extended her arms in front of her and said, "I am all right," +in a theatrical manner, and then added, "Why don't you go away?" + +There seems to be some correlation between inaccessibility and muscular +resistiveness. For example, Charlotte W. (Case 12), whose condition +varied a great deal, always lost the resistiveness when she became +accessible, during which periods she also showed some facial expression. +The resistiveness would invariably return when the inaccessibility +reappeared. Caroline DeS. (Case 2) lost her resistiveness as she became +more accessible, although the inactivity and apathy persisted. This +tendency, which is quite common, suggests that muscular resistiveness +represents a lower level of expression of opposition which patients put +into words or purposeful actions when there is other evidence of some +contact with the environment. Sometimes one observes both general +resistiveness and specific acts. For instance, Mary G., who said, "Leave +me alone," and covered her head or buried it in the pillows, accompanied +her muscular resistiveness with laughter. This shows the affective +nature of the apparently purposeless muscular tension. The case of Annie +K. (Case 5) is more instructive. In the stage of deeper stupor she had +the automatic type of resistiveness but also outbursts of anger, +particularly toward the nurses, striking one of them she said, "You are +the cause of it all." When food was offered her, she said, "I wonder +people would not leave me alone sometimes." Again, when her bed was +approached, she would clutch and hold the bed clothes in an apparently +aimless way as if the impulse to resist never reached its goal. +Retrospectively she could not account for her muscular rigidity on the +basis of definite ideas, and could recall only that she felt stubborn. +In a later period when more accessible, she felt cross and did not want +to be bothered. This emotional attitude was quite conscious with her, +whereas the acts and speech of the earlier period, when her stupor was +more profound, seemed more automatic and impulsive. In other words, the +resistiveness looks like a larval attempt to express an idea which is +probably not fully conscious and therefore gives the appearance of being +aimless. As another example of this we may cite the case of Pearl F. +(Case 9), who said when she recovered, "I was stubborn." In addition to +the muscular resistiveness she had shown, she would often bite the bed +clothes or scratch herself when she was approached. Mary F. (Case 3), +while in a stupor, slapped at nearby patients quite aimlessly. When +somewhat better, this conduct appeared in a more conscious form, as +sullenness, indifference and smearing of feces (again the behavior of a +naughty child). Here one might quote Laura A. once more, whose +resistiveness when stuporous was intense but who in her manic spells +expressed her negativism in a definite idea, "I don't want my face +washed." + +To summarize, then, we may say that negativism is apparently the result +of a desire to be left alone, and that muscular resistiveness is a +larval exhibition of the same tendency. But the appearance of this +attitude in such aimless, impulsive acts or habits reminds us strongly +of the dissociation of affect, which was commented on in the previous +chapter. It would seem to be another example of this rather fundamental +tendency of the stupor reaction, not merely to diminish conative +reactions in general, but to reduce their appearance to that of +isolated, partial and therefore rather meaningless expression. + +3. CATALEPSY. The last of the cardinal symptoms to be considered is +catalepsy. It occurred in thirteen of thirty-seven cases, although it +was present only as a tendency in three of these. If we define it as the +maintenance of position in which a part of the body is placed regardless +of comfort, we can see that sometimes it is difficult to differentiate +from the phenomenon of resistiveness with its rigidity. It is most +frequently observed in the hands and arms, perhaps because it is, as a +rule, most convenient to demonstrate the retention of awkward positions +in the upward extremities. But any part or even the whole body may be +involved; for example, Charles O. retained standing positions even where +balance was difficult. This phenomenon is often accompanied by "waxy +flexibility," where the joints move stiffly but retain whatever bend is +given them, like a doll with stiff joints. + +The significance of catalepsy is best studied by considering its +relationship to other symptoms and by noting remarks made by the +patients in reference to it. The most important observations which we +have made seem to indicate that it never occurs with that degree of deep +inactivity which suggests a complete lack of mentation on the part of +the patient. One is therefore forced to conclude that back of this +phenomenon there must be some purpose, some kind of an ideational +content, although this may be of a primitive order. This is demonstrably +true in some cases, at least such as that of Isabella M., who left her +arm sticking up in the air but took it down to scratch herself and then +put it back. Somewhat similarly, Charlotte W. (Case 12), when she was +shown during convalescence a photograph of herself in a cataleptic +state, said that that was when she was waiting to go to Heaven and was +afraid to move. Again she remarked, "I was mesmerized." Josephine G., +who showed only a tendency to catalepsy, said that she feared the devil +would get control of those about her if she moved. Sometimes there is a +development of this symptom from others which seem to be ideational in +their origin. For instance, Charles O. began making flail-like +movements. These passed over into slow circular motions which finally +subsided into the maintenance of fixed position. + +References to hypnotism are not infrequent, and in many cases there is +evidence of a delusion that the posture is desired by those in charge of +the patient. Annie G. (Case 1) said so directly. In retrospect she +explained the holding of her arms in the air by saying, "I thought you +wanted me to have them up." Henrietta B. at one examination kept her +arms raised in the position in which they had been put for a minute and +then dropped them, saying, "Stop mesmerizing me." But she then put them +up again of her own accord and now presented intense resistance to any +motion. Later she extended her arms in front of her and said, "I am all +right," in a theatrical manner. Some patients give evidence in other +symptoms of larval efforts at coperation with the actual or supposed +wishes of the physician and in such cases it is not impossible that +passive movements are interpreted as orders. One must remember in this +connection that the more primitive are the mental operations of any +individual, the more important do signs, rather than speech, come to be +a medium of communication with other people. As an example of this type +we might mention Rose Sch. (Case 6), who flinched from pin pricks +(showing that she felt them) but made no effort to get away. When +somewhat clearer she said that she was "here to be cured." Similarly +Mary D. (Case 4), who showed no catalepsy from ordinary tests, kept her +head off the pillow for a long time after it was raised to have her hair +dressed. She showed such perseveration in many constrained positions. +She too flinched from pin pricks but not only made no effort to prevent +them but would even stick out her tongue to have a pin stuck in it. + +The relationship of catalepsy to resistiveness is interesting but +unfortunately complicated and unclear. In only one of our cases was +catalepsy definitely present without resistiveness, and in one other a +"tendency to catalepsy" was noted without muscular rigidity being +observed. In this latter case, when the catalepsy became unquestionable, +resistiveness also appeared. It is one thing to note this coexistence +and another to explain it adequately. All that we can offer are mere +speculations as to the real meaning of the association of these +phenomena. It may be that the tension of muscles that occurs when +resistiveness is present gives the idea to the patient of holding the +position. There would be two possible explanations for this. We might +think there is a dissociation of consciousness, like that of hysteria, +where the feeling of tenseness in the muscles that comes from the +resistance to gravity is not discriminated from the resistance to the +movements made by the examiner. On the other hand, there might be a +similar dissociation where the perception of contraction in the +antagonistic muscles is interpreted as the action of the examiner in +placing the limb in a given position. This latter view would seem, on +the face of it, ridiculous, inasmuch as its presumes the existence of +two directly opposed tendencies, namely, those of opposition to the will +of the physician and compliance with it. But ambivalent tendencies are +frequently present in psychopathic states, and moreover we find +occasionally some evidence in the behavior of the patient to +substantiate this view. For example, at one stage of the stupor of Annie +G. (Case 1), her arm could be moved without resistance. Then the elbow +would catch and at this moment the position would be maintained. Such +observation is highly suggestive of the resistance being signal for the +catalepsy. In Isabella M. the catalepsy appeared when resistance to +passive movements also developed. On the other hand, when the resistance +became extreme, the catalepsy was reduced, and vice versa. This makes +one think of two tendencies: suggestibility on the one hand, and +opposition on the other. We might presume that when both are present and +equally strong, stiffness with passive movements results as a kind of +compromise, but when there is a greater development of one, the other is +inhibited. + +Such speculations remind one strongly of the psychology of conversion +hysteria and of hypnotism. In some cases of stupor hysterical symptoms +are quite definitely present. For instance, Celia G. began her psychosis +with hysterical convulsions which would terminate with short periods of +stupor. Later the stupor became persistent and during this stage she had +catalepsy (and restiveness as well) in her left arm only. On recovery +from her stupor she complained of stiffness in her hands, which +examination proved to be a purely hysterical difficulty. + +This whole subject is without question obscure and many more and very +careful observations are needed before really satisfactory explanations +can be given for these phenomena. That it is a reaction which is related +to the primitiveness of the mental content and the intellectual deficit +in stupor would seem to be a reasonable view, inasmuch as quite similar +phenomena have been observed in a large number of animals, even among +crustaceans. As a result of our own observations the only thing we feel +at liberty to state with real confidence is that catalepsy is presumably +a phenomenon mental in origin rather than somatic, because it always +occurs in conditions which show other evidence of mentation. + +Whatever may be the origin of the idea of the posture assumed, there can +be little doubt that its indefinite maintenance is a phenomenon of +perseveration. The conception of the position being in the patient's +mind, it is easier to hold it than elaborate another idea. This, of +course, is part of the intellectual disorder in stupor. In fact, it is +difficult to imagine any one whose critical faculty was functioning +coperating in a test for catalepsy. + + + + +CHAPTER VIII + +SPECIAL CASES: RELATIONSHIP OF STUPOR TO OTHER REACTIONS + + +We have described typical cases of benign stupor and isolated certain +interrelated symptoms which, when they dominate the clinical picture, we +believe establish the diagnosis of stupor, regardless of the severity of +the reaction. These symptoms are apathy, inactivity, a thinking disorder +and, quite as important as these, an absorbing interest in death. It is +typical that the patient contemplates his dissolution with indifference +or, at most, with mild or sporadic anxiety. There seems little reason to +doubt that when these four symptoms occur alone, we are justified in +making a diagnosis of stupor. The next problem is to consider the +meaning and classification of cases where these symptoms occur in +conjunction with others. This naturally introduces the subject of +relationship of stupor to other manic-depressive reactions. + +It is probably best to begin with presentation of three such cases. + + + CASE 16.--_Anna L._ Age: 24. Admitted to the Psychiatric + Institute August 21, 1916. + + _F. H._ Maternal grandmother temporarily insane during + illegitimate pregnancy, thereafter a little odd. Mother + high strung and emotional. Father high strung, impulsive + and irritable. + + _P. H._ As a child she was quick tempered, quite a spitfire + and given to tantrums. At the age of 14 she became a + vaudeville actress in Cleveland, which was the home of her + childhood. When 17 she married a Jew, although she was + herself a Catholic. Her husband noted that she was fretful, + sensitive, resentful and quick tempered, although apt to + recover quickly from her rages. Previously healthy, + neurotic symptoms began with marriage, taking the form of + stomach trouble and a tendency to fatigue. Shortly after + marriage an abortion was induced. After being married for + two years she had a quarrel and separated from her husband. + They were reconciled later, but in the meantime she had + been having relations with another man. When 20 an + abdominal operation was performed in the hope of relieving + her gastric symptoms, but no improvement occurred. The + patient after recovery stated that she continued to be + nervous, shaky and dizzy, at times trembling when going to + bed at night. Two years later, however, she took up + Christian Science and showed objectively some improvement + in her health, although according to her later accounts she + continued to feel somewhat nervous and fatigable. Her + husband stated that at this time she also began to ponder + much about such questions as the difference between life + and death, what "matter" was, and also studied "grammar" + and "etiquette." According to the patient some five or six + months before admission she began to have peculiar + sensations following intercourse--a feeling of bulging in + the arms, legs and back of the neck. One evening after an + automobile ride there were peculiar sensations on her right + side like "electricity" or as if she were inhaling an + anesthetic. She gasped and thought she was dying. Two + months before her admission she went with her husband and + his family to a summer resort where she felt increasingly + what had always been a trouble to her, namely, the nagging + of this family. + + Just before her breakdown, because she went daily to the + Christian Science rooms in order to avoid the family, they + suspected her of immorality and accused her of going to + meet other men. Even her husband began to question her + motive. Retrospectively the patient herself said that she + now felt she was losing her mind and did not wish to talk + to any one. At the time she told her husband that she felt + confused and as if she were guilty of something and being + condemned. Repeatedly she said she knew she was going to + get the family into a lot of trouble. Once she spoke of + suicide, and for a while felt as if she were dying. Finally + she became excited and shouted so much that she was taken + to the _Observation Pavilion_, where she was described as + being restless and noisy, thinking that she was to be + burned up and that she had been in a fire and was afraid to + go back. + + _On admission_ she looked weary and seemed drowsy. + Questions had to be repeated impressively before replies + could be obtained, when she would rouse herself out of this + drowsy state. She seemed placid and apathetic. She said + that nothing was the matter, but soon admitted that she had + not been well, first saying that her trouble was physical + and then agreeing that it had been mental. When asked + whether she was happy or sad, she said "happy," but gave + objectively no evidence of elation. Her orientation was + defective. She spoke of being in New York and on + Blackwell's Island, but could not describe what sort of + place she was in, saying merely that it was "a good place," + or "a nice country place," again "a good city." Once when + immediately after her name L. had been spoken and she was + asked what the place was, she said "The L." She knew that + she had arrived in the hospital that day but said that she + had come from Cleveland, and to further questions, that she + had come by train, but she could not tell how she reached + the Island. She claimed not to know what the month was and + guessed that the season was either spring or autumn + (August). She gave the year as 1917, called the doctor "a + mentalist," and the stenographer "a tapper," or "a mental + tapper." She twice said she was single. When asked directly + who took care of her, said "Mr. Marconi," who she claimed + at another time had brought her to the hospital. To the + question, who is he? she replied, "Wireless," and could not + be made to explain further. That night she urinated in her + bed, and later lay quite limp, again held her legs very + tense. + + For five days she remained lying quietly in bed for the + most part, although once she called out "Come in, I am + here," "Jimmie, Jimmie" (husband's name). Several times she + threw her bed clothes off. Otherwise she made no attempt to + speak and took insufficient food unless spoon-fed. At one + examination she looked up rather dreamily but did not + answer. When shaken she breathed more quickly and seemed + about to cry but made no effort to speak. When left to + herself she closed her eyes and did not stir when told she + could go back to the ward. She was then lifted out of her + chair and took a step or two and stopped. Such urging had + to be repeated, as she would continue to remain standing, + looking about dreamily, although finally when taken hold of + she whimpered. When she got to the dining-table she put her + hand in the soup and then looked at it. So far there is + nothing in this case atypical of what we would call a + partial stupor. The cardinal symptoms of apathy, + inactivity, with a thinking disorder, are all present and + dominate the clinical picture. There is, further, the + history of a delusion of death during the onset of the + psychosis. Had her condition remained like this, there + would be no difficulty in classifying the case, but other + symptoms appeared. + + Five days after admission she was restless, somewhat + distressed, and announced that she wanted to talk to the + physician. When examined, the distress, with some + whimpering, continued. She asked the doctor not to be harsh + to her, frequently said there was something wrong and began + to cry. A normal interest appeared only once, when she + spontaneously said she wanted to see her relatives. A most + interesting feature, however, was a certain perplexity that + now appeared. She spoke of this directly: "I do not know + what it is all about. I know you are a doctor, that is all. + I don't know whether I passed out and came back again or + what--I don't know what to make of it." She also felt + confused about her marriage--"There is where all the mixup + is. I was married when I was 16." She was reminded that she + had said she was single, and replied "I am single." Then + where is your husband? she was asked. "He must be dead." + She recalled the examination on admission and remembered + some of the questions that she was asked then, also knew + that she had been at the Observation Pavilion and that she + had reached this hospital by boat. On the other hand she + still claimed that the year was 1917, and in connection + with the delusion of having died was quite unclear as to + the time. She said that it seemed as if she had died many + years ago and that she had come to the hospital years ago. + She also spoke of having died at a summer resort the year + before. When asked for her age, she said that she must be + very old, but on the other hand claimed that she was + supposed to die and to come to the hospital when she was 26 + (two years more than her actual age). + + Her psychosis continued from then on for about ten weeks. + She soon began to feed herself, but otherwise for most of + this period remained quietly in bed, looking about a good + deal, although showing no particular mood reaction until + questioned, when she was apt to make repeated statements + about her perplexity--that she did not know what it was all + about, every one had mixed her up, everything was so + strange, "my head is mixed up, I am trying to straighten + things up." She frequently when interviewed became + lachrymose and often with her subjective confusion there + was considerable anxiety. Another unusual phenomenon for a + stupor patient was that she was frightened at a thunder + storm. On the whole, however, her apathy and indifference + were quite marked. For instance, during the latest phase of + her psychosis, when the nurses would sometimes make her + dance with them, she did so but without showing any + interest and not until immediately before her recovery did + she begin to speak spontaneously to any extent whatever. A + marked difference from the ordinary stupor was that this + apathy was invariably broken into when she was questioned + and ideas came to her mind, the nature of which seemed to + be essentially connected with her perplexity. + + Not only did ideas appear more frequently than one meets + them in stupor cases, but they were present in greater + variety. The dominant stupor death idea was, it is true, + almost constantly present, but it did not come to the + direct and unequivocal expression which we are accustomed + to see in typical stupor. She did not say "I am dead," or + "I was dead," but it was always "It seems as if I were + dead," or "I think I must have died," or some such dubious + statement. Other ideas were that her mother was dead and + had been put into a box. She frequently gave her maiden + name and said that she lived in Cleveland with her mother + and that this was Cleveland. At times she thought she was + engaged and was going to be married to her husband shortly. + Again there were notions that her husband had married + somebody else or that some harm was going to come to him. + Sometimes she thought that her mother's name was her own, + that is, Mrs. L. The hospital once seemed like a convent to + her. + + Her subjective and objective confusion seemed quite + definitely to be connected with the insecurity and + changeability of these ideas. It appeared as if insight and + delusion were struggling for mastery in her mind, so that + reality and fancy were alternately, even simultaneously, + possessing her, and that this gave her the feeling of + perplexity from which she suffered. Once when she remarked + "It seems as if I had been dead all the time," she was + questioned more about this and replied, "Well, sometimes I + thought I was dead, at other times it seemed as if I + wasn't." In answer to a direct question about her feeling + of confusion she said "I don't know. I know I have lots of + good friends, they all want to help me and it seems as if + everything got mixed up between the L.'s (her married name) + and the G.'s (her maiden name)." This was apparently an + elaboration of the wavering ideas she had about her + singleness or her married state. Once after referring to + her husband as her sweetheart whom she was to marry, and + immediately thinking that perhaps he had married somebody + else, she added, with a sigh, "The more this goes on, the + more mixup." In short, any question, even on some + apparently neutral topic, seemed to start up conflicting + ideas in her mind, the inconsistency of which she + recognized without being able to control their appearance. + Hence, whenever she was spoken to, she became perplexed and + distressed. + + Her orientation gradually improved so that, although it + remained vague, it was no longer glaringly inaccurate. Then + quite suddenly she one day came to a nurse and asked how + long she had been in the hospital. When told, she remarked + that it seemed as if she had spent the whole winter there. + She was examined at once and found to be quite clear and at + first in good control of her faculties. She remembered a + good many of her ideas, in fact was able to elaborate a + little from memory on what had already been reported from + her utterances during the psychosis. The recovery was not + immediately complete, however, for at this examination, + when told that she had constantly given her maiden name, + she became distressed and said the physician was trying to + mix her up and was reluctant for this reason to discuss her + ideas. This soon passed, however, and within a few days + she was quite normal and had remained so for some months + after her discharge from the hospital, when last seen. In + fact, according to the husband, she was in better mental + and physical health following the psychosis than she had + been for years. + +Essentially, then, this case shows what was at first a typical partial +stupor, but soon became complicated by a tendency for questioning to +provoke rather a free flow of ideas and a distressed perplexity. This +symptom of perplexity soon grew to dominate the clinical picture, so +that the psychosis was really a perplexity ushered in by a brief stupor +reaction with a background of stupor symptoms running through it. The +second case shows similar tendencies but different from the one whose +history has just been cited in that the perplexity was never complained +of by the patient herself and that her emotional reactions were more +marked and varied. + + + CASE 17.--_Celia C._ Age: 18. Admitted to the Psychiatric + Institute May 2, 1914. + + _F. H._ Four years after this attack her mother was a + patient in the hospital with an atypical manic-depressive + psychosis from which she apparently recovered. + + _P. H._ The patient herself was described by superficial + observers as being bright, sociable, well-informed and very + ambitious. + + When 18 years of age she was working very hard preparing + for some examinations, and worried lest she should fail in + them. Some years later the patient accounted for her + psychosis by saying she had a quarrel with her sister, + immediately after which she began to feel depressed. The + anamnesis states that she was slow, complained of not being + able to think and feeling as if she had no brain. She was + sent to a general hospital, where she was apprehensive, + wanted her mother to stay with her and one night called out + "Mother." + + The case being recognized after a few days as a psychosis, + she was sent to the _Observation Pavilion_, where she was + described as jumping about in bed in a jerky, purposeless + manner, resistive when anything was done for her, and mute. + Her sister reported that when she visited her the patient + said "Go away, I am dead." + + _On admission_ she looked dazed, stared vacantly and had a + tendency to draw the sheet over her. When put on her feet + she let herself fall limply. At times she became agitated, + sobbed and cried loudly, especially when attempts were made + to examine her physically, or, when she was asked + questions, she scarcely spoke. + + Her psychosis lasted but a little more than three months + under observation and was characterized by the following + symptoms: She was usually in bed, staring blankly or + appearing otherwise quite indifferent and apathetic, but + not infrequently, especially during the first few weeks, + she was quite restless, resistive, whined and suddenly + appeared startled or distressed with no occasion for this + reaction in the environment. Rarely she was suddenly + assaultive. When attempts were made to examine her, she was + frequently mute or would repeat the question with a rising + inflection, not getting anywhere, or would say, "What shall + I say," or "I, I----" never finishing her sentence. After + orientation questions she might say "This is--this is--this + is----" all this, together with a rather perplexed + appearance, gave the impression of considerable + bewilderment, but at no time did she complain of + autopsychic perplexity. It was difficult to judge of her + orientation on account of her failure to answer questions, + but it soon appeared that she knew the names of the nurses, + for she sometimes called them spontaneously by name. She + always ate reluctantly. + + During these examinations, however, other symptoms often + appeared. When she was talked to, she was apt to indulge in + depressive statements and show considerable distress. Such + remarks were: "I must confess my guilt," "I am a bad girl + and I have to face my guilt," or "I have sinned," or, + standing up with a dramatic air, "I must stand up and tell + the truth." Once she said, "It is too late to live now." + She spoke of having lied and usually would not say what + about, but once on questioning replied "I said I would not + tell what happened here." She was asked, What do you mean? + and answered "I took my oath not to tell anything." Pressed + further she said that the nurses poisoned her. Another time + she said she was in prison. To her aunt who visited her she + said, "I am a prostitute," and once she remarked to the + doctor, "I have killed my honor," and on another occasion + in the middle of the night she called out, "Chinatown + Charlie, come here." She thought the doctor was her + brother. + + Most of these statements were associated with painful + emotion, but there were a few occasions when an element of + elation cropped out. Thus on one occasion she laughed, + another time gripped the doctor's pad and tried to read it. + When the nurse laughed, she made a funny grimace at her and + said "Why do you laugh?" Again she once sang two songs, but + after the first verse got stuck and kept repeating one + word. + + At the end of three months she improved rather rapidly and + was in a condition for discharge as "recovered" a month + later. Retrospectively she said that she recalled feeling + guilty, thinking that her mother was dead, having been + killed by the patient as a result of worrying over the + latter's failure in her examinations and refusal to eat. + She remembered, too, that at times she thought the building + was burning. Some things like "Chinatown Charlie" she + denied remembering, although she had a good recollection + for the external facts throughout the psychosis. Her + insight was superficially good, but she was reluctant to + discuss her psychosis, in fact claimed that she had been + made more of a lunatic by coming to the hospital than she + was on admission. + + Some five years later she had another somewhat similar + attack, again following a quarrel, this time with a fellow + employee. In this second psychosis, however, manic elements + were much more prominent. + +Here again, then, we have the symptoms of apparent apathy, inactivity, +and similar ideas of death, but the thinking disorder was possibly not +very profound, inasmuch as she had a good memory for external events. +Her ideas, too, are much more florid than those which we customarily +meet with in stupor cases, but the most marked peculiarity was that +this "stupor" was liable to constant interruption, either spontaneously +or as a result of questioning, which always produced a mood reaction. +She was apathetic only so long as she was left alone. In other words, +whenever an effort was made to test what seemed to be apathy, the +evidences of it disappeared. + +The third case to be considered is somewhat like that of the first, Anna +L. (Case 16), in that with the inactivity and apathy there was a +coincident subjective perplexity. The apathy, however, was less marked +than in the case of Annie L. + + + CASE 18.--_Catherine M._ Age: 24. Admitted to the + Psychiatric Institute November 10, 1913. + + _F. H._ Information as to the family is confined to the two + parents. The mother, who was frequently seen, seemed to be + a natural, sensible woman. The father, on the other hand, + had been alcoholic all his life, had had two convulsions + while drinking, and had little respect from any member of + the family, including the patient. + + _P. H._ The patient was said always to have been healthy, + from a physical standpoint, although never robust. She got + on well at school, and then worked first as a stock girl + and later as clerk in a department store, where her work + was efficient and she advanced steadily. As a child she + played freely with other girls but little with boys. As she + grew older she moved about socially a little more, made the + acquaintance of men as well as of girls, but never cared + much for the former and had no love affairs until she met + her husband. She was never demonstrative but always rather + quiet and modest. Occasionally she spoke of thinking that + people talked about her, but the informant doubted if she + brooded over this, because she was not of a worrying + disposition. Considering the ideas which appeared in her + psychosis, it is striking that in her normal life she was + rather antagonistic towards her father on account of his + alcoholism and the crudity of his speech and manners. + + When she met her husband she liked him from the first, + although she at no time became really demonstrative. They + were engaged for a year, during which time she agreed to a + postponement of three months for the marriage, which was + suggested by her mother. For some time before this event + she was working harder than usual and seemed a bit worn + out. She ceased working a month before marriage and + improved physically, although she became rather nervous, + that is, she was more easily startled, an accentuation of + what had been a characteristic for some years. Her husband + stated that at this time she became fearful of the + approaching marriage relations and asked him to be kind to + her in this respect. She was married a year before + admission. For two and a half months she refused + intercourse and visited her mother's home a great deal. She + finally submitted. She was quite frigid but became pregnant + at once. Her abnormality then became apparent. She kept the + fact of her pregnancy to herself for several months and + then when she told her mother wanted to have an abortion + performed. Neurotic symptoms appeared. She became sensitive + with her husband, correcting his grammar, and cried easily. + She also began to be anxious about the approaching + childbirth, and with this became more religious. + + For the first few days after the delivery, she was fussy + with the nurse so that two in succession had to be + discharged. On the fifth day she woke up and seeing a nurse + lying on the couch beside her bed thought the latter was + colored. On the seventh day she had a dream in which she + thought she "nearly died in childbirth." Then she began to + talk of dying for her baby or of having two babies, of + dying herself and rising again after Easter Sunday. She + became antagonistic to her husband and with this excited + and confused so that she was taken to the Observation + Pavilion. + + On _admission_ she looked pale and exhausted, had a slight + temporary fever and a coated tongue. Her orientation was + usually vague but sometimes she gave fair answers. Her + verbal productions were rather fragmentary and with the + exception of some repetitions there did not seem to be any + special topics which dominated her train of thought. + + For some days the great weakness and the slight fever + continued, and then, as it gradually cleared up, there came + a change in her mental condition that settled into the + state which characterized the rest of her psychosis. She + talked less and was often quite inactive, frequently lying + with her eyes closed for long periods, or sat or stood + about. Such movements as she made were slow and languid. + Her expression was either blank, absorbed, or gave the + appearance of peculiar appealing perplexity. This last was + not infrequently associated with a rather sheepish smile. + She was never resistive and always ate and slept well. With + the exception of a few times she did not soil herself. The + most interesting feature of her mood reaction was that in a + general setting of a slight perplexity there appeared at + times and evidently associated with definite ideas, changes + in her emotional state. Sometimes this was a matter of + distress or of mild ecstasy, sometimes she became markedly + blocked. There was at no time any frank elation, but often + an appropriate smile, that is, appropriate to the situation + and to the thought to which she was giving expression at + the time. Then, rarely, there were sudden bursts of + peculiar conduct, such as throwing herself on the floor or + running down the hall. When questioned as to her motive for + these acts, she would flush, look perplexed and apparently + be unable to explain them. + + Her verbal productions dealt with a rather limited range of + topics which can be briefly summarized. As in the other + cases, the reader will notice that the bulk of these ideas + are of a kind not usually prominent in the typical stupor + cases. Many of her thoughts seemed centered around her + husband. She always knew him when he visited her, but in + her thoughts there was a constant change as to his + personality. She persistently confused him with the + physicians, with her father, and with God, and one remark + is typical, "I thought he was God, priest, doctor, + lawyer--well, I wanted to go to Heaven; I thought he would + still be my husband; I always hoped that I would be home in + Heaven." Not unnaturally with this confusion there were + doubts about her marriage. People said her marriage was + wrong and her husband bad. Frequently she thought he was + dead, or voices informed her that she was not married to + him, or that he was the devil in Hell. In this connection + she also said that people called her a whore, or it seemed + as if she were accused of not being married. + + As prominently as appeared the ideas of the invalidity or + impossibility of her marriage, to the same extent did her + father assume an important rle for her. As a rule he + appeared in religious guise as God, but often he was the + doctor--"I knew my father at home and my father in Heaven; + which God do you mean? did you say God or father?" At times + she spoke of being in Heaven and that God seemed to be God, + doctor or priest. In this connection there were ideas of + being under the power of some one, God, devil or father. + + As is usually the case where strong interest is expressed + in the father, ideas of the mother being dead occurred, + although in the frankest form she reported them as dreams; + for instance, one night she woke up screaming, said that + she had dreamed that her mother was dead and her sister + dying. That, in the psychoanalytic sense, this represented + a removal of a rival, making union with her father easy, + appeared in the statement that her father was dead but that + she had dreamed he had come to life again for some one + else. When asked what she meant, the question had to be + repeated several times, then she said "My mother died, my + father and mother had a quarrel." There is more than a + suggestion here of a difference in the significance of + death, in so far as it concerned the two parents. The + mother dies and remains dead, that is, she is gotten rid + of. The father dies but takes on a spiritual existence and + comes to life again, a frequent method in psychoses for + legitimizing the idea of union with the parent by + elimination of the grossly physical. + + There were strikingly few allusions to the plainly sexual. + She spoke of being married to the doctor, and even went so + far as to say that they belonged together in bed. On + another occasion she called him "darling." Once she + reported that it was said that she was going to have babies + and babies and babies. These references were, however, + quite isolated, so that the erotic formed a very small part + of her productions. + + Delusions of death, we have seen, are the most constant + content of true stupors. In this case they were present but + distinctly in the background. She spoke quite frequently of + being in Heaven. She also talked of being crucified. Once + she said "I died but I came back again." This last + utterance was rather significant in that frankly accepted + ideas of death were unusual; for instance, she would say + sometimes, "I think I am in Heaven, again not. It confuses + me, but I know I am in Heaven." + + In general, then, her ideas were, on the whole, not at all + typical of stupor but much more like those met with in + other manic-depressive conditions. Correlated with this was + an unusual mood picture. Quietness and apparent apathy of + the patient were interrupted by little bursts of emotion, + and throughout the psychosis there was a coloring of + perplexity. Not only was this last objectively noticeable, + but she spoke very frequently of it and always in + connection with the inconsistency of the ideas in her mind + which puzzled her. For instance, in speaking to the doctor + she said "I think of you as Bill (her husband's name) + sometimes--I get confused thinking of Bill as God, doctor, + lawyer, priest." Again, referring to her husband, she made + these curious statements: "They seemed to speak of him as + being in the wrong--the right--it seems that the right + devil is the wrong one for me--they say he is not the right + one for me; they say he went wrong from the time we were + married." Again, she said that she did not know who her + father was, and went on: "It puzzles me, this father + business, I knew my father at home and my father in + Heaven." Again, "Which God do you mean? Did you say God or + father?" A hint as to how this subjective confusion made + the environment seem uncertain comes from the statement, + "You looked like the devil and yet you were God." + + Distress and anxiety appeared not infrequently and always + appropriately. The distress was usually occasioned by an + idea of injury to others, as when she cried over the + fancied accusation of drowning her husband and mother; or + in connection with accusations of herself, such as when she + reported "They called me a whore." As has been stated, + there was never any frank elation, but an element of + pleasurable expansive emotion was frequently present in + connection with her religious utterances. This came + particularly when she spoke of union with her father as + God. She seemed to swell with ecstatic emotion. It was + especially well marked once when she threw herself on the + floor and when asked what she was trying to do replied, "I + want to do what God wants me to do, drop dead or anything + at all." Perhaps the most unusual affective reaction was a + blocking which occurred when certain topics appeared. This + is a phenomenon quite unusual for stupor, where speech + seems to stimulate and arouse the patient as a rule. One + got the impression that ideas tended to come into this + patient's mind which were painful enough to disturb her + capacity for connected thought. A good example of this + reaction was when she was speaking of her father having + died and coming to life again. On being asked what she + meant, she became quite blocked and the question had to be + repeated several times, when finally the apparently + unrelated statements appeared: "I dreamed my mother + died--they had a quarrel." Who had a quarrel? she was + asked, and replied "My mother and father." Apparently her + thinking about her father coming to life for some one not + her mother stimulated deeply unconscious ideas concerning + the separation of her mother and father, and her taking the + mother's place, and these ideas were sufficiently + revolutionary to upset her capacity of speech for the time + being. + + She recovered completely about six and a half months after + her admission. + +If we consider together the common features of these three cases, we see +that they resemble stupors only in the presence of inactivity and +apparent apathy. It is true that death appears in the ideational content +but not with that prominence, bordering on exclusiveness, which +characterizes such delusions in the true stupors. These three patients +give one the impression of being absorbed in thoughts that have many +variations. It seems as if they had difficulty in grasping the facts of +the environment, while feeling at the same time the vividness of the +changing internal thoughts, hence a confusion develops which is either +subjective, objective, or both. It is probably the introversion of +attention which gives rise to the apparent apathy, because normal +emotions emerge as part of our contact with reality around us. This lack +of contact with the environment leads also to inactivity. If one's +attention and interest is turned inwards, there can be no evidence of +mental energy exhibited until the patient is roused to contact with the +people or things about him. It is noteworthy that in these cases +emotional expression emerged when the patients were stimulated to some +productiveness in speech. + +These conditions really constitute a different psychosis in the +manic-depressive group, essentially they are perplexity states such as +have recently been described by Hoch and Kirby.[7] Not infrequently we +see exhibitions of this tendency in what are otherwise typical stupors. +For example, Mary F. (Case 3) (the third case to be described in the +first chapter), showed for a few days after admission a condition when +she was essentially somewhat restless in a deliberate aimless way. At +the same time she looked dazed or dreamy. With this restlessness she +appeared at times "a little apprehensive." Although she spoke slowly, +with initial difficulty she answered quite a number of questions. Her +larval perplexity was evidenced by the doubt expressed in a good many of +her utterances, such as, "Have I done something?" "Do people want +something?" "I have done damage to the city, didn't I?" When asked what +she had done, she said, "I don't know." She asked the physician, "Are +you my brother?" and when questioned for her orientation said, "Is not +this a hospital?" The atmosphere of perplexity also colored the +information which she did recall correctly; for instance, when asked her +address, she said, "Didn't I live at ----?" then giving the address +correctly. + +As stated in Chapter V dealing with the ideational content of stupor, +one has to look on the delusions of patients as symptoms subject to +analysis and classification just as truly as the variations in mood or +intellectual processes, in fact they should be subject to the same +correlation as are the mental anomalies which are usually studied, +particularly if we are to understand these psychoses as a whole. Let us, +therefore, consider the death ideas in the three cases studied in this +chapter. We find that, as in the ordinary stupors, there are delusions +of death, also of mutual death (with the father), but there is a +tendency to elaboration so that the death is only part of a larger +OEdipus drama, the rest of which is usually lacking in stupors. Here it +is present. So we have thoughts of the death of the mother or husband, +another rival, considerable preoccupation with Heaven, and also erotic +fancies. + +We find in manic-depressive insanity a tendency for more or less +specific ideational contents with different types of the psychoses.[8] +For example, there are religious and erotic fancies or ambitious schemes +dominating the thoughts of manic patients, fears of aggression and +injury met with in anxiety cases, and so on. In stupors, death seems to +be a state of non-existence with other meanings lacking or only hinted +at occasionally. When it tends to be elaborated, it leads over to +formulations suggesting personal attachments and emotional outlet, and +then we are apt to find interruptions of the pure stupor picture. For +example, Charlotte W. (Case 12), whose case has been described, thought +much about being in Heaven and ended with a hypomanic state. Atypical +symptoms appear just as constantly in these cases, as do the atypical +ideas. In other words, the thought content is definitely correlated with +the clinical picture. + +As the clinical pictures show the relationship of stupor to other +psychoses, so there is also a correlation with varying formulations of +the death fancy. We are now in a position to define more narrowly what +death means in stupor. It is an accepted fact, a Nirvana state. When +death means union with God or appears in other religious guise, manic +symptoms tend to develop. When it is unwelcome and appears as "being +killed," we find anxiety symptoms. A patient can conceive of death +variously and have various clinical pictures. A knowledge of the +metamorphoses of ideas and their relationship to other symptoms enables +us to understand such cases, that, without this key, seem confused and +lawless jumbles of symptoms. Such theories tend to justify the view of +essential unity of the manic-depressive group. + +It would be instructive at this point to consider another case which +illustrates beautifully how a stupor reaction may crystallize out of +other manic-depressive states when attention has become focused on +personal death. This patient went through four phases while under +observation. First, while showing a perplexed expression but with fair +orientation, she gave utterance to erotic and expansive fancies. She was +restless, somewhat intractable and gave the impression of brooding over +her imaginations rather than luxuriating in them. In other words, her +condition seemed to be more that of absorbed than active mania. Second, +these same ideas, somewhat reduced, continued in an apathetic state +while impulsive symptoms developed: She began to shout like a huckster +to be taken to Heaven and made numerous affectless, suicidal attempts. +Third, came a true stupor and, fourth, a period of recovery when the +stupor symptoms all disappeared but insight into the falsity of her +ideas was lacking. + + + CASE 19.--_Celia H._ Age: 19. Admitted to the Psychiatric + Institute October 22, 1913. + + _F. H._ The father was living; he always drank, and + especially in later years contributed little to the support + of the family. The mother was living and said to be + normal, while a brother was coincidentally insane, with a + recoverable psychosis. + + _P. H._ The mother stated that the patient was bright at + school, enjoyed company and going out, had a droll wit, was + not at all seclusive, no dreamer, helped to support the + family and was efficient. She was very much attached to her + brother and once said that if anything should ever happen + to him she thought she would die. She also cared much for + her older sister, with whom she worked, and for her mother. + + Three months before the patient's admission her brother + became depressed, mute, seemed worried, cried at times. He + was sent to the country. Two months before admission, when + the mother and the patient went to bring the brother to + town, and while they were at the station, he suddenly tried + to throw himself under a train but was restrained just in + time. The patient appeared intensely frightened, but did + not talk. In fact, she seemed somewhat bewildered and at + once became dull. "Her movement and manner were much as at + present." + + When the patient was able later to give a retrospective + account of the onset, she claimed that for some months + before this incident she saw that her brother was losing + his mind. She worried about this as well as about her work, + and felt worn out. She said that when the brother tried to + throw himself under the train she was terrified and could + not speak or move, and that her mind got upset at once, "I + lost my memory." The others forgot her and left her alone + on the platform. Strangers put her on another train and she + knew nothing until she arrived at home. + + The mother added that at the time when the incident with + the brother happened, the patient was menstruating and that + this ceased at once. + + At home she sat about inactive and did not seem even to + worry. Whenever any one asked her about her brother she + replied that he was dead. For two weeks before admission + she said she was rich, that she owned all the property + around. She also said she was married to Mattie S. In this + connection the mother says that a foolish neighborwoman, + the mother of Mattie S., told the patient since her + sickness, by way of encouragement, that she should marry + her son (the man mentioned). Finally, the patient also + expressed the idea that her mother was a stranger, that her + real mother was dead. + + At the _Observation Pavilion_ she was described as + wandering about in a perplexed manner, restless, resistive, + answering few questions and in a low tone. She said things + were "changed," also that she was married to S. + + _Under Observation:_ 1. For about ten days the patient's + condition may be described as follows: The most striking + feature was a certain restlessness with insistence on going + out, with complaints that this and that had been done to + her and with senseless struggling when interfered with. But + all the motions were slow, the whole restlessness aimless + and impulsive. Although the facial expression was somewhat + perplexed, it changed remarkably little, and whenever asked + whether she felt worried or anxious she denied it, and, + indeed, there was only a suggestion of perplexity in her + face. + + The ideas which she expressed during this time referred to + a few topics only, namely, marriage, wealth, and State + prison. The remarkable fact was that all the ideas about + marriage and wealth were spoken of, often immediately, + again after some interval, now in the positive and again in + the negative sense. Thus she said she was "Mrs. S.," again + "You kept me from marrying Mattie S.," or "I am not + supposed to be here--I am a married person," but also "You + kept me from getting married." Or, "Take off that black + dress, I am a bride," again "You have taken my bridal crown + off my head," "The steamboats (seen from the window) are + mine--I own the ships, the oceans, the land and + everything," or again, she said she owned a kingdom, was + Sh.'s wife, a wealthy woman, had millions. Sometimes she + connected the millions with Sh. "Sh. has millions." On the + other hand, she said: "I owned all this before I came. I + have nothing now," or "You have taken the regal crown from + me," "You have made a pauper of me," "They did it again, + they took my millions away," or "Let me out, they are + taking my millions." + + Other ideas throughout this period were that this was a + State prison, that "bums" were around. On one occasion she + said "You can't put down all these things and make me out a + lunatic." At another time she pulled a patient's hair and + then said without fun: "I fixed the leading lady of the + dump--she knows a lot, but she does not know enough to + keep her soup cool." When questioned about this woman (who + at the time while cleaning had moved the furniture), she + said: "I don't know where I am at." + + The orientation during these days was not markedly + disordered, when one got down to it. Although she spoke of + State prison, it was always found she knew the name and the + location of the hospital, the names of people around her, + even the date approximately, though she was apt to say it + was February 19, 1492, or October 19, 1492, or when the + year was not given as 1492 she said it was "1900 or 1901, + or 1911 or 1912." Frequently, however, it was hard to hold + her attention. + + Finally, it should be mentioned that she very often wet + herself in bed or when standing, even when standing in the + examining room. + + 2. The period following and lasting for two months may be + given in the form of abstracts of each note. + + _November 7:_ Yesterday quiet, though struggling. Says + without change of expression, "I saw four people killed--my + mother, my brother, a priest, and my dear sister--we were + all killed." Again, "I don't know where I am," "I am an + orphan, my people died" (without affect). + + _November 20:_ More quiet recently, says little, but tries + to get out when brought to the examining room, but when not + prevented walks slowly about as before, says she wants to + go home. Looks peculiarly blank. + + _November 23:_ Has remained quiet, says she is Dr. M.'s + wife. But when told she is not married, she agrees. Her + attitude towards the doctor is not changed, but when the + nurses talk to him, she has tried to prevent it. + + _December 6:_ Has remained quietly in bed, gazing about. + Slow in motion. She has spoken of being Dr. M.'s wife, + again President Wilson's wife, again "Vincent (brother) is + the ruler of the world." + + At interview says little, seems abstracted, answers briefly + in low tone. (Does anything bother you?) "No." (Are you + natural?) "Yes." (Who are you?) "C. H." (correct). (You + said you were the President's wife?) "No." (Are you + married?) "No." (You talked about the kingdom?) "I own the + kingdom" (affectlessly). (Where is Vincent?) "Here." (Have + you heard him?) "Yes." (What did he say?) "Nothing." (Is + he all right?) "Yes." (Where is your mother?) "Home." (Why + don't you go home?) "I can't." (Why not?) "I can't." (Why + not?) "The family tree is broken, the Cardinal." (What + about him?) "Nothing." (Retrospectively she said later she + thought her brother was a cardinal.) + + _December 8:_ When her mother visited her she said "It is + about time you come--I thought you were dead." Has walked + down the hall "looking" for her dead cousin. When asked if + she wanted to see her brother, said, "Ain't he dead?" + + _December 12:_ Cries out in an affectless tone like a + huckster, "Father MacN., take me to Heaven," repeating this + over and over. + + _December 15:_ Quiet as a rule, then for a time at the + door, pulling at it and with whining voice but affectlessly + saying "Give me the key--I want to go to the river--you + can't keep me from Heaven--it is either Heaven or the + river, give me the keys, give me the keys, open the door," + "The niggers are taking possession." To the physician to + whom she had claimed to be married, often repeats "You + don't belong to me, I don't belong to you." (What about the + niggers?) "A band of niggers, that is all they are." (Are + the nurses niggers?) "That is all they are." Asked about + her people, she says "They are in Heaven." (Where are you?) + "I am in Heaven" (without change of expression). Again, + when asked where her people are, says "At home." Then she + went willingly back to bed and was quiet. In the afternoon + she again went to the door and tried to get out. When + questioned, she said "I don't want to be an animal," + "Everybody is making an animal of me" (pointing to an + animal picture). Then again, while trying the door, repeats + in the same affectless manner that she wants to go "to the + river," "to the bottom of the river," "to Heaven to see my + mother." This last was said in a whining tone, with some + tears. She kept turning the knob, tried to get the keys, + and struggled impulsively when prevented. + + _December 23:_ Though quiet on the whole, when a visitor + came yesterday, she ran after this woman saying "I want my + generations," and clung to her, and to-day at intervals + keeps talking about wanting to see her generations but is + often quiet. (Retrospectively she said she wanted to see + all her ancestors from the beginning of time.) + + _December 27:_ Of late often talks affectlessly about + wanting to die or wanting to go to Heaven, struggling + impulsively to get medicine away from the nurses, asking + for poison, trying to drink her own urine, or even the + fluid in the bed pan after she had been given an enema, all + evidently with suicidal intent. + + _December 28:_ Still constant, impulsive and apparently + affectless attempts at suicide, tries to get medicine away + from nurses, to get the fire extinguisher bottles, a bottle + of ink, etc., struggling when prevented. + + But when examined quiet, even smiles at a joke. When + questioned, denies feeling either worried or depressed. She + said she wanted to go home. She gave poor attention to the + questions. Later she threw a wet sheet over a patient and + laughed (this is rare). Later she slapped another patient. + Again she began to talk about wishing to go to the grave. + Calls Dr. M. "Uncle John." + + _December 30:_ Talks either about wanting to die, or + wanting to go to Heaven, or wanting to go to Ireland, all + this as usual in an affectless way. Calls Dr. M. "Uncle + John." Keeps shouting "Take me to Ireland." + + _January 9, 1914:_ Often quiet in bed, again goes to door, + talks about wanting to go "to Heaven" or "to Ireland." On + the whole, says little. + + It seems, then, that the transition was not abrupt, that + many traits of the first period remained, but that she was + on the whole much quieter, with the exception of some + spells when she insisted on going out or killing herself. + At such times she showed an affectless, impulsive + excitement. Whether there was an element of perplexity then + is not clear from the notes. The topics of which she spoke + also changed. The idea of wealth was rarely expressed, also + the idea of marriage was much in the background, but + prominent ideas were those of death, Heaven, killing + herself, going to Ireland--all of which she produced in an + affectless way. It should be added that she persistently + wet and soiled during this, as well as in the first period. + + 3. Then followed three months of greater inactivity. She + lay in bed gazing, moving very little, not even when her + meals were brought. She answered but little and + consistently wet and soiled. This state lasted from about + the middle of February until the beginning of April. + + 4. From this stuporous state she emerged during the next + four weeks, the awakening being associated with persistent + efforts to arouse her. She then was, for six or seven + weeks, nearly normal, so far as her mood went, but had a + tendency to cling to some of her ideas and was + overtalkative. Her memory for the earlier phases of the + psychosis was good, as she recalled not only many external + events but most of her false ideas. She said, however, that + her mind had been a blank for the third stage and she + remembered nothing of it. At the end of this time she + cleared up entirely and was discharged as "recovered." She + continued well for some months, during which she was + occasionally examined. + +This case gives an excellent example of the relationship of stupor to +other manic-depressive reactions. She begins with an absorbed state, +showing elements of perplexity and mania. With this there are expansive +ideas but, also, statements about losing everything and being in prison, +which suggest abandonment of life. Next, with increasing apathy, she +begins to speak of death and soon makes impulsive suicidal attempts. +Evidently her mind was becoming more and more focused on death and with +this there was an appropriate emotional change. She was either apathetic +or the affect exhibited itself in pure impulsiveness. Then comes the +stupor, when all ideas disappear and mentation is reduced or absent. +When the stupor lifts, the original ideas appear not only in memory but +occasion a wavering insight. It is appropriate that she recalled all of +her psychosis fairly well with the exception of the pure stupor, which +she remembered only as a time when her mind was a blank. + +FOOTNOTES: + +[7] Hoch, August, and Kirby, George H.: "A Clinical Study of Psychoses +Characterized by Distressed Perplexity." _Archives of Neurology and +Psychiatry_, April, 1919, Vol. I, pp. 415-458. + +[8] Hoch, August: "A Study of the Benign Psychoses." _Johns Hopkins +Hospital Bulletin_, May, 1915, XXVI, 165. + +A book on "the psychology of manic-depressive insanity" will shortly +appear by the editor. + + + + +CHAPTER IX + +THE PHYSICAL MANIFESTATIONS OF STUPOR + + +We must now discuss the most difficult of all the aspects of the stupor +problem. The subject is so involved and the evidence so inconclusive +that observers will probably interpret the phenomena here reported +according to their individual preconceptions. What we have to say is +therefore published not so much to convince as to stimulate further +work. The problem is wider than that of the mere etiology of the stupors +we are considering. Their relationship to manic-depressive insanity is +so intimate that we must tentatively consider this affectless reaction +as belonging to that larger group. A discussion of the basic pathology +of manic-depressive insanity is outside the sphere of this book. The +author, therefore, thinks it advisable to state somewhat dogmatically +his view, as to the etiology of these affective reactions, merely as a +starting point for the argument concerning stupors specifically. + +It is our view that the manic-depressive psychoses may be, and probably +are, determined remotely but fundamentally by an inherent neuropsychic +defect, but this physical and constitutional blemish is non-specific. +The actual psychosis is determined by functional, that is, +psychological factors. A predisposed individual exposed to a certain +psychic stress develops a manic-depressive psychosis. Naturally any +physical disease reduces the capacity for normal response to mental +difficulties; hence physical illness may facilitate the production of a +psychosis. But this intercurrent factor is also non-specific. + +Such is our view of the etiology of manic-depressive insanity as a +whole. When we approach the study of benign stupors, however, difficult +problems appear. As will be discussed in a later chapter on the +literature, reactions resembling benign stupors occur as a result of +toxins, particularly following acute rheumatism. Recently the medical +profession has been called on to treat many cases of encephalitis +lethargica where similar symptoms are observed. If the resemblance +amounted to identity, we would have to admit that a specific toxin may +produce a specific mental reaction which we have concluded on other +grounds to be psychogenic. As a matter of fact, in two particulars these +reactions show relationship to organic delirium. Knauer reports that in +post-rheumatic stupors illusions are frequent--an ice bag thought to be +a cannon, or a child, etc.--and there are bizarre misinterpretations of +the physical condition, such as lying on glass splinters, animals +crawling on the body, and so on. Such illusions are, in our experience, +not found in stupor, and, on the other hand, are cardinal symptoms of +delirium. Further, Knauer reports that even at the height of +post-rheumatic stupor, external stimuli make some impression, in that a +thoughtful facial expression appears. In deep stupors, such as occurred +in our series, this response is not seen. The same phenomenon of +"rousing," larval in Knauer's cases, is often well marked in +encephalitis lethargica and is, of course, a pathognomonic symptom of +delirium. We might therefore think that these conditions are mixtures of +two organic tendencies, namely, delirium and coma. It is not impossible +that resemblances to benign stupor are due to functional elements +appearing in the reduced physical state as additions to the organic +symptoms. The prominence of pain might be taken as a likely cause for an +instinctive reaction of withdrawal, which would account for the +emotional palsy of these conditions on psychogenic grounds. [This +argument can be better understood when the chapter on Psychological +Explanation of Stupor has been read.] We therefore feel justified in +holding that the resemblance of the symptoms of certain plainly organic +reactions to those of benign stupor do not necessitate a splitting of +these stupors from the manic-depressive group. + +When we consider certain bodily manifestations of these typical stupors, +however, fresh difficulties are encountered. Unlike depressions, +elations and anxieties, certain physical symptoms appear with frequency, +even regularity. This would seem to indicate the presence of physical +disease. Inasmuch as the most constant of them is fever, the natural +conclusion would be that we are dealing with an infection which +produces a mental state called stupor. If we were not faced with an +obvious relationship to manic-depressive insanity, where such symptoms +are usually accidental and intercurrent, we would accept this +explanation, but this quandary necessitates further analysis. + +Let us first consider the fever. In 35 cases, on whom data of +temperature could be found from the records extant, 28 showed fever +usually running between 99 and 100, often up to 101 or slightly over +this point. When these cases were analyzed, however, it was found that +27 were typical and 8 atypical, showing pictures resembling those +described in the last chapter. Of the latter only one had a rise of +temperature, while of the typical group only one was afebrile. +Therefore, since out of 27 typical cases 26 had the typical slight +fever, we must conclude it to be a highly specific symptom. Of these 28 +cases the incidence of the fever was as follows: 8 showed it only on +admission; in 7 it was highest on admission but continued at a low rate +throughout the rest of the psychosis; in 5 it extended without much +variation throughout the psychosis; in 4 it appeared intermittently, +while in 2 it was accentuated during periods when the mental symptoms +were most pronounced. We see, then, that there is a distinct tendency +for the fever to be associated with the onset of the disease. + +When we look for other data from which we might discover causes for the +fever, we find less than we would like. The records are of observations +made, some of them, twenty years ago. Although the mental examinations +were careful, the records of the physical symptoms either were not made +or were lost in many cases. Consequently our description must be +tentative and is published merely to stimulate further research as cases +come to the attention of psychiatrists. + +One looks, first, for other evidence of infection. Some of the cases +were thoroughly examined with modern methods and nothing whatever found. +Blood examinations were made in five cases; three of these had rather +high temperature with the following blood pictures: Charles O., 103, +leucocytosis of 23,000, with 91.5% polymorphonuclears; Annie G. (Case +1), 103, leucocytosis of 12,000 to 15,000, and 89% polymorphonuclears; +Caroline DeS. (Case 2), 104, 15,000 leucocytes, no differential made, +Widal and diazo reaction negative. These three cases, then, had marked +febrile reactions and leucocytosis. It is quite possible that they had +infections which were not discovered. Of the other two Rosie K. (Case +11) had a temperature of 100 and 17,500 leucocytes associated with a +fetid diarrhea, an unquestioned infection, while Mary C. (Case 7), with +a temperature of only 100, had no rise in number of total white cells +but 41% of lymphocytes. This last might be due to an internal secretion +or an involuntary nervous system anomaly. The possibility of the three +high temperatures with leucocytosis being due to intercurrent infections +must be considered. Charles O. had high fever only for ten days during +a psychosis of several months. Annie G.'s high fever was of about the +same duration. Caroline DeS. had short periods of marked pyrexia in the +first and seventh months of her long psychosis. Except for these +episodes, these three patients had the typical slight elevation of +temperature. Three cases out of thirty-five, in which high fever and +leucocytosis appeared episodically, are hardly enough to justify the +view that stupors are the result of a specific infection. We must +remember, too, that no focal neurological symptoms are ever observed, +which makes the possibility of a central nervous system infection highly +unlikely. + +An alternative view might be that the slight rise of fever is somehow +the result of stupor, not the cause of it. The editor consulted +Professor Charles R. Stockard, of Cornell Medical College, as to this +possibility. The following argument is the result of his suggestions: + +What we call a normal temperature is, of course, the result of a balance +maintained between heat production and heat loss. Either an increase in +the former or a decrease in the latter must produce fever. It is +possible that heat production may be increased in many stupors as a +result of the muscular rigidity. Some cases showed higher temperature +when this was more marked, but this was not sufficiently constant to +justify any conclusions being drawn. + +Heat loss occurs preponderantly as a result of radiation from the skin +and by sweating with consequent evaporation of the secretion. These +processes are functions of the skin and surface circulation. Are they +disturbed in our stupors? We find considerable evidence that they are. +Flushing or dermatographia occurred in six cases, cold or blue +extremities in four cases, greasy skin in four, marked sweating in +three, the hair fell out in two cases, while the skin was pathologically +dry in one case, in fact there were few patients who showed normal skin +function. Circulatory anomalies were also observed. The pulse was very +rapid in eleven cases, weak or irregular in two, and slow in one case. +All these symptoms are expressions of imbalance in the involuntary +nervous system, further evidence of which is found in the rapid +respiration of six cases and the shallow breathing of one patient. These +pulse and respiration findings are the more striking in that individuals +in stupor are, by the very nature of their disease, free from emotional +excitement. + +This imbalance could result from a poverty of circulating adrenalin +which is necessary for the activation of the sympathetic nerves. A cause +for low suprarenal function is to be found in the apathy of the stupor +case. As Cannon and his associates have so conclusively demonstrated, +any emotion which was open to investigation resulted in an increase of +adrenalin output. As our emotions are constantly operating during the +day--and often enough during sleep as well in connection with dreams--we +must presume that emotional stimulus is a normal excitant for the +production of adrenalin. It is therefore inconceivable that the blood +could receive its normal supply of adrenalin with an apathy of the +degree seen in stupor unless some purely hypothetically substitutive +excitant were found. + +We may therefore tentatively assume that the fever which marks the onset +and frequently the course of these benign stupors is the result of a +failure of the heat loss function, this being due to an imbalance in the +involuntary nervous system that is occasioned, in turn, by insufficient +circulating adrenalin, and the final cause for the poor suprarenal +function is to be traced to the most consistent symptom of the stupor, +namely, apathy. This hypothesis is welcome, not only because it would +account adequately for the fever, but it also tends to accentuate the +relationship with other forms of manic-depressive insanity, all of which +are marked fundamentally by a pathological emotion. Naturally enough, +one turns to the records again to see if the blood-pressure of these +patients was low, as would be expected with a poor adrenalin supply. +Unfortunately record was made of the blood-pressure in only two cases, +in both of which the reading was 110 m.m. Two such isolated observations +mean, of course, nothing whatever. It is possible that the drooling +which so many stupor cases show is not merely the result of the failure +of the swallowing reflex, but represents as well a compensation for +anhydrosis by excessive salivary secretion. + +Another symptom suggestive of involuntary nervous system or endocrine +disorder is the highly frequent suppression of the menstrual function. +At times this may occur as a sequel to mental shock, as it did in the +case of Celia H. (Case 19), who was menstruating when, frightened by the +suicidal attempt of her brother, the flow ceased abruptly. That purely +psychic factors can produce marked changes in such functions has been +demonstrated by Forel and other hypnotists time and again; presumably +the effect is produced by way of alteration in the endocrine or +involuntary nervous system influence. In such cases, however, we can +trace the menstrual suppression directly to an emotional cause. On the +other hand, most women in stupor fail to menstruate during the bulk of +the psychosis at a time when we believe emotions to be absent or greatly +reduced in their intensity. The recent work of Papanicolaou and +Stockard[9] offers a simple explanation for this phenomenon. They have +shown that in the guinea pig the oestrous cycle can be delayed by +starvation, while in weaker animals a period may be suppressed +completely. When one considers that even with the greatest care the +nutrition of tube-fed patients is bound to be poor, it would be only +natural to suppose that this malnutrition would cause such a disturbance +in the oestrous cycle and was evidenced objectively by a failure to +menstruate. Even in patients who are not tube-fed, under-nutrition is +to be expected and, as a matter of fact, is usually observed. The work +of Pawlow and Cannon has shown how essential psychic stimulus is for +gastric digestion. Any condition of apathy would therefore tend to +retard digestion and indirectly affect nutrition. + +Finally, under the heading of Physical Manifestations of Stupor, we must +consider epileptoid attacks, of which there was a history in two of our +cases, both of which have already been described in the first chapter of +this book. Anna G. (Case 1), in her second attack, was treated at +another hospital, and from the account which they sent it appears that +the stupor was immediately preceded by a seizure in which the whole body +jerked. This is, of course, rather thin evidence of the existence of a +definite convulsion, but in the case of Mary F. (Case 3) we have a +fuller description. During the two days when the stupor was incubating, +she had repeated seizures of the following nature. She sometimes said +that prior to the attacks it became dark before her eyes and that her +face felt funny or that she had a pain in the stomach which worked +toward her right shoulder. The attack would begin when sitting in a +chair, with the closing of her eyes, clenching her fists and pounding +the side of the chair. She would then get stiff and slide on to the +floor, where she would thrash her arms and legs about and move her head +to and fro. The warning of the pain working from the stomach to the +right shoulder is highly suggestive of an epileptic aura, although the +other symptoms mentioned so far could have been considered hysterical or +poorly described epileptic phenomena. The rest of the description +indicates an epileptic seizure more strongly. She frothed at the mouth +and once wet herself during an attack. They lasted only for a few +minutes and she would breathe heavily after them. At the end of one +attack she wiped the froth from her mouth with her handkerchief and gave +it to her aunt, saying, "Burn that, it is poison." This is perhaps a +little less like epilepsy. It is plainly impossible for us to say with +any positiveness that either these were or were not genuine convulsions, +but it is nevertheless important to record them, because such phenomena +are observed fairly frequently in dementia prcox cases but are +practically unknown in manic-depressive insanity. This, then, would be +another example of the resemblance to dementia prcox in these stupors +which are unquestionably benign.[10] + +We see, then, in reviewing all the physical manifestations of the +benign stupors, that none occurred which cannot be explained as +secondary to the mental changes, and therefore, until such time as +physical symptoms are reported which cannot be so explained, we see no +reason for changing our view that the benign stupor is to be regarded as +one of the manic-depressive reactions. + + +FOOTNOTES: + +[9] Papanicolaou, G. N., and Stockard, C. R., "Effect of Under-feeding +on Ovulation and the OEstrous Rhythm in Guinea-pigs." _Proceedings of +the Society of Experimental Biology and Medicine_, Vol. XVII, No. 7, +Apr. 21, 1920. + +[10] As a matter of fact, if the views of Clark and MacCurdy[B] be +accepted, some reason for these epileptic-like attacks may be imagined. +According to them, epilepsy is a disease characterized by a lack of the +natural instinctive interest in the environment which is expressed +chronically in the deterioration, and episodically in the attacks, the +most consistent feature of which is loss of consciousness. Now, in +stupor we have an analogous reaction where, although consciousness is +not disturbed in the sense in which it is in epilepsy, it is +nevertheless considerably affected, inasmuch as contact with the +environment is practically non-existent. The coincident thinking +disorder is quite similar, both in epileptic dementia and the torpor +following seizures and in these benign stupors. MacCurdy has suggested +tentatively that the epileptic convulsion may be secondary to a very +sudden loss of consciousness which removes a normal inhibition on the +muscles, liberating the muscular contractions which constitute the +convulsion. If this view were correct, it would not be hard to imagine +that during the onset of these stupors the tendency to part company with +the environment, which ordinarily comes on slowly, might occur with +epileptic suddenness and hence liberate convulsive movements. This is, +however, a pure speculation but not fruitless if it serves to draw +attention to the analogies existing between the stupor reaction and some +of the mental symptoms of epilepsy. These analogies are strong; aside +from the obvious clinical differences, the stupor and epileptic +reactions are dynamically unlike in that they are the product of +different temperaments and precipitated by different situations. + + +FOOTNOTES: + +[B] Clark, L. Pierce. "Is Essential Epilepsy a Life Reaction Disorder?" +_Am. Jour. of the Medical Sciences_, November, 1910, Vol. CLVIII, No. 5, +p. 703. This paper gives a summary of Dr. Clark's theories. + +MacCurdy, John T., "A Clinical Study of Epileptic Deterioration." +_Psychiatric Bulletin_, April, 1916. + + + + +CHAPTER X + +PSYCHOLOGICAL EXPLANATION OF THE STUPOR REACTION + + +In the previous chapter mention has been made of our view that +manic-depressive insanity is a disease fundamentally based on some +constitutional defect, presumably physical, but that its symptoms are +determined by psychological mechanisms. In accordance with this +hypothesis we seek, when studying the different forms of insanity +presented in this group, to differentiate between the different types of +mental mechanisms observed, and by this analysis to account for the +manifestations of the disease on purely psychological lines. If benign +stupors belong to this group, then we should be able to find some +specific psychology for this type of reaction. + +All speech and all conduct, except simple reflex behavior, are +presumably determined by ideas. When an individual is not aware of the +purpose governing his action, we assume, in psychological study, that an +unconscious motive is present, so that in either case the first step in +psychological understanding of any normal or abnormal condition is to +discover, if possible, what the ideas are that lead to the actions or +utterances observed. In the case of stupors the situation is fairly +simple, in that the ideational content is extremely limited. As has been +seen, it is confined to death and rebirth fancies, other ideas being +correlated with secondary symptoms, such as belong to mechanisms of +other manic-depressive psychoses. It is not necessary to repeat the +catalogue of the typical stupor ideas, as they have been given in an +earlier chapter. Our task is now to consider the significance of these +death and rebirth delusions and their meaning for the stupor reaction. + +Thoughts concerned with future and new activities require energy for +their completion in action and are therefore naturally accompanied by a +sense of effort which gives pleasure to an active mind. When the sum of +energy is reduced, one observes a reverse tendency called "regression." +It is easier to go back over the way we know than to go forward, so the +weakened individual tends to direct his attention to earlier actions or +situations. To meet a new experience one must think logically and keep +his attention on things as they are, rather than imagine things as one +would like to have them. + +Progressive thinking is therefore adaptive, while regressive thinking is +fantastic in type, as well as concerned with the past--a past which in +fancy takes on the luster of the Golden Age. Sanity and insanity are, +roughly speaking, states where progressive or regressive thinking rule. +The essence of a functional psychosis is a flight from reality to a +retreat of easeful unreality. + +Carried to the extreme, regression leads one in type of thinking and in +ideas back to childhood and earliest infancy. The final goal is a state +of mental vacuity such as probably characterizes the infant at the time +of birth and during the first days of extra-uterine life. In this state +what interest there is, is directed entirely to the physical comfort of +the individual himself, and contact with the environment is so +undeveloped that efforts to obtain from it the primitive wants of warmth +and nutrition are confined to vague instinctive cries. Evolution to true +contact with the world around implies effort, the exercise of +self-control, and also self-sacrifice, since the child soon learns that +some kind of _quid pro quo_ must be given. Viewed from the adult +standpoint, the emptiness of this early mental state must seem like the +Nirvana of death. At least death is the only simple term we can use to +represent such a complete loss of our habitual mental functions. When +life is difficult, we naturally tend to seek death. Were it not for the +powerful instinct of self-preservation, suicide would probably be the +universal mode of solving our problems. As it is, we reach a compromise, +such as that of sleep, in which contact with reality is temporarily +abandoned. In so far as sleep is psychologically determined, it is a +regressive phenomenon. It is interesting that the most frequent +euphemism or metaphor for death is sleep. Sleep is a normal regression. +It does not always give the unstable individual sufficient relaxation +from the demands of adaptation and so pathological regressions take +place, one of which we believe stupor to be. It is important to note +that objectively the resemblance between sleep and stupor is striking. +So far as mental activity in either state can be discovered by the +observer, either the sleeper or the patient in stupor might be dead. +Briefly stated, then, our hypothesis of the psychological determination +of stupor is that the abnormal individual turns to it as a release from +mental anguish, just as the normal human being seeks relief in his bed +from physical and mental fatigue. When this desire for refuge takes the +shape of a formulated idea, there are delusions of death. + +The problem of sleep is, of course, bound up with the physiology of +rest, and as recuperation, in a physical sense, necessitates temporary +cessation of function, so in the mental sphere we see that relaxation is +necessary if our mental operations are to be carried on with continued +success. This is probably the teleological meaning of sleep in its +psychological aspects, for in it we abandon diurnal adaptive thinking +and retire to a world of fancy, very often solving our problems by +"sleeping over them." The innate desire for rest and a fresh start is +almost as fundamental a human craving as is the tendency to seek release +in death. In fact the two are closely associated both in literature and +in daily speech, for in many phases we correlate death with new life. If +one is to visualize or incorporate the conception of new life in one +term, rebirth is the only one which will do it, just as death is the +only word which epitomizes the idea of complete cessation of effort. +Not unnaturally, therefore, we find in the mythology of our race, in our +dreams and in the speech of our insane patients, a frequent correlation +of these two ideas, whether it comes in the crude imagery of physical +rebirth or projected in fantasies of destruction and rebuilding of the +world. Many of our psychotic patients achieve in fancy that for which +the Persian poet yearned: + + "Ah Love! could you and I with Him conspire + To grasp this Sorry Scheme of Things entire, + Would we not shatter it to bits--and then + Re-mold it nearer to the Heart's Desire!" + +A vision of a new world is a content occurring not infrequently in manic +states, but before the universe can be remolded it must be destroyed. +Before the individual can enjoy new life, a new birth, he must die, and +stupor often marks this death phase of a dominant rebirth fantasy. In +this connection it was not without significance to note that stupors +almost universally recover by way of attenuation of the stupor symptoms, +or in a hypomanic phase where there seems to be an abnormal supply of +energy. Antus-like, they rise with fresh vigor from the Earth. They do +not pass into depressions or anxieties. + +Rebirth fancies unquestionably, then, contain constructive and +progressive elements, but, as has been stated above, any thinking which +implies a lapse of contact with the environment is, in so far as that +lapse is concerned, regressive, and in consequence rebirth fancies, as +dramatized by the stupor patients, are regressive, just as are the +delusions of death itself. + +It is obvious that an acceptance of death implies rather thorough mental +disintegration. Before that takes place there may be some mental +conflict. The instinct of self-preservation may prevent the individual +from welcoming the notion of dissolution, so that this latter idea, +though insistent, is not accepted but reacted to with anxiety; hence we +often meet with onsets of stupor characterized by emotional distress. It +has already been suggested that death may foreshadow another existence. +Often in the psychoses we meet with the idea of eternal union in death +with some loved one whom the vicissitudes and restrictions of this life +prevent from becoming an earthly partner. This fancy is frequently the +basis of elation. Similarly, new life in a religious sense as expressed +in the delusion of translation to Heaven, is a common occasion for +ecstasy. These formulations of the death idea may occur as tentative +solutions of the patient's problems leading to temporary manic episodes +while the psychosis is incubating. It seems that stupor as such appears +only when death and nullity are accepted. + +The above are more or less a priori reasons for regarding the stupor as +a regressive reaction. We must now consider the clinical evidence to +support this view. In the first place, we always find that stupor occurs +in an individual who is unhappy and who has found no other solution +than regression for the predicament in which he is. There is nothing +specific in the cause of this unhappiness. At times the factors +producing it are mainly environmental; at others, the problem is +essentially of the patient's own making. Of course almost any type of +functional psychosis may emerge from such a state of dissatisfaction, +but it is important to note that unlike manic states, for instance, +stupors invariably develop from a situation of unhappiness. Quite +frequently the choice of the stupor regression is determined by some +definitely environmental event which suggests death. This often comes as +the actual death of the patient's father (in the case of a woman) or +employer, events which inflate the already existing, although perhaps +unconscious, desire for mutual death. Again, the precipitating factor +may be a situation which adds still another problem and makes the burden +of adaptation intolerable, forcing on him the desire for death. In these +cases the actual psychosis is sometimes ushered in dramatically with a +vision of some dead person (often a woman's father) who beckons, or +there are dream-like experiences of burial, drowning, and so on. + +A few cases taken at random from our material exemplify these features +of the unhappiness in which the psychosis appears as a solution with its +development of the death fancy. + +Alice R., at the age of 25, was much troubled by worrying over her +financial difficulties and the shame of an illegitimate child. +Retrospectively she stated, "I was so disgusted I went to bed--I just +gave up hope." Shortly before admission she said she was lost and +damned, and to the nurse in the Observation Pavilion she pleaded, "Don't +let me murder myself and the baby." + +Caroline DeS. (Case 2) for some time was worried over the engagement of +her favorite brother to a Protestant (herself a Catholic) and the +threatened change of his religion. At his engagement dinner she had a +sudden excitement, crying out, "I hate her--I love you--papa, don't kill +me." This excitement lasted for three weeks, during two of which she was +observed, when she spoke frequently of being killed and going to Heaven. +The conflict was frankly stated in the words, "I love my father but +don't want to die." Then for two weeks she had some fever, was tube-fed, +muttered about being killed or showed some elation, there being +apparently interrupted stuporous, manic and, possibly, anxiety episodes. +Finally she settled down to a year of deep stupor. + +Laura A. had for three months poor sleep with depression over her +failure in study. Another cause for worry was that her father was home +and out of work. She reached a point where she did not care what +happened but continued working. Ten days before admission she was not +feeling well. The next morning she woke up confused and frightened, +speedily became dazed, stunned, could not bring anything to her memory. +This rather sudden stupor onset was not accompanied by any false ideas, +at least none which the family remembered. + +Mary C. (Case 7) was an immigrant who felt lonely in the new country. +Two weeks before admission her uncle with whom she was living died. She +thought she had brought bad luck, complained of weakness and dizziness, +then suddenly felt mixed up, her "memory got bad," and she thought she +was going to die. Next she was frightened, heard voices, thought there +was shooting and a fire. For a short time she was inactive and later +began shouting "Fire!" When taken to the Observation Pavilion, she was +dazed, uneasy, thought she was on a boat or shut up in a boat which had +gone down; all were drowned. Then came a mild stupor. + +Maggie H. (Case 14), while pregnant, fancied that her baby would be +deformed and that she would die in childbirth. Three weeks before +admission this event took place. For five days she worried about not +having enough milk, about her husband losing his job (he did lose it) +and thought her head was getting queer. On the fifth day she cried, said +she was going to die, that there was poison in the food, that her +husband was untrue to her. She became mute but continued to attend to +her baby. She saw dead bodies lying around, and by the time she was +taken to the Observation Pavilion was in a marked stupor. + +Turning now to the symptoms of the stupor proper, we note, first, the +effects of the loss of energy which regression implies. The inactivity +and apathy which these patients show is too obviously evidence of this +to require further comment. Another proof of the withdrawal of the +libido or interest is found in the thinking disorder. Directed, accurate +thinking requires effort, as we all know from the experience of our +laborious mistakes when fatigued. So in stupor there is an inability to +perform simple arithmetical problems, poor orientation is observed, and +so on. Similarly what we remember seems to be that which we associate +with the impressions received by an active consciousness. Actual events +persist in memory better than those of fancy, in proof of which one +thinks at once of the vanishing of dreams on waking, with its +restablishment of extroverted consciousness. This registration of +impressions requires interest and active attention. Without interest +there is no attention and no registration. The patient in stupor +presents just the memory defect which we would expect. Indifference to +his environment leads to a poor memory of external events, while on +recovery there may be such a divorce between consciousness of normal and +abnormal states that the past delusions are wiped from the record of +conscious memory. Withdrawal of energy then produces not only inactivity +and apathy but grave defects in intellectual capacity. + +The natural flow of interest in regression is to earlier types of +ambition and activity. This is betrayed not merely by the thought +content dealing with the youth and childhood of the patient, but also is +manifested in behavior. Excluding involution melancholia there is +probably no psychosis in which the patients exhibit such infantile +reactions as in stupor. Except for the stature and obvious age of these +patients, one could easily imagine that he was dealing with a spoiled +and fractious infant. One thinks at once of the negativism which is so +like that of a perverse child and of the unconventional, personal habits +to which these patients cling so stubbornly. Masturbation, for instance, +is quite frequent, while willful wetting and soiling is still more +common. We sometimes meet with childishness, both in vocabulary and mode +of expression. In one case there was evidently a delusion of a return to +actual childhood, for she kept insisting that she was "in papa's house." + +The frequency with which the delusion of mutual death occurs in stupor +is another evidence of its regressive psychology. The partner in the +spiritual marriage is rarely, if ever, the natural object of adult +affection, but rather a parent or other relative to whose memory the +patient has unconsciously clung for many years, reawakening in the +psychosis an ambition of childhood for an exclusive possession that +reaches its fulfillment in this delusion. Closely allied with this is +another delusion, that of being actually dead, which the patients +sometimes express in action, even when not in words. The anesthesia to +pin pricks, the immobility and the refusal to recognize the existence of +the world around, in patients who give evidence of some intellectual +operations still persisting, are probably all part of a feigned death, +with the delusion expressing itself in corpse-like behavior. + +Finally we must consider the meaning of the deep stupor where no +mentation of any kind can be proven and where none but vegetative +functions seem to be operating. This state is either one of organic +coma, in which case it marks the appearance of a physical factor not +evidenced in the milder stages, or else it is the acme of this +regression by withdrawal of interest. As has been stated, back of the +period of primitive childish ideas there lies a hypothetical state of +mental nothingness. If we accept the principle of regression we find +historically an analogue to what is apparently the mental state of deep +stupor in the earliest phases of infancy. This view receives +justification from the study of the phenomenon of variations in +symptoms. Mental faculties at birth are larval, and if such condition be +artificially produced mental activity must be potentially present (as it +would not be if we were dealing with coma). In Chapter IV phenomena of +interruption of stupor symptoms were detailed. One case that was +mentioned is now of particular importance as demonstrating that an +appropriate stimulus may dispel the vacuity of complete stupor by +raising mental functions to a point where delusions are entertained. +This patient retrospectively recalled only certain periods of her +deepest stupor, occasions when she was visited by her mother. At these +times, as she claimed, she thought she was to be electrocuted and told +her mother so, adding, "Then it would drop out of my mind again." +Otherwise her memory for this state was a complete blank. Here we see a +normal stimulus producing not normality but something on the way towards +it, that is, a condition less profound than the state out of which the +patient was temporarily lifted. + +This case exemplifies the principle of levels in the stupor reaction +which we have found to be of great value in our study. These levels are +correlated with degrees of regression, as a review of the symptoms +discussed above may show. In the first place, the dissatisfaction with +life, the first phase of regression, leads to the quietness--the +inactivity and apathy, which are the most fundamental symptoms of the +stupor reaction as a whole. Initiative is lost and with this comes a +tendency for the acceptance of other people's ideas. That is the +probable basis for the suggestiveness which we concluded was a prominent +factor in catalepsy. Indifference and stolidity may exist with those +milder degrees of regression which do not conflict with one's critical +sense, and hence may be present without any false ideas. The next stage +in regression is that where the idea of death appears. Although not +accepted placidly by the subject, its non-acceptance is demonstrated by +the idea being projected--by its appearance as a belief that the patient +will be killed. This notion of death coming from without has again two +phases, one with anxiety where normality is so far retained that the +patient's instinct of self-preservation produces fear, and a second +phase where this instinct lapses and the patient so far accepts the +idea of being killed as to speak of it with indifference. The next step +in regression is marked by the spoiled-child conduct, interest being so +self-centered as to lead to autoerotic habits and the perverse reactions +which we call negativism. When death is accepted but mental function has +not ceased, the latter is confined to a dramatization of death in +physical symptoms or to such speech and movements as indicate a belief +that the patient is dead, under the water, or in some such unreal +situation. Finally, when all evidence of mentation in any form is +lacking, we see clinically the condition which we know as deep stupor +and which we must regard psychologically as the profoundest regression +known to psychopathology, a condition almost as close to physiological +unconsciousness as that of the epileptic. + +Naturally we do not see individual cases in which all these stages +appear successively, each sharply defined from its predecessor. To +expect this would be as reasonable as to look for a man whose behavior +was determined wholly by his most recent experience. Any psychologist +knows that every human being behaves in accordance with influences whose +history is recent or represents the habit of a lifetime. At any given +minute our behavior is not simply determined by the immediate situation, +but is the product of many stages in our development. Quite similarly we +should not expect in the psychoses to find evidences of regression to a +given period of the individual's life appearing exclusively, but rather +we should look for reactions at any given time being determined +preponderantly by the type of mentation characteristic for a given stage +of his development. As a matter of fact, we see in psychoses, +particularly in stupor, more sharply defined regressions to different +levels than we ever see in normal life. + +Our psychological hypothesis would be incomplete and probably unsound if +it could not offer as valid explanations for the atypical features in +our stupor reactions as for the typical. The unusual features which one +meets in the benign stupors are ideas or mood reactions occurring +apparently as interruptions to the settled quietude or in more +protracted mild mood reactions, such as vague distress, depression or +incomplete manic symptoms, which have been described in the chapter on +affect. The interruptions are easily explained by the theory of +regression. If stupor represents a complete return to the state of +nothingness, then the descent to the Nirvana or the re-ascent from it +should be characterized by the type of thinking with the appropriate +mood which belongs to less primitive stages of development. A review of +our material seems to indicate that there is a definite relationship +between the type of onset and the character of the succeeding stupor. +For instance, in the cases so far quoted in this book, the onsets +characterized by mere worry and unhappiness and gradual withdrawal of +interest had all of them typical clinical pictures. On the other hand, +of those who began with reactions of definite excitement, anxiety or +psychotic depression, there were interruptions which looked like +miniature manic-depressive psychoses in all but one case. This would +lead one to think that these patients retraced their steps on recovery +or with every lifting of the stupor process, moved slightly upward on +the same path on which they had traveled in the first regression. The +case of Charlotte W. (Case 12), which is fully discussed in the chapter +on Ideational Content, offers excellent examples of these principles. + +The next atypical feature is the phenomenon of reduction or dissociation +of affect, the frequency of which is mentioned in Chapter V. As the law +of stupor is apathy, normal emotions should be reduced to indifference +and no abnormal moods, such as elation, anxiety or depression, should +occur. What often happens is that these psychotic affects appear but +incompletely, often in dissociated manifestations. This looks like a +combination of two psychotic tendencies, the stupor reduction process +which inhibits emotional response and the tendency to develop abnormal +affects which characterize other manic-depressive psychoses. There is no +general psychological law which makes this view unlikely. One cannot be +anxious and happy at the same instant, although one can alternate in his +feelings; but one can fail to react adequately to a given stimulus when +inhibited by general indifference. In fact it is because apathy is, +properly speaking, not a mood but an absence of it, that it can be +combined with a true affect. It is possible, therefore, to have a +combination of stupor and another manic-depressive reaction, while the +others cannot combine but only alternate.[11] + +Finally we must discuss the psychological meaning of cases, such as +those described in Chapter VIII, where we concluded that there were +psychoses resembling stupors superficially. It seemed likely that these +patients were absorbed in their own thoughts, rather than being in a +condition of mental vacuity. It is not difficult to explain the +objective resemblance. All evidence of emotion (apart from subjective +feeling tone which the subject may or may not report) is an expression +of contact with the outer world. There must be externalization of +attention to environment before a mood becomes evident. A moment's +reflection will show this to be true, for no further proof is needed +than the phenomena of dreaming. The attention being given wholly to +fantasies, the subject lies motionless, mute and placid, although +passing through varied autistic experiences. Only when the dream becomes +too vivid, disturbs sleep and re-directs attention to the +environment--only then is emotion objectively betrayed. There is an +appearance of apathy and mental vacuity which the dreamer can soon +declare to be false. He was feeling and thinking intensely. In any +condition, therefore, such as that of perplexity or of an absorbed manic +state, the patient may be objectively in the same condition as a typical +stupor. The histories of the two psychoses differentiate the two +reactions which may be indistinguishable at one interview. The keynote +of one reaction is _indifference_, while that of absorption is +_distraction_, a perversion of attention to an inner, unreal world. + +In summary we may recapitulate our hypotheses. Stupor represents, +psychologically speaking, the simplest and completest regression. +Adaptation to the actual environment being abandoned, attention reverts +to earlier interests, giving symptoms of other manic-depressive +reactions in the onset or interruptions, and finally dwindles to +complete indifference. The disappearance of affective impulse leads to +objective apathy and inactivity, while the intellectual functions fail +for lack of emotional power to keep them going. The complicated mental +machine lies idle for lack of steam or electricity. The typical +ideational content and many of the symptoms of stupor are to be +explained as expressions of death, for a regression to a Nirvana-like +state can be most easily formulated in such a delusion. Other clinical +conditions may temporarily and superficially resemble stupor on account +of the attention being misdirected and applied to unproductive +imaginations. To employ our metaphor again, in these false stupors the +current is switched to another, invisible machine but not cut off as in +true stupor. + + +FOOTNOTES: + +[11] The reader will note that this view is opposed to that of +Kraepelin, who has written largely on so-called "_mixed conditions_" in +manic-depressive insanity. We believe that careful clinical studies +confirm our opinion and that his classification is based on less +thorough observation and analysis. This subject will be discussed at +greater length in a forthcoming book on "The Psychology of Morbid and +Normal Emotions," by Dr. MacCurdy. + + + + +CHAPTER XI + +MALIGNANT STUPORS + + +As we have seen, the benign stupors are characterized by apathy, +inactivity, mutism, a thinking disorder, catalepsy and negativism. All +these symptoms are also found in the stupors occurring in dementia +prcox. In fact this symptom complex has usually been regarded as +occurring only in a malignant setting. There can be no question about +the resemblance of benign to dementia prcox stupors. Even such symptoms +as poverty and dissociation of affect, usually regarded as pathognomonic +of dementia prcox, have been described in the foregoing chapters. +Either recovery in our cases was accidental or there is a distinct +clinical group with a good prognosis. If the latter be true, the +symptoms must follow definite laws; if they did not, we would have to +abandon our principles of psychiatric classification. Naturally, then, +we seek to find the differences between the cases that recover and those +that do not. There is never any difficulty in diagnosis where a stupor +appears as an incident in the course of a recognized case of catatonic +dementia prcox. We shall therefore consider only such clinical pictures +as resemble those described in this book, in that the symptoms on +admission to a hospital or shortly after are those of stupor. It should +be our ambition to make a positive diagnosis before failure to recover +in a reasonable time leads to a conclusion of chronicity. + +It is probably safe to assume, on the basis of as large a series as +ours, that the symptoms of stupor _per se_ imply no bad prognosis. +Further, it has been noted that a relatively pure type of reaction is +seen, the symptoms appearing with tolerable consistency. In analyzing +the histories of dementia prcox patients, therefore, one looks for +inconsistencies among, or additions to, the stupor symptoms. We may say +at the outset that we have been able to find no case of malignant stupor +that showed what we regard as a typical benign stupor reaction, and it +is questionable whether partial stupor as we have described it, ever +occurs with a bad prognosis. Usually the discrepant symptoms in the +dementia prcox cases are sufficiently marked to enable one to make a +positive diagnosis quite soon after the case comes under observation. + +The law of benign stupor is a limitation of energy, emotion and +ideational content. In dementia prcox we have a re-direction of +attention and interest to primitive fantastic thoughts and a consequent +perversion of energy and emotion. In many malignant stupors one can +detect evidence of this second type of reaction in symptoms that are +anomalous for stupor. For instance, one meets with frequent silly and +inexplicable giggling. Then, too, smiling, tears or outbursts of rage, +the occasions for which are not manifest, are much more frequent than in +typical stupor. Similarly, delusional ideas (not concerned with death at +all) may appear or the patient may indulge in speech that is quite +scattered, not merely fragmentary. Two cases may be cited briefly to +illustrate these dementia prcox symptoms superadded to those of stupor. + + + CASE 20.--_Winifred O'M._ Age: 19. Single. Admitted to the + Psychiatric Institute May 6, 1911. + + _F. H._ The occurrence of other nervous or mental disease + in the family was denied. + + _P. H._ The patient seems to have been rather shy and + goody-goody in disposition. According to her mother this + seclusiveness did not begin to be markedly noticeable until + the winter before her psychosis, when there was some + trouble about getting work. She had previously been to a + business school. Then she held a position as stenographer + temporarily. When this job was over she had a number of + positions that did not last long and was once idle for two + months. In February (three months before admission) her + father was out of work, which added to her worry. + + _Onset of Psychosis:_ Nine days before admission a young + man died in the house where they lived. The next day her + mother insisted on the patient and her sister going to the + funeral. On coming home the patient complained of being + afraid and having a funny feeling. She woke up at 2:30 that + night and lit all the gas, for which she could give no + explanation. The day following, or a week before admission, + she was slow, confused, could not get her clothes together. + The next day she was restless and worried, giving a + superficial explanation for the latter. She played the + piano a great deal. The following day she was fidgety and + cried. At 4 p.m. she was put to bed and appeared to fall + asleep. At midnight when a priest called she said to him + privately that she was all over the world, that she went to + the 12th floor of the Metropolitan Building, that she sat + down and took the man's money, $7, and came right away. She + recognized the priest. Three days before admission she + wanted to stay in bed, kept her eyes closed. When spoken to + she would smile but did not open her eyes. She did not pass + her urine all day. Her mother then gave her some medicine + which the doctor had left. The patient immediately had a + peculiar attack in which she heaved her breast, drew her + head back, clenched her fists and worked her feet. Saliva + escaped from the side of her mouth. This attack lasted some + three to five minutes. + + Her mother then called an ambulance and she was taken to + the _Observation Pavilion_. She thought that the ambulance + doctor was an uncle, a soldier in the Philippines, of whom + she was very fond. There she remained in bed, with all her + muscles relaxed, her mouth constantly open, saying nothing + and indeed resisting efforts which were made to get her to + open her eyes. + + _Under Observation:_ She sat or lay down with her eyes + closed and usually limp, although occasionally resistive. + There was practically no reaction to pin pricks. Sometimes + she opened her mouth as if to speak but rarely did so + except in a very low tone and after repeated questioning. + Her answers were rarely relevant. To the usual orientation + questions she gave no answers that would indicate that she + knew where she was. Sometimes she said "Jimmy" when asked + her name, and replied to another question, "Jimmy big smile + on." Once she said, "I don't know myself--what I am talking + for--what I am doing." In general her speech seemed to + indicate that her thought was directed entirely inward and + that she paid no attention whatever to the questions. In + most benign cases such a condition is accompanied by + perplexity or a dreamy, dazed expression. This the patient + had not. On the other hand, she was sometimes definitely + scattered. For example, when asked, How do you feel? she + replied, "Large all name." Again to the command, Tell me + your trouble, her answer was, "I couldn't tell my mother + last night and I can't tell her this night and I can't tell + my _proud_." She referred in a fragmentary way to being + crazy and to having been dead. She admitted hearing voices + but may not have understood the question. + + A week after admission, when visited by her mother, the + latter asked her to kiss her. The patient opened her mouth + widely and put out her tongue. This is a type of response + which we have never seen in our benign cases. + + Two days later repeated questioning made it evident that + the patient knew more about her environment than would be + expected, judging from her other symptoms. She gave the + month correctly knew that she was in a hospital and told of + having recently been visited by her father. At the same + interview she spoke of masturbation, of wanting to marry + her uncle, and of having been in bed with her father. The + last she referred to as a "fall." Such frank incest ideas + are never found in benign psychosis in our experience. + Other dementia prcox ideas appeared quite soon, for within + three days, when she was talking slightly more freely, she + spoke of having often imagined she was having sexual + experiences as a result of the influence of a man who lived + upstairs, and that even when sitting with her family at the + table she felt sexual sensations. + + Her condition then remained essentially the same for some + time. Then about six weeks after admission she became + somewhat less resistive, was frequently seen sitting up in + bed, moving her lips considerably (without speech) and + regarding the surroundings with a bright interested + expression and occasionally smiles. About this time she + began exposing herself and chewing her finger nails. + + Four months after admission she was noted as being very + resistive and negativistic, allowing saliva to accumulate + in her mouth and making no attempt to keep the flies off + her. At the same time she would keep in her mouth food that + had been put there without chewing it. + + Two months later she seemed to laugh occasionally when + other patients did so, but at the same time she showed a + cataleptic tendency and was quite mute. + + Six months after admission she began to feed herself but + rather sloppily. When one would speak to her, she would + occasionally smile, but if shaken she would weep silently. + About this time she began to do a little work in the ward, + pushing a floor polisher. + + For the next couple of months her condition was about the + same. She would stand around the ward, doing a little work + if urged, might even dance if forced to. She was + consistently mute. She was dirty but often decorated + herself. Rarely she was assaultive. + + Then ten months after admission she one day suddenly + became talkative, distractible and emotional, laughing and + crying. There was with this, however, no open elation. Her + talk was obscene, at times flighty, at times definitely + scattered. All her habits were filthy. + + This pseudomanic episode lasted for a couple of months, and + then she settled down to a fairly consistent deterioration + with indifference, silly laughter, occasional + assaultiveness, destructiveness and untidiness. + + Nearly two years after admission she had another period of + excitement lasting about a couple of months. Shortly after + this she began to fail physically, and in November, 1913, + two years and five months after her admission, she died of + pulmonary tuberculosis. + +In summary, then, we see that this patient exhibited symptoms of +dementia prcox from the outset of her stupor, with scattering, genital +sensations and incest ideas. The stupor symptoms gradually gave way to +the typical indifference, negativism, obscenity, filthiness and +inexplicable conduct of dementia prcox. At the beginning, however, the +condition was superficially similar to that of a benign stupor, it being +only on careful observation that other symptoms were noted. + + + CASE 21.--_Rose S._ Age: 23. Admitted to the Psychiatric + Institute April 5, 1905. + + _F. H._ The mother was living, the father dead. Otherwise + no pertinent information was secured. + + _P. H._ The patient was said always to have been somewhat + seclusive, mingling little with other people; this tendency + was so strong that she would leave the room when visitors + came. She always slept a great deal. It was stated that she + was able to do heavy housework quite well, but never + learned cooking. + + At 16 she hired out as a servant for a year and a half, and + then did laundry work. When 18 she had an illegitimate + child by a co-worker. + + _History of Psychosis:_ About a year before admission the + patient's sister was burned to death. When the patient + heard of this she said that something had come up in her + throat. Henceforth she often complained of a lump in her + throat, and often bit her nails. Two months before + admission she suddenly left the laundry, again spoke of the + lump in her throat, and claimed to have seen the dead + sister. Two weeks later when the family had an anniversary + mass for the sister the patient appeared sad, but the + following day laughed, said she had seen her "sister + beckoning her to come." She also thought she saw her + picture "and Heaven was behind it." She also talked of + "dead relatives and friends." A reaction of levity in + connection with a sister's death is highly suggestive of a + malignant psychosis. + + Two weeks before admission her mother found her in a + stupor, immovable, with her eyes closed. In 24 hours she + woke up, began to sing "Rest for the Weary," prayed, then + was stuporous again for six hours. When she came out of + this, she said she was "going to die," God had told her so + and talked of her own funeral arrangements. She again went + into a stupor, in which she was sent to the Observation + Pavilion. + + At the _Observation Pavilion_ she was described as happy, + laughing, singing, saying she felt happy, but adding, "I + like to be sad too, I am going to Heaven Easter Sunday." + She claimed that her sister frequently stood in front of + her, and that she knew she wanted her to go with her. + + _Under Observation:_ For about three weeks the patient + showed a variable stupor. She would lie with a mask-like + face inaccessible, cataleptic, drooling saliva, often with + her mouth open. When taken up, she was usually perfectly + flaccid, but once she let herself slide on the floor after + she had stood immobile at the window. Sometimes there was + marked resistance to passive motions, especially when + attempts were made to open her mouth or eyes, or on one + occasion when the examiner tried to open her hand in which + she held her handkerchief. Yet when one persisted in urging + her to respond there frequently could be elicited more or + less marked reactions. Thus repeatedly she could be made to + obey some commands, as showing the tongue, etc., even when + she would not answer. Once when her eyes were opened, tears + rolled down her cheeks--again, she usually reacted to pin + pricks by slight flushing, once she said, "Stop! it + hurts." Again, she said, "Leave me alone, I want to sleep." + + So far the description of this reaction is that of a benign + stupor. There were, however, other symptoms. In the first + place, she could sometimes be made to open her eyes and + write, although she would not speak. In spite of the + penmanship being careless, there were no mistakes. This + exhibition of an unhabitual and more difficult intellectual + effort when the patient was mute is suggestive of an + inconsistency. So was her habit of sometimes singing a + hymn, "Rest for the Weary," when no other sign of mental + life was given. But, more important than these, she could + not infrequently be induced to answer questions and at such + times she spoke promptly and with natural affective + response. + + A number of her replies were of the type to be expected in + a benign stupor. In the first place, she spoke of her + condition as "going off to sleep" and also as "death," "I + was dead all day." "I died three times yesterday," or she + merely described it by saying "I go off into states when I + lie with my mouth open and eyes closed, and cannot speak or + open my eyes." When asked how she got into this condition, + she said "My sister died and I think it was on my mind." + Again she said she became sad at the anniversary mass of + the sister and had been sad ever since. On the other hand, + she also stated that when she came home from the mass she + first was silly and danced. Spontaneously she spoke of + having frequently had visions of her dead sister; once she + saw her with wings. In explanation of her singing "Rest for + the Weary," she said it was the hymn sung at her father's + funeral. An anomalous feature had to do with her + description of her feelings. She claimed to have no memory + of her stupor periods and yet said of them: "I feel + peaceful-like," or "I feel awfully happy and sad together," + or "I am sad and contented--I like it that way." + + A striking symptom was that, when a sensory examination was + made during the first few days during one of the periods + when she responded well, she showed glove and stocking + anesthesia, also anesthesia of neck and left breast. + + But in addition to the above statements the patient also + began to make others of a definite dementia prcox type. + About ten days after admission she said, "What any one says + goes right through my brain," or she talked of being + hypnotized. "The typewriting machine turned my eyes--three + or four girls turned my eyes--they look at me and get their + chance, their left eye--turning me into images. I want to + be the way I was born--turn my body! look how their bodies + are turned before they die," or "Take it if you get it--he + got the name out--I was over there to death--himself to + death--of, you know--you played out--she is played out." + ... This while she snickered between the sentences. As + early as four weeks after admission she had begun to giggle + or laugh, often in an empty fashion, and a transition from + the more constrained stuporous state, with interruptions of + laughter, to an indifferent silly, muttering to herself was + gradual. + + In 1909 she was described as not talking, standing around, + showing no interest in anything, muttering. The only + response obtained was "I don't know." In December, 1911, + she was transferred to another hospital as a case of + deteriorated dementia prcox. + +_To Recapitulate:_ We have here a young woman who for a year had +indefinite mental symptoms and suddenly developed a stupor. This was +atypical in that she sang and wrote when otherwise apparently deeply +stuporous. When persuaded to talk, her utterances, even as early as ten +days after admission, were of a malignant type and with such statements +she giggled. This last is apparently a highly important sign. Quite +frequently in our cases the first signal of a dementia prcox reaction +has been giggling in a setting of what was apparently a typical benign +stupor. + +As has frequently been stated, symptoms of benign stupor are closely +interrelated. Consequently the reaction is, when benign, a consistent +one. We do not find free speech with profound apathy and inactivity, +nor do we expect to meet with unimpaired intellectual functions when +other evidences of deep stupor are present. The inconsistency of mental +operations which characterize dementia prcox, however--the "splitting" +tendency which Bleuler has emphasized in his term "schizophrenia"--is +just that added factor which may produce disproportionate developments +of the various stupor symptoms in the dementia prcox type of that +reaction. Examples of this have been given in the two cases just quoted. +The history of the following patient shows this tendency more +prominently. + + + CASE 22.--_Nellie H._ Age: 20. Admitted to the Psychiatric + Institute June 11, 1907. + + _F. H._ The father had repeated depressions; he died of + typhus fever. The mother was living. + + _P. H._ The brother of the patient stated that she was like + other girls, and very good at school. At 16 she became + quieter, less energetic. She came to America at 17. After + arriving here she has seemed low spirited, cranky and + faultfinding. She often complained of indefinite stomach + trouble and headaches; when at home she often had a cloth + around her head. The informant recalled that she said, "I + wish I could get sick for a long time and get either cured + or die." However, she worked. For one and a half years + prior to admission her "crankiness" is said to have become + much worse. She complained continually of being tired; + quarreled much with her mother; said she did not have + enough to eat. It is also stated that she was constantly + afraid of losing her job. + + _History of Psychosis:_ For six months before admission she + said frequently that her boss was giving her hints that he + liked her. (She did not know him socially at all.) Six days + before admission she came home, saying the boss had told + her he had no more work for her. Nevertheless, she went + back next day and was again sent home. At home she sat + gazing. Next day again wanted to go and see the boss, but + was prevented. At times she tried to get out of the window; + again sat gazing, repeating to herself "Always be true." + She said she was in love with the boss. When the doctor + gave her medicine she thought it was poison. Finally she + began to be talkative and elated. At the _Observation + Pavilion_ she became very quiet. + + _Under Observation:_ She lay in bed indifferent, not + eating, unless spoon-fed, when she would swallow. She + soiled herself. She answered no questions as a rule, and + only on one occasion, when urged considerably, said in + answer to questions that this was a hospital, so that she + evidently had more grasp on the nature of her environment + than her behavior indicated. To her brother who called on + her during the first ten days she said she could not find + her lover here (an idea inconsistent with the benign stupor + picture). + + Then she became more markedly stuporous, drooling saliva, + very stiff, often lying with head half raised, gazing + stolidly, never answering, soiling. Later, after a month, + this was less consistent. She now and then went to the + closet, sometimes she smiled, ate some fruit brought to + her, spoke a little. Repeatedly when people came she clung + to them, wanted to go home, again was seen to weep + silently. On another occasion she suddenly threw the dishes + on the floor with an angry mood, without there being any + obvious provocation. Again she got quite angry when urged + to eat her breakfast, and on that occasion pulled out some + of her own hair. Usually she had to be fed, was stiff, + sitting with closed fists, not reacting as a rule in any + other way, wholly inaccessible and has been that way for + years. The stupor merged into a catatonic state merely by + the development of the inconsistency in her affective + reactions. + +We see then that inconsistencies among the stupor symptoms themselves +and the intrusion of definitely dementia prcox symptoms differentiate +the malignant from the benign reactions. As a matter of fact, we find, +as a rule, that careful examination of the onset reveals further +atypical features, suggestions or definite evidences of a dementia +prcox reaction before the stupor itself appears. One common occurrence +is a slow deterioration of character and energy that proceeds for months +or years before flagrantly psychotic symptoms appear. + +Then when delusions or hallucinations are eventually spoken of by the +patient, an appropriate or adequate reaction is lacking. In a benign +psychosis false ideas do not appear with an equable mood unless the +stupor reaction has already begun. + +More important than this, although in benign stupors there may be a +reduction or an insufficient affect, it is never inappropriate. This +pathognomonic symptom of dementia prcox frequently occurs in the onset +to malignant stupors. In fact we often find in reviewing such cases that +a plain dementia prcox reaction has been in evidence, that a diagnosis +has not been made simply because the stupor picture blotted out this +earlier psychosis before an opinion was formed. Frequently these early +symptoms are reported in the anamnesis and not actually observed by the +physician. + +Three cases may be cited as examples of dementia prcox onsets. It will +be noted that the ensuing stupors were, like those already quoted, +atypical. + + + CASE 23.--_Catherine H._ Age: 21. Admitted to the + Psychiatric Institute October 10, 1904. + + _F. H._ The mother's brother had two attacks of delirium + tremens. The mother died when the patient was eleven years + old; she is said to have been normal. The father was + living. + + _P. H._ The patient was always a nervous child, had very + bad dreams, but she was smart at school up to ten or + eleven, and played with other girls. Then she began to work + less well, got thin, more nervous, complained of headaches. + It was about that time that her mother died. (The reaction + to the death was said not to have been different from that + of her sister.) She was kept at home and was quiet.... "You + could see something was working on her." She began to + menstruate at 14, and it was claimed that she then wakened + up a little. It was further stated that she was always + "stuck up" about her clothes. + + At 16 she went to work in a factory, but her sister thought + the work was too much for her, so she was taken home. + Thereafter she lived alone with her father, doing his + housework, her sister having married about that time. At 17 + her hair began to come out excessively, so that she had to + cut it, and when it grew again it was gray. She became very + sensitive about this, even refused to take positions + because she thought people would remark about it. + + For two years before admission she evidently was different. + Although she did her father's housework well enough, she + turned against her sister and refused to speak to her + because, she alleged, the sister had not come to help her + in her housework. Another pronounced manifestation during + that time was her frequent talk about her bowels. She + complained of constipation, creepy, crawling sensations in + the stomach which she thought was a "tapeworm." She got + pamphlets and took patent medicines. She was taken to a + physician nine months before admission, who operated on her + for piles. While still in the hospital she asked her father + to take her home to die (although there was no reason for + such a request). Again she said the gauze had been left in + the rectum too long and that the rectum was full of wind. + Later she said the rectum was closing up. After this, the + sister stated, she was extremely nervous if she passed a + day without a movement of the bowels. She was quiet + henceforth, went out less and said little, claiming it was + better for her head if she said little. She often sat, head + in hand, in the hall. All through the summer she frequently + remarked, "I am a good girl." Four months before admission + during a period of five weeks she would let her bowels move + when standing up. This was relieved by enemas. The father + states that she was cranky to him, that sometimes when he + merely asked a question she would say, "You hurt my + feelings," and once, "You break my heart." Occasionally she + seemed to worry about the money spent for her on doctors + and medicine. + + About two months before admission she said everybody was + looking at her. Ten days before admission she said, "I have + been sick all this time and thought I was going to die. Now + I think Tom (her brother) is going to die." She became + fearful of being left alone. Finally she went to the + priest, who told her to go home. Then she prayed, leaving + the candles burning in the room. That night she was found + kneeling before a church in her nightgown. Again she threw + a lot of articles into the yard, saying a curse had been + put on her by her father, and she did not wish to give him + anything. When she was taken to the Observation Pavilion + she said, "I am a good girl--my mother is dead--it is all + my father's fault." + + At the _Observation Pavilion_ she put her arm under a hot + water faucet "to save the world," prayed and laughed--again + sank back and appeared as if asleep. She said, "I hear + angels telling me how to pray when I lose my + thoughts--sisters and nuns are all around me here, to save + and purify the world now and forever, and at the hour of + our death." + + _Under Observation:_ On admission the patient kept her eyes + closed, sang hymns in measured tones, or prayed, or showed + a certain ecstasy in her face while her lips quivered and + tears ran down her cheeks. On the whole, she answered few + questions. When asked how she felt, she said she was happy. + (Why do you cry?) "I was crying when I asked God to save + souls." (Are you afraid?) "Not now, I have been afraid of + everything on Earth ever since my mother died." (What do + you mean?) "No one would look at me or talk to me--they + said I was a bad girl, but I was pure." Again she said, + "They laughed about me, talked about me--and they drew up a + play about me--Devil's Island." Or she spoke about having + had stomach trouble, bowel trouble, teeth trouble, eye + trouble, compound, complicated trouble. (What do you mean?) + "Father scolding all the time, he sent me to get bug + medicine (true). God gives that medicine to the one that + started all the trouble--Devil's Island." + + She soiled her bed and was asked why she did it. She said + "I have been transformed into a baby, the Lord said I was + too pure to be a woman--I had to become a baby to save the + world." Or when asked her name she called herself "Baby + Chadwick of the whole world--divine Irish Catholic + World--Amen," or again "I am the Roman Catholic Irish + Divine Baby." + + Although she was not essentially disoriented she called the + place "mid-heaven," or "a holy house, sort of a hospital." + She also said, "In two years more there will be a new world + and it will be more happy and holy." + + The day after entrance the patient, though in part as + described, had a spell when she kept her eyes closed and + was rigid. Spells like these returned. (About a month after + admission she became completely stuporous.) She prayed at + times, at other times was constrained, or kept her eyes + closed. Her orientation throughout was good. The content of + her psychosis, in addition to the praying attitude, had a + more or less vague religious coloring. Thus she called the + hospital the "House of God." Again, when on one occasion + she had jumped at the window guard and was asked "why?" she + said "holy communion." Again she said she was "Mary, Virgin + Mother." But this religious trend was intermingled with + remarkable elements of another sort. Thus when in order to + study her knowledge of the events after admission, she was + asked what she had done when she was brought into the ward, + she said, "I went into the sanctuary where my bowels moved + and water passed from me." (Why do you call it sanctuary?) + "Because Jesus did the same thing I did." + + Possibly vague sexual allusions are also contained in the + following: She said one day to the doctor, "Everything went + wrong last night, good, pure, true and holy doctor, I led + you astray and you were dying last night, may the Almighty + God forgive me, I ought to have died, but I fought it out, + for, if I had died, my mother's soul would not have been + saved in Heaven and from the flames of Hell." Again, "I + will not look at you again, good, pure, holy doctor of the + world." (Why?) "I am afraid I will lead you astray." And + also: "I led James. Peter astray too." It should be added + that she sometimes masturbated rather shamelessly. + + She said she heard her mother's voice. (What did she say?) + "Something in the sky for me, angels call for me." (What do + the angels say?) "The name of my good mother in Heaven." + Again she said she had heard her mother the night she came + here. (What did she say?) "It was like a voice--feed the + calf--that means me, I suppose." + + Then after a month the stupor became more continuous. She + lay totally inactive for the most part, had to be fed, + soiled herself, drooled saliva, was at times cataleptic, + often rigid. Her limbs became cyanotic. A few times tears + were seen. On other occasions she whispered "peace," or + "peace for hazing," or "pray--peace," or "I like to be + good." Usually no responses could be obtained. + + After some months she was at times seen laughing. This + gradually passed into a state of total disinterestedness + and inaccessibility. She could finally be made to polish + the floor in an automatic fashion, but never spoke, and + five years after admission she was transferred to another + hospital, where she died (eleven years after admission to + the ward of the Institute) without any change in her mental + condition having taken place. + + + CASE 24.--_Adele M._ Age: 22. Admitted to the Psychiatric + Institute November 11, 1904. + + _P. H._ The father stated that the patient was always + "cranky," had outbursts of temper, even when a small child + and was quarrelsome; also said that she was "seclusive," + had few friends, was averse to meeting people, never had a + beau. She was taken out of school at 14 because she was not + promoted on two successive occasions from the same class. + Then she was put to work, but she was usually discharged + for incompetency. + + _Onset of Psychosis:_ Three years before admission it was + noted that she laughed occasionally without cause. She was + idle. This laughing, and also crying, was sometimes more + frequent, again less noticeable. + + Six months before admission she began to say she wanted to + leave home, but made no move to do so. Then she began to + speak of bad odors, made some remarks about the neighbors + talking about her--saying she should kill herself; again + she said the family would be brought to death, or the + mother was falling to pieces, the father looked sick. She + also said her head was swelling and was getting thick. + Finally she wanted to hire a furnished room and kill + herself and asked if 75 cents which she had was enough to + do it with. + + Two weeks before admission she left home, wandered about + all night, was picked up by the Salvation Army, and + returned to her home. She said she wanted to die. + + At the _Observation Pavilion_ she stated that her mother + was falling to pieces and her father sick. She also said + she wanted to die. + + _Under Observation:_ The patient was at first petulant, + saying "I don't want to stay here," turning her face away + from the doctor, generally uninterested. Though it could be + established that she was quite oriented, often her answers + were "I don't know," or she did not answer. But she was + also seen crying at times, and she was apt to bite her + finger nails. She had to be tube-fed. Gradually these + tendencies increased so that she lay in her bed with head + covered, saying in a peevish tone, when spoken to, "Oh, let + me alone." And for years she was mute, lying with her head + covered, tube-fed. When rexamined in 1914 (ten years + later), she was found lying in bed with an empty smile. + There was paper stuffed in her ears. When approached, she + turned her head away and would not talk. + + + CASE 25.--_Catherine W._ Age: 42. Admitted to the + Psychiatric Institute November 11, 1904. + + _F. H._ The father died at 75, the mother at 44. Two + sisters died of tuberculosis. A brother wanted to marry but + was opposed by the father; he set fire to the house of the + girl and then drowned himself. + + _P. H._ The patient came to this country when 20, and + worked for some years as a servant. Then she married after + a short acquaintance. The husband, according to his own + statement, drank, and there was friction from the first. + She left him a few weeks after marriage, and a few months + later he went to Ireland; she also went some time later but + did not go to see him. Then they lived together again. They + had four children, but had had no intercourse for nine + years. + + _Development of Psychosis:_ Eight years before admission + the patient became nervous, slept badly, but got better. It + was claimed that for six years she had been quieter and + more sullen than before. Three years before admission the + patient had to take a place as janitress, since she needed + the money. From the first she had trouble with the tenants + and accused everybody of being in league against her. Some + six or eight weeks after she had taken the position, she + developed what was called typhoid fever, and some time + later the daughter came down with the same disease. After + the typhoid she was more antagonistic towards her husband, + accused him of infidelity, repeatedly locked him out of the + house, but continued to do her housework. About six months + after this illness she left her home, but returned in a + week. She had vague ideas thereafter that the priests were + saying things against the family, and she often quarreled + with the tenants. For a year she had done no work but sat + about. Ten days before admission she stopped eating. + + _Under Observation:_ The patient was mute, stolid, gazing + straight ahead, sometimes cataleptic. She had to be + tube-fed, was usually very resistive to any passive + motions; quite often she retained her urine, but she did + not hold her saliva. Yet there was some quick responses at + least in the beginning. At such times it was found that she + was oriented, but nothing could ever be obtained about her + feelings, etc., except that she once said, when asked + whether she was worried, that she "felt weak," had "nothing + to worry about." Occasionally she was seen to cry silently; + at times she would breathe faster when questioned, or + flush; once she took hold of the doctor's hand when he + questioned her, and cried, but made no reply. On another + occasion she was affectionate to her son, kissed him, + although she paid no attention to her daughter who + accompanied the son. Later she said to the nurses, "He is + the best son that ever lived." But more and more she became + disinterested, totally inaccessible, resistive, had to be + tube-fed. In this condition she remained for five and a + half years. At the end of that time she died of tubercular + pneumonia. + + + + +CHAPTER XII + +DIAGNOSIS OF STUPOR + + +In any functional psychosis an offhand diagnosis is dangerous. When one +deals with such a condition as stupor, however, the problem is exacting, +for, although "stupor" may be seen at a glance, what is seen is really +only a symptom or a few symptoms. "Stupor," then, is more of a +descriptive than a diagnostic term. The real problem is to determine the +psychiatric group into which the case should be placed. This is a +difficult task, for the differential diagnosis rests on the observation +and utilization of minute and unobtrusive details. A correct +interpretation can be only reached by obtaining a complete history of +the onset and observing the behavior and speech of the patient for a +long period, usually of weeks, sometimes of months. With these +precautionary words in mind, it may be well to summarize briefly the +diagnostic problems in connection with benign stupor. + +In the first place one naturally considers the differentiation from +conditions of organic stupor or coma. Since psychotic stupors never +develop without some signs of mental abnormality, the history is usually +a sufficient basis for final judgment. In case no anamnesis is +obtainable the functional nature of the trouble may be recognized by the +absence of those physical signs which characterize the organic stupors. +One sees no violent changes in respiration, pulse or blood-pressure, +such as are present in the intoxication comas of diabetes or nephritis. +There is no characteristic odor to the breath, and the urine is +relatively normal. The unconsciousness of trauma or apoplexy is +accompanied by focal neurological signs. Even in aerial concussion (so +frequently seen in the war) where no one part of the brain is +demonstrably affected more than another, there are neurological +evidences of what one might call "physiological" unconsciousness. The +eyes roll independently, the pupils fail to react to light. On the other +hand, there are definite symptoms characteristic of the functional +state. Mental activity is evidenced by a muscular resistiveness or +retention of urine. Even in states of complete relaxation the eyes move +in unison, the pupils react to light, and almost universally the corneal +reflex is present. The patient appears in a deep sleep rather than +actually unconscious. + +The post-epileptic sleep may resemble a stupor strongly. But this +condition is temporary and the situation and appearance of the patient +betrays the fact that he has just had a convulsion. Rarely, protracted +stuporous states occur in epilepsy which closely resemble the conditions +described in this book. In fact it is probable the true stupors may +occur in epilepsy just as in dementia prcox or manic-depressive +insanity. + +There is usually little difficulty in the discrimination of hysterical +stupor. Occasionally it shows, superficially, a similarity to the +manic-depressive type. Fundamentally, there is a wide divergence between +the two processes, in that in the hysterical form a dissociation of +consciousness takes place, the patient living in a reminiscent, +imaginary or artificially suggested environment, while in a true stupor +there is a withdrawal of interest as a whole and a consequent diffuse +reduction of all mental processes. This difference is sooner or later +manifested by the appearance in the hysteric of conduct or speech +embodying definite and elaborated ideas. + +As has been stated fully in the last chapter (to which the reader is +referred), the stupor of dementia prcox is to be differentiated from +that of manic-depressive insanity by the inconsistency of the symptoms +in the former and the appearance of dementia prcox features during the +stupor, such as inappropriate affect, giggling, or scattering. Further, +the nature of the disorder is usually manifest before the onset of the +stupor as such. + +Sometimes very puzzling cases occur in more advanced years when it is +difficult to say whether one is dealing with involution melancholia or +stupor. Such patients show inactivity, considerable apathy and wetting +and soiling, and with these a whining hypochondria, negativism, and +often a rather mawkish sentimental death content without the dramatic +anxiety which usually characterizes the involution state. In these cases +the diagnosis is bound to be a matter of taste. In our opinion it is +probably better to regard these as clinically impure types. They may be +looked on as, fundamentally, involution melancholias (the course of the +disease is protracted, if not chronic) in whom the regressive process +characteristic of stupor is present as well as that of involution. + +Great difficulties are also met with in the manic-depressive group +proper. So often a stupor begins with the same indefinite kind of upset +as does another psychosis that the development may furnish no clew. Any +condition where there is inactivity, scanty verbal productivity and poor +intellectual performance resembles stupor. This triad of symptoms occurs +in retarded depressions, in absorbed manic states and in perplexities. +Negativism and catalepsy are never well developed except in stupor. So +if these symptoms be present the diagnosis is simplified. But they are +often absent from a typical stupor. Let us consider these three groups +separately. + +The most important difference between stupor and depression lies in the +affect. Although inactive and sometimes appearing dull the depressive +individual is not apathetic but is suffering acutely. He feels himself +wicked, paralyzed by hopelessness, and finds proof of his damnation in +the apparent change of the world to his eyes and in the slowness of his +mind. But he is acutely aware of these torments. The stupor patient, on +the other hand, does not care. He is neither sad nor happy nor anxious. +This contrast is revealed not only by the patients' utterances but by +their expressions. The stuporous face is empty, that of the other lined +with melancholy. The intellectual defect, too, is different. In retarded +depression the patient is morbidly aware of difficulty and slowness, but +on urging often performs tests surprisingly well. In the stupor, +however, one is faced with an unquestionable defect, a sheer +intellectual incapacity. + +In Chapter VIII the differential diagnosis between perplexity and stupor +has already been touched upon. Here again the affect is a point of +contrast. The patient has not too little emotion but too much. The +feeling of intangible, puzzling ideas and of an insecure environment +causes the subject distress, of which complaint is made and which can be +witnessed in the furrowed brow and constrained expression. There is +also, as we have seen, a rich ideational content in these cases, if one +can get at it. The mind is not a blank, as in the stupor, or concerned +only with delusions of death. + +Finally, there are the absorbed manic states. These are the most +difficult, inasmuch as the patient is often so withdrawn and so +introverted that at any given interview there may be no objective +evidence of mood or ideas. Here the development of the psychosis is +often an aid to diagnosis. The patient passes through phases of +hypomania to great exultation, the flight becomes less intelligible, +with this the activity diminishes until finally expression in any form +disappears. If this sequence has not been observed, continued +observation tells the tale. The patient still has his ideas and may be +seen smiling contentedly over them (not vacuously as does the +schizophrenic) or he may break into some prank or begin to sing. Any +protracted familiarity with the case leads to a conviction that the +patient's mind is not a blank, but that his attention is merely directed +exclusively inward. Then, too, when his ideas are discovered, it is +found that they are not exclusively occupied with the topic of death. + + + + +CHAPTER XIII + +TREATMENT OF STUPOR + + +In dealing with cases of benign stupor the first duty of physician and +nurse is naturally the physical hygiene of the patient. More is needed +to be done in the bodily care of these persons than for most of the +inmates of our hospitals for the insane. It is perhaps no exaggeration +to claim that a deeply stuporous patient needs as much attention as a +suckling babe. In the first place, the patient must be fed. It is +important for mental recovery that the individual in stupor should be +stimulated to effort as much as possible. Consequently there is an +economy of time in the long run in taking pains to get the patient to +feed himself in so far as that is possible. He should be led to the +table and assisted in handling his own spoon and cup. If this is not +practicable, he should then be spoon-fed, and if this in turn is found +to be out of the question, tube-feeding should be resorted to. But this +last should never be looked on as a permanent necessity, but only as a +method of maintaining the patient's health until such time as he may be +capable of independent taking of nourishment. In exactly the same way it +is of prime importance to get the patient to attend to the natural +habits of excretion. He should be led to the toilet or to a chair +commode, and efforts to this end should be persistent, just as are those +of a good child's nurse who has the ambition of making her charge +develop normal habits. Naturally those who retain urine and feces should +be watched to see that this retention does not last long enough to +menace health. The physical aspects of treatment are exhausted with +consideration for cleanliness. On account of the stupor patients' +inactivity and frequent tendency to wetting and soiling, this is a +particularly important consideration. It goes without saying that the +perineal region should be kept scrupulously clean. If any infections are +to be avoided, eyes, nose and mouth should also be cleansed frequently. +A patient who is so indifferent as to keep the eyelids open for such a +long time that the sclera dry and ulcerate is also apt to let flies +settle and produce serious ophthalmic disease. + +Less obvious and more important are the measures undertaken for the +mental hygiene of the case. On account of the tendency present in so +many patients for sudden action while in the midst of an apparently deep +and permanent inactivity, it is necessary that these cases be not +isolated but remain under constant observation. This is particularly +true of those who have demonstrated impulsive suicidal explosions. + +Not only on the basis of the psychological theory of the stupor process, +but from the observed phenomena of recovery, we gather that mental +stimulation is of first importance if an amelioration of the condition +is to be attempted. If the stupor reaction be a regression, which is +essentially a withdrawal of interest and energy rather than a fixation +on a false object, then excitement is desirable and interest must be +reawakened. The withdrawal is temporary (inasmuch as the psychosis is +benign), but just as a normal person wakes more readily on a clear +sunshiny day than when it rains, so the more cheering the environment +the more rapid the recovery. + +Consequently, although trying to those in charge, persistent attention +should be given the patient. Feeding and hygienic measures probably have +considerable value in this work. As soon as it is at all possible the +patients should be got out of bed and dressed. When up, efforts should +be directed towards making them do something, even if it be something as +simple as pushing a floor polisher. On account of their lack of +enthusiasm the stupor cases are often omitted from the list of those +given occupation and amusement. Even if they go through the motions of +work or play with no sign of interest, such exercise should not be +allowed to lapse. Then, too, the environment should be changed when +practicable. A patient may improve on being moved to another building. + +Perhaps the most potent stimulus that we have observed is that of family +visits. In most manic-depressive psychoses visits of relations have a +bad effect. The patients become excited, treat the visitors rudely, +perhaps even assault them, and all their symptoms are aggravated. But +the stupor needs excitement, and an habitual emotional interest is more +apt to arouse him than an artificial one. In another point the situation +differs. As a rule manic-depressive patients have delusional ideas or +attitudes in connection with their nearest of kin, so that contact with +these stirs up the trouble. The stupor regression going beneath the +level of such attachments leaves family relationships relatively +undisturbed. Hence, while the visit of a husband is likely to produce +nothing but vituperation or blows from a manic wife, the stuporous woman +may greet him affectionately and regain thereby some contact with the +world. + +So many cases begin recovery in this manner that it cannot be mere +chance. One patient's improvement, for instance, dated definitely from +the day a nurse persuaded her to write a letter home. It is striking, +too, how quickly a patient, while somewhat dull and slow, will brighten +up when allowed to return home. A similar improvement under these +circumstances is often seen in partially recovered cases of involution +melancholia, in whom a psychological regression similar to that of +stupor takes place. Such experiences make one wonder whether perhaps +these alone of all our insane patients would not recover more quickly at +home than in hospitals, provided nursing care could be given them. + +This is a mere suggestion. Before treatment can be rational the nature +of any disease process must be known, and we do not pretend to have done +more as yet than outline the probable mental pathology of the benign +stupors. The next step is to put theory into practice and experiment +widely with various means to see if by appropriate stimulation the +average duration of these psychoses cannot be reduced. It is largely +with the hope of inducing other psychiatrists to carry on such work that +this book is written. There is no other manic-depressive psychosis +which, theoretically, offers such hope of simple psychological measures +being of therapeutic value. + + + + +CHAPTER XIV + +SUMMARY OF THE STUPOR REACTION + + +Having discussed in detail the various symptoms and theoretic aspects of +the benign stupors, it may be well to have these observations and +speculations summarized. + +It being established that stupors occur as a temporary form of +insanity[12] psychiatry is faced at once with the problem of describing +these conditions accurately in order to ascertain their nosological +position. To this end we first examined typical cases of deep stupor and +found that the clinical picture is made up of the following symptoms: In +the foreground stands _poverty of affect_. The patients are almost +unbelievably apathetic, giving no evidence by speech or action of +interest in themselves or their environment, unmoved even by painful +stimuli. Their faces are wooden masks; their voices as colorless when +words are uttered. In some cases sudden mood reactions break through at +rare intervals. The second cardinal symptom is _inactivity_. As a rule +there is a complete cessation of both spontaneous and reactive movements +and speech. So profound may this inhibition be that swallowing and +blinking of the eyes are often absent. The trouble is not a paralysis, +however, for reflexes without psychic components are unaffected. +Possibly related to the inactivity is the preservation of artificial +positions which is called _catalepsy_, a fairly frequent phenomenon. A +tendency opposite to the inactivity is seen in _negativism_. This +perversity is present in all gradations from outbursts of anger with +blows and vituperation to sullen, or even emotionless, muscular +rigidity. This last occurs most often when the patient is approached but +may be seen when observations are made at a distance. Frequently +_wetting_ and _soiling_ are due to negativism, when the patient has been +led to the toilet but relaxes the sphincters so soon as he leaves it. A +constant feature is a _thinking disorder_. On recovery memory is largely +a blank even for striking experiences during the psychosis and, when +accessible during the stupor to any questioning, a failure of +intellectual functions is apparent. An _ideational content_ may be +gathered while the stupor is incubating, during interruptions, or from +the recollections of recovered patients. Its peculiarity is a +preoccupation with the theme of death, which is not merely a dominant +topic but, often, an exclusive interest. Probably to be related to this +is a tendency, present in some cases, to sudden suicidal impulses, that +are as apparently planless and unexpected as the conduct of many +catatonics. Finally the disease is prone to exhibit certain _physical_ +peculiarities. A low fever is common and so are skin and circulatory +anomalies. A loss of weight is the rule, and menstruation is almost +always suppressed. + +As to the frequency of stupor no figures are available, for the simple +reason that the diagnosis in large clinics has not been made with +sufficient accuracy to justify any statistics. Most of these cases are +usually called catatonia, depression, allied to manic-depressive +insanity or allied to dementia prcox. The majority of the stupors +reported in this book were in women, but this is merely the result of +chance, since it has been easier in the Psychiatric Institute to study +functional psychoses in the female division, while the male ward has +been reserved largely for organic psychoses. The majority of the +patients seem to be between 15 and 25 years of age, so that it is, +presumably, a reaction of youthful years. In our experience most cases +occur among the lower classes, which agrees with the opinion of Wilmanns +who found this tendency among prisoners. + +This gives a brief description of the deep stupor. But even our typical +cases did not present this picture during the entire psychosis. They +showed phases when, superficially viewed, they were not in stupor but +suffered from the above symptoms as tendencies rather than states. There +are also many psychoses where complete stupor is never developed. This +gives us our justification for speaking of the _stupor reaction_, which +consists of these symptoms (or most of them) no matter in how slight a +degree they may be present. The analogy to mania and hypomania is +compelling. The latter is merely a dilution of the former. Both are +forms of the manic reaction. We consequently regard stupor and partial +stupor as different degrees of the same psychotic process which we term +the stupor reaction. To understand it the symptoms should be separately +analyzed and then correlated. + +The most fundamental characteristic of the stupor symptoms is the change +in affect which can be summed up in one word--apathy. It is fundamental +because it seems as if the symptoms built around apathy constitute the +stupor reaction. The emotional poverty is evidenced by a lack of +feeling, loss of energy and an absence of the normal urge of living. +This is quite different from the emotional blocking of the retarded +depression, for in the latter the patient shows either by speech or +facial expression a definite suffering. The tendency to reduction of +affect produces two effects on such emotions as internal ideas or +environmental events may stimulate. Exhibitions of emotion are either +reduced or dissociated. For instance, anxiety is frequently diminished +to an expression of dazed bewilderment; or, isolated and partial +exhibitions of mood occur, as when laughter, tears or blushing are seen +as quite isolated symptoms. This latter--the dissociation of +affect--seems to occur only in stupor and dementia prcox. It should be +noted, however, that inappropriateness of affect is never observed in a +true benign stupor. A final peculiarity is the tendency to interruption +of the apathetic habit, when the patient may return to life, as it were, +for a few moments and then relapse. + +Closely related to the apathy, and probably merely an expression of it, +is the inactivity which is both muscular and mental. It exists in all +gradations from that of flaccidity of voluntary muscles, with relaxation +of the sphincters, and from states where there is complete absence of +any evidence of mentation to conditions of mere physical and psychic +slowness. After recovery the stupor patient frequently speaks of having +felt dead, paralyzed or drugged. + +By far the commonest cause of emotional expression or interruption in +the inactivity is negativism. This is a perversity of behavior which +seems to express antagonism to the environment or to the wishes of those +about the patient. In the partial stupors it is seen as active +opposition and cantankerousness. In the more profound conditions it is +represented by muscular resistiveness or rigidity, or refusal to swallow +food when placed in the mouth. Occasionally, too, the patient may even +in a deep stupor retain urine so long that catheterization is necessary. +All the explanations which one may gather from the patients' own +utterances, mainly retrospective, seem to point to negativism expressing +a desire to be left alone. The appearance of perverse behavior in +aimless striking or mere muscular rigidity seems to be an example of +dissociation of affect. + +Catalepsy is an important symptom because, although it occurred in +slightly less than a third of our cases, it seems to be a peculiarity of +the stupor reaction found but rarely in other benign psychoses. It seems +never to occur without there being some evidence of mental activity, +and, consequently, we are forced to conclude that it is of mental rather +than of physical origin. Just what it means psychically it is impossible +to state without much more extended observations. We conjecture +tentatively, however, that the retention of fixed positions is in part +merely a phenomenon of perseveration, and in part an acceptance of what +the patient takes to be a command from the examiner, and sometimes a +distorted form of muscular resistiveness. + +The intellectual processes suffer more seriously in stupor than in any +other form of manic-depressive insanity. Not only do the deep stupors +betray no evidence of mentation during the acme of the psychosis, but +retrospectively they usually speak of their minds being a blank. +Incompleteness and slowness of intellectual operations are highly +characteristic features of the partial stupors and of the incubation +period of the more profound reactions. The features of this defect are a +difficulty in grasping the nature of the environment, a slowness in +elaborating what impressions are received, with resulting +disorientation, poor performance of any set tests and incomplete memory +for external events when recovery has taken place. At times the thinking +disorder may develop with great suddenness or improve as quickly, and a +tendency to isolated evidences of mental acuity is another example of +the inconsistency which is so highly characteristic of stupor. We should +note, however, that these sporadic exhibitions of mentality are always +associated with brief emotional awakening. + +When we turn to examine the fragmentary utterances of stupor patients, +we are surprised by the narrowness and uniformity of the ideational +content. It seems to be confined to thoughts of death or closely related +conceptions. Thirty-five out of thirty-six consecutive cases at one time +or another referred literally to death. It is commonest during the +onset, as all but five of these patients spoke of it during the +incubation of their psychoses. Hence we conclude that death ideas and +stupor are consecutive phenomena in the same fundamental process. As +two-thirds of the series interrupted the stupor to speak of death or to +attempt suicide, we assume that this relationship persists. Only a +quarter gave any retrospective account of these fancies, so we presume +that their psychotic experiences were repressed with recovery. + +The usual form in which the idea appears is as a delusion of going to +die or, literally, of being dead. It may appear as being in Heaven or +Hell. A theoretically important group is that which includes the +patients who, in addition, speak of being in situations such as under +the water or underground, which we have mythological and psychological +evidence to believe are formulations of a rebirth fantasy. Not rarely, +preoccupation with death is expressed in sudden impulsive suicidal +attempts. + +The affective setting of these different formulations is important. A +delusion of literal death occurs with complete apathy. The wish to die +is apt to appear without the usual accompaniment of sadness or distress +but still with considerable energy when impulsive suicidal attempts are +made. A prospect of death, particularly when there is anticipation of +being killed, is apt in manic-depressive insanity to occur in a setting +of anxiety. Similarly one ordinarily observes fear in the patient who +has delusions of drowning or burial. In the stupor cases, however, this +painful affect seems to be reduced to a mere dazed bewilderment or +feeble exhibitions of a desire for safety, such as the slow swimming +movements of a patient who thought she was under the water. When these +ideas of danger become allied to everyday interests--husband or child +imperiled, etc.--a weak affect in the form of depression is apt to +occur. + +Physical symptoms are more common than in any other benign psychosis. Of +these the most nearly constant is a low fever, the temperature running +between 99 and 101. Twenty-eight out of thirty-five cases had this +slight elevation with a tendency for it to occur immediately at the +beginning of marked stupor symptoms. Although the evidence does not +positively exclude any possibility of infection, it speaks distinctly +against this view. A possible explanation is that the low fever is a +secondary symptom. The suprarenal glands may function insufficiently as +a consequence of the emotional poverty, since all emotions which have +been experimentally studied seem to stimulate the production of +adrenalin. Without this normal hormone for the activity of the +sympathetic nervous system, there would be a disturbance of skin and +circulatory reactions that would interfere with the normal heat loss. +Suggestive evidence to support this view comes from the frequency with +which the extremities are cyanotic or cold, the skin greasy, sweating +profuse or absent, and so on. Further observations are necessary to +confirm or disprove this hypothesis, but we feel inclined to accept it +tentatively because it is plausible and consistent with the view that +stupor is essentially a psychogenic type of reaction. Another physical +anomaly, which is presumably of endocrine origin, is the suppression of +the menses. This probably results from lowered nutrition. In some cases +it ensues directly on a psychic crisis before any nutritional change can +have taken place. Finally, among the symptoms of possible physical +origin, epileptoid attacks were described in two of our cases. This is +chiefly of interest in that such phenomena are extremely rare in the +benign psychoses. + +We believe that the mental symptoms summarized above constitute a +specific psychotic type of reaction capable of appearing in any severity +from mere lethargy and indifference to profound stupor. Since the +prognosis is good, we feel obliged to classify this with the +manic-depressive reactions. Further justification for this grouping is +found in the occurrence of the stupor reaction as a phase in many +manic-depressive psychoses. A patient may swing from mania to stupor as +from mania to depression, and when the partial stupors are recognized as +milder forms of the same process, it seems to be a frequent type of +reaction. + +If stupor be a reaction type, its laws must be psychological. According +to the view of modern psychopathology, the essence of insanity is +regression with indolent thinking as opposed to progressive and +energetic mentation. One can look on stupor as being a profound +regression. Effort is abandoned (apathy and inactivity), while the +ideational content expresses a desire for a retreat from the world in +death. It is possible to think of this regression as a return to the +mental habit of the suckling period, when spontaneous effort is at its +minimum. This, too, is the time when petulance and tantrums are frequent +expression of a wish to be left alone, which may account for the +negativism as a consistent symptom of the same regressive progress. + +Just as we regress in sleep, to rise refreshed for a new day's duties, +so the stupor case often shows excessive energy in a hypomanic phase +before complete normality is reached. This corresponds again to the +age-old association of the ideas of death and rebirth which we see +together so frequently in stupor. It is the psychology of wiping the +slate clean for a fresh start. + +The development and symptoms of stupor furnish evidence in support of +the hypothesis of this type of regression. Dissatisfaction of any kind +is the setting in which the psychosis begins and the commonest +precipitating factor is some reminder of death. That loss of energy +appears with the stupor is evident from the inactivity and apathy, while +the thinking disorder can be shown to be the result of the same loss. +The different "levels" of the stupor reaction also conform to a theory +of regression. First there is mere indifference and quietness; then +appear false ideas when normality is so far abandoned as to mean a loss +of the sense of reality; withdrawal of interest from the environment, +with its consequent centering of self, leads to the next stage--that of +the spoiled child reaction; then follows the exclusion of the world +around in the dramatization of death; finally, in the deepest stupor, +mentation is so far abandoned that we can gather no evidence of even +this delusion being present. + +Atypical features in stupor have to do mainly with interruptions, +interludes as it were, of elation, anxiety or perplexity. These are +explicable as awakenings from the nothingness of stupor into +imaginations such as characterize the other manic-depressive psychoses. +When such tendencies are present, the co-existence of the stupor process +may tone down the emotional response or prevent its complete repression +so that insufficient or dissociated affects appear. A combination of the +stupor tendency to apathy with the mood of another reaction is probably +the only combination of affects to be met with in psychiatry. + +The stupor reaction, then, is a simple regression, with a limitation of +energy, emotion and ideational content, the last being confined to +notions of death. All functional psychoses are regressions. How do the +others differ from this? We need only answer this question in so far as +it concerns the clinical states resembling benign stupors. Stupors occur +frequently in catatonic dementia prcox. In this disease there is a +regression of interest to primitive fantastic thoughts, and with this a +perversion of energy and emotion. This corrupts the purity of the stupor +picture so that inconsistencies, such as empty giggling, atypical +delusions and scattered speech, occur. Other impurities are to be found +in the frequent orientation of the dementia prcox stupor patient which +is discovered to be astonishingly good, or in free speech associated +with apathy and inactivity. Such symptoms usually appear quite early and +should enable one to make a positive diagnosis within a short time after +patient comes under observation. As a matter of fact, in many if not +most cases there is a slow onset characterized by the pathognomonic +symptoms of dementia prcox before the actual stupor sets in. + +Other psychoses superficially resembling stupor are the perplexity and +absorbed manic (manic stupor) states. We have reason to believe that +both these conditions are essentially the result of absorption in +kaleidoscopic ideas. Their appearance is that of inactivity and +indifference to the outside world, just as a dreamer seems placid and +apathetic. But these reactions are not without emotion which may +sometimes be obvious, and the richness of the mental content is sooner +or later manifest. + +Finally, from a practical standpoint, an important peculiarity of benign +stupor is the tendency for response to stimulation in amelioration of +the process. Close attention to these patients is advisable, therefore, +not merely for the sake of their physical health, but also because any +attention tends to keep them mentally alive or revive their waning +energy. Visits of relations often initiate recovery in a striking way. +From occurrences such as these, psychiatrists should gain hints for +valuable therapeutic experiments. + +So much for the technical, psychiatric aspects of the stupor problem. We +have frequently spoken of it, however, as a psychobiological reaction. +If this be a sound view, similar tendencies should appear in everyday +life, the psychotic phenomena being merely the exaggerations of a +fundamental type of human and animal behavior. Shamming of death in the +face of danger and animal catalepsy come to mind at once, but since we +know nothing of the associated affective states we should be chary of +using them even as analogies. We are on safer ground in discussing +problems of human psychology. + +It is evident that there are psychological parallels between the stupor +reaction and sleep, while future work may show physiological +similarities as well. Apathy towards the environment, inactivity and a +thinking disorder are common to both. But sleep reactions do not occur +in bed alone. Weariness produces indifference, physical sluggishness, +inattention and a mild thinking disorder such as are seen in partial +stupors. The phenomena of the midday nap are strikingly like those of +stupor. The individual who enjoys this faculty has a facility for +retiring from the world psychologically and as a result of this psychic +release is capable of renewed activity (analogous to post-stuporous +hypomania) that cannot be the result of physiological repair, since the +whole affair may last for only a few minutes. + +In everyday life there are more protracted states where the comparison +can also be made. When life fails to yield us what we want, we tend to +become bored--a condition of apathy and inactivity, forming a nice +parallel to stupor inasmuch as external reminders of reality and demands +for activity are apt to call out irritability. A form of what is really +mental disease, although not called insanity, is permanent boredom, a +deterioration of interest, energy and even intelligence by which many +troubled souls solve their problems. A sudden withdrawal from the world +we call stupor. When the same thing happens insidiously, the condition +is labeled according to the financial and social status of the victim. +He is a bum, a loafer, a mendicant or, more politely, a disillusioned +recluse. Frequently this undiagnosed dement has satisfied himself with a +weak, cynical philosophy that life is not worth while. + +It is but a step from valueless life to death and the same tendency +which makes the patient fancy he is dead, leads the tired man to sleep, +the poet to sigh in verse for dissolution, and the myth maker to +fabricate rebirth. The religions of the world are full of this yearning, +which reaches its purest expression in the belief and philosophy of +Nirvana. The ideational content of stupor has also its analogue in +crime. The desire for perpetuation of relationships unprosperous in this +world is not seen only in the delusion of mutual death. One can hardly +pick up a newspaper without reading of some unhappy man or woman who has +slain a disillusioned lover and then committed suicide. + + +FOOTNOTES: + +[12] Kirby, George H.: "The Catatonic Syndrome and Its Relation to +Manic-Depressive Insanity." _Jour. of Nervous and Mental Disease_, Vol. +XL, No. 11, 1913. + + + + +CHAPTER XV + +THE LITERATURE OF STUPOR[C] + + +The cases of benign stupor which we report here are not clinical +curiosities. Taking the symptoms as the products of a reaction type, the +latter is really quite common. One, therefore, asks what other +psychiatrists have done with this material. How have they described +these stupors, how classified them? This chapter, essentially an +appendix, attempts to give a brief answer to this inquiry. No attempt is +made to catalogue all that has been written on or around this subject +but only to mention typical reports and viewpoints. + +The French, beginning with Pinel in the 18th Century, were the first to +write extensively of stupor. An excellent paper by Dagonet[13] appeared +in 1872, in which such literature as had appeared up to that time is +discussed. He defines "Stupidity" as a form of insanity in which +"delirious" ideas may or may not be present, which has for its +characteristic symptoms a state of more or less manifest stupor and a +greater or less incapacity to cordinate ideas, to elaborate sensations +experienced and accomplish voluntary acts necessary for adaptation. This +would seem to include our "partial stupor," as well as the more marked +cases. + +He quotes an excellent definition from Louyer Villermay (Dict. des sc. +md. t. LIII, p. 67). "Stupor is a term applied to stupefaction of the +brain. It is recognizable by the diminution or enfeeblement of internal +sensation and by a greater difficulty in exercising memory, judgment and +imagination. It is accompanied by a general numbness and a weakness of +feeling and movement. The patient, then, has an indefinite and stupid +expression, he understands questions put to him with difficulty, and +answers them with effort or not at all. He seems overwhelmed with sleep, +he forgets to withdraw his tongue after showing it to the doctor, he +complains of no uncomfortable sensation, of no illness, he seems to take +no interest in what goes on about him.... The stupor patient is a fool +who does not speak, in this being more tolerable than the one who speaks +[delightful naivet!]. One who is dumbfounded by surprise or fright is +also to be called stuporous." + +Dagonet says stupor results from various causes, such as exhaustion, or +emotional and intellectual factors. Clinically it varies in kind and +degree according to the situation in which it develops. When it develops +during normal mental health, it disappears when its cause does. In +insanity it appears in the course of a psychosis of some duration, of +which it seems a part, an exaggeration of some symptom of the general +condition. Evidently he views stupor as a type of reaction: as a more or +less complete suspension of the operation of intellectual faculties, a +more or less sudden subtraction of nervous forces. This reaction can +result from a fright or the memory of it, a brain lesion or trauma, the +action of narcotics, exhausting fevers, excessive grief, the terrors of +alcoholic hallucinations, epileptic seizures, profound anemia and +nervous exhaustion consequent on sexual excess. He is careful to say +that both symptoms and treatment vary with the varied etiologies. + +He credits Pinel with being the first to call attention to stupor. This +author claimed that some persons with extreme sensibility could be so +upset by any violent emotion as to have their faculties suspended or +obliterated. He noted, too, that stupors frequently terminated in manic +phases of 20 to 30 days' duration. Pinel also emphasized the apathy of +these cases. Esquirol called stupor "acute dementia," a term which +persisted in French literature for a long time. He described an +interesting circular case where alternations between mania and typical +stupor took place. He mentions too the dangerous, impulsive tendencies +of many patients. Georget emphasized the fact which Pinel had also +noted, that retrospectively the stupor patient says his mind was a blank +during the attack. In 1835 Etoc-Demazy published on the subject. He +regarded stupor not as a separate form of insanity but a complication +ensuing on monomania or mania. He recognized the partial as well as +complete stupor. He thought the condition was due to cerebral edema, as +did other writers of that period. Dagonet remarks about this last--a +lesson not learned in fifty years by the profession--that demonstrable +edema does _not_ produce the typical symptoms of stupor. Baillarger in +1843 (Annales Mdico-psychologiques) was the first whose ambition to +simplify psychiatric types led to denial of a separate kind of reaction. +He claimed that stupor was not a form of insanity but an extension of a +"dlire mlancholique." As Dagonet remarks, every symptom by which he +characterizes stupor is a psychiatric symptom and insanity can consist +just as well in the diminution as the perversion or exaltation of normal +faculties. Some of Baillarger's cases had false ideas, some apparently +none at all. Dagonet thinks this justifies two types, one a dream-like +state and another where no ideas are present, although he admits one may +be an exaggeration of the other. Brierre de Boismont (Annales +Mdico-psychologique, 1851, p. 442) compares these two kinds of stupors +to deep sleep when intelligence is completely suspended and to sleep +with dreams. (These two types would correspond to our "absorbed mania" +and true deep stupor.) He urges strongly the separation of stupor from +melancholia as an entirely different type of reaction, in this +connection citing the views pro and con of various authors. Of these +Delasiauve is particularly cogent in discriminating stupor from +melancholia on the grounds of the difference of the emotional reactions +and of the intellectual disorder and the real paucity of thought in the +former psychosis. + +After quoting these and other authors, Dagonet offers an explanation for +the diversity of opinion. He says that stupor following another +psychosis may retain some of its symptoms, so that a mixture obtains, as +often in medicine. He then gives excellent descriptions of three types: +the deep stupor with paralysis of the faculties, the cases that are +absorbed in false ideas, and ecstatic cataleptics. + +The remainder of his paper is concerned with cases and discussions about +them. He cites examples of stupor following fear or other emotional +shocks, following grave injuries such as the loss of a limb, following +head trauma and with typhoid fever. As to the last he points out that +delirious features are prominent. Many authors have assigned sexual +excesses as a cause of stupor. The psychosis, Dagonet says, is not pure +but more a mixture of hypochondria and depression. Relationship with +mania is next considered. He says that stupor may succeed, alternate +with or precede mania. His cases seem mainly to have been what we call +absorbed manics or manic stupors. In fact, he uses the last term. The +commonest introductory psychosis, he claims, is depression, but from his +brief case reports it would seem that most of his patients were not +stuporous, in the narrow sense of the term, but severely retarded +depressions. In fact, in perusing his case material comprising "stupors" +in the course of many types of functional insanity, or as a complication +of epilepsy or general paralysis, it is evident that in practice he does +not follow the discriminative definitions of the earlier portion of his +paper. For him, apparently, patients who are markedly inaccessible to +examination from whatever cause are "stuporous." He closes with +excellent remarks on physical and psychic treatment. As to prognosis he +has nothing to say beyond the opinion that most of the cases recover. + +If Dagonet be accepted as summarizing the early French work, we can +conclude that their generalizations were on the whole quite sound. These +were: that stupor is an abnormal mental reaction, usually psychogenic +but often the result of exhaustion, that it consists in a paralysis of +emotion, will and intelligence; that the prognosis is usually good; that +mental stimulation may produce recovery. What remained to be done after +this work was the refinement in detail of these generalizations, +particularly in respect to the differentiation of prognostically benign +and malignant types. But other Frenchmen did not take up this work, +apparently, for the brilliant psychopathologists of the next generations +attended to stupor only in so far as it was hysterical. + +An Englishman, however, soon took up the task, adding more exactness to +his formulations. Newington[14] published his important paper in 1874. +A nascent stage of stupor, he thinks, is a common reaction to great +exhaustion, "such as hard mental work, prolonged or acute illness, +dissipation, etc." Such conditions, like the grave psychotic forms, he +regarded as due to physical exhaustion of the brain cells, but, since he +thought psychic stress could produce this exhaustion, this "organic" +view did not bias his general formulations. He makes a division into two +stupors: Anergic Stupor and Delusional Stupor. The former may be +primary, being generally caused by a sudden intense shock (Esquirol's +"Acute Dementia"), or secondary (a) to convulsions of any kind, (b) to +mania in women, (c) to any other prolonged nervous exhaustion. The +delusional form results from (a) intense melancholia, (b) from general +paralysis in which it may be intercurrent, (c) from epileptic seizures. +When one examines his points of difference between these two types, it +becomes clear that Newington really gave an excellent differentiation of +benign and malignant stupor--in fact, it is the only serious attempt at +such discrimination prior to this present work. What is more remarkable +is the fact that, although he clearly saw the clinical differences, he +failed to see that the two types differed prognostically. His +description is given in a table sufficiently concise to justify its +quotation _in extenso_. + + _ANERGIC STUPOR_ _DELUSIONAL STUPOR_ + + _Etiology_--Hereditary and Hereditary. + individual liability to + sudden loss of _vis nervosa_. + + _Onset_--Rapid. Usually insidious, may be almost + instantaneous. + + _Symptoms_--Intellect greatly Conduct shows reasoning power. + impaired. + + _Memory_--Seems to be swept Found after recovery to have + away as far as possible. been preserved to a great + extent. + + _Emotional Capacity_--Nil or Evidence of grief, fear, etc., in + almost so. Tears frequent facial expressions and wringing + but due to relaxation of and clasping of hands. + sphincter muscles. Features Tears rare. Great contraction + relaxed, eyes vacant and not of features [grimacing?]. + constantly fixed. Eyes fixed on one + point, usually upwards or + downwards, or else obstinately + closed. + + _Volition_--Almost absent. Frequently great stubbornness, + refusal to do what is + wanted. On the other hand, + intense determination in + following out own plan. + + _Motor System_--Weak and uncertain. But little interfered with, + Patient has to be independently of sheer + led about and if placed on a asthenia, produced by + seat or in some position does patient's conduct. May stand + not move. ("Cataleptoid" behind door or kneel on floor + condition.) in constrained position even + for days. + + _Sensory System_}--Both dull. Ditto. There seems to be a + _Reflex System_ } much greater ability to bear + severe pain. + + _Pupils_--Dilated. Tendency to contraction. + + _Sleep_--Generally good. Intense sleeplessness. + + _General bodily condition_-- Affected _pari passu_ with + Emaciation, sometimes extreme, mental state and seems + usually rapid, with governed by it. + rapid recovery of flesh. + Often not much loss of + weight, though whole tone is + lowered. + + _Vascular System_--Pulse slow, Pulse weak and often quick + sometimes almost imperceptible. and thready. Complexion + Cyanotic appearance, edema anemic and sallow. The + and iciness of extremities. other appearances may be + Great decrease of vitality present but come on later + in peripheral structures, and are less marked. + as shown by asthenic + eruptions and production of + vermin. + + _Digestive System_--Tongue Tongue dry, small and furred. + clean or if furred it is moist. Refusal of food. Great + Appetite _apathetic_, bowels constipation. Dirtiness of + not irregular, but habits habits rare. + very dirty. + +If one compares these data with those given in the chapter on Malignant +Stupors, it is seen that in the main Newington has made the same +discrimination as we have. He is certainly wrong in denying "negativism" +to his anergic type. Probably, too, he attempts too fine a distinction +between the physical symptoms of the two groups. His conclusions are +interesting: that in the anergic cases there is an _absence_ of +cerebration, while amongst the delusional there is an abnormal +_presence_ of intense but perverted cerebration. This is not unlike our +own view. He thinks the difference in memory is the most important +differential point. Sex is important in determining the nature of the +stupor, for he found the anergic type following mania in females only. +He observed such an end to manic attacks in 6 out of 36 cases. All his +cases were under 30 and he regards the prognosis as good on the whole. +As to treatment he emphasizes the necessity for "moral pressure" as a +stimulus and cites a case of rapid improvement after a change of scene. + +Since 1874 very little advance has been made by British psychiatrists, +as seen by a perusal of Clouston's[15] summary in 1904. He regards sex +exhaustion as a highly frequent cause, although Dagonet had shown 32 +years before that sex abuse does not produce a true stupor. He thinks +stupor usually follows depression or mania and says that "the +'Confusional Insanity' of German and American authors is just a lesser +degree of stupor." Omitting his stupors in general paralysis and +epilepsy he makes three clinical divisions: _melancholic or conscious +stupor_, which is not a product of delusions, although delusions of +death or great wickedness may be present, impulsiveness and fits may be +observed; _anergic or unconscious stupor_, which corresponds roughly to +our deep, benign stupor; and _secondary stupor_ after acute mental +disease, which resembles our partial stupor. He warns against a rash +diagnosis of dementia in this last group. His views on the importance of +mental causation and the relation to manic-depressive insanity may be +gathered from these sentences: "The condition of the mental portion of +the convolutions in stupor is probably analogous to the stupidity of a +nervous child when terrified or bullied." "Stupor is frequently one of +the stages of alternating insanity following the exalted condition. It +is more apt to occur in those where the exalted period is acutely +maniacal. The stupor is usually melancholic in form." Since he claims +that the anergic is a "very curable form of mental disease," while only +50% of the melancholic cases recover, it seems clear that this division +is not prognostically final. The "melancholic" is evidently Newington's +"delusional" without his more accurate discrimination of symptoms. + +From the standpoint of accurate description the opinion may be ventured +that there is a gap in the literature from the early French writers and +Newington up to the paper by Kirby, which has been discussed in the +first chapter. This gap is filled by literature of the German schools +and their adherents in other countries. German psychiatry has been +concerned mainly with classification or the elaborate examination of +certain symptoms. Inevitably such a program militates against detached +objective clinical description. It is hard to record symptoms that +interfere with classification. German psychiatry has tended to make the +insane patient a type rather than an individual. Hence the gap in the +descriptive literature of stupor. + +The necessity of establishing the possibility of some stupors having a +good prognosis has arisen from Kraepelin's work. He can rightly be +viewed as the father of modern psychiatry because he introduced a +classification based on syndromes and taught us to recognize these +disease groups in their early stages. Inevitably with such an ambitious +scheme as the pigeon-holing of all psychotic phenomena some mistakes +were made. Most of these appear in the border zone between dementia +prcox and manic-depressive insanity. The latter group being narrowly +defined, the former had to be a waste basket containing whatever did not +seem to be a purely emotional reaction. Clinical experience soon proved +that many cases which, according to Kraepelin's formul, were in the +dementia prcox group, recovered. Adolf Meyer was one of the first to +protest and offered categories of "Allied to Manic-Depressive Insanity" +or "Allied to Dementia Prcox," as tentative diagnostic classifications +to include the doubtful cases. + +Difficulties with stupor furnish an excellent example of the confusion +which results from the adoption of rigid terminology. The earlier +psychiatrists were free to regard a patient in stupor as capable of +recovery as well as deterioration. When Kahlbaum included stupor with +"Catatonia," the situation was not changed, for he did not claim a +hopeless prognosis for this group. But when Kraepelin made catatonia a +subdivision of dementia prcox, all stupors (except obvious phases of +manic-depressive insanity) had to be hysterical or malignant. Faced with +this dilemma psychiatrists have either called recoveries "remissions" +or, like E. Meyer, claimed that one-fifth or one-fourth of catatonics +really get well. + +As a matter of fact it seems clear that stupor is a psychobiological +reaction that can occur in settings of quite varied clinical conditions. +It is not necessary to detail publications describing stupors in +hysteria, epilepsy, dementia prcox or in the organic psychoses. It may +be of interest, however, to cite some examples of acute, benign stupors +and the discussion of them which appear in the literature of recent +years. + +An important group is that of stupors occurring as prison psychoses. +Stern[16] mentions that acute stupors are found in this group. +Wilmanns[17] examined the records for five years in a prison and +discovered that there were two forms of psychotic reaction, a paranoid +and a stupor type. It is interesting psychologically that the former +appeared largely among prisoners in solitary confinement, while the +stupors developed preponderantly among those who were not isolated. The +stupors recovered more quickly. He describes the psychosis thus: The +prisoner becomes rather suddenly excited, destructive and assaultive; +then soon passes into an inactive state, where he lies in bed, mute, +with open expressionless eyes. He is clean, however; eats spontaneously +and attends to his own hygienic needs. Some cases are roused by +transport from the jail to the hospital but sink into lethargy again +when they reach their beds. Physically, they show disturbances of +sensation which vary from analgesia to hypesthesia. There are a rapid +pulse, positive Romberg sign, exaggerated reflexes, fibrillary twitching +of the tongue and tremor of the hands. Recovery takes place gradually. +They begin to react to physical stimuli and to answer questions, +although still inhibited, until consciousness is quite clear. When +speech begins, it is found that they are usually disoriented for place +and time as the result of an amnesia which sets in sharply with the +excitement. This memory defect gradually improves _pari passu_ with the +other symptoms. + +Two attacks in the same prisoner of what seem to have been typical +stupor are reported by Kutner[18] and Chotzen.[19] The patient was a +recidivist of unstable mental make-up. At the age of 34 he was sent to +prison for three years. Shortly after confinement began, he became +stuporous, being mute and negativistic, soiling, refusing food and +showing stereotypy. On being shifted to another institution he appeared +suddenly much better, although he remained apathetic and dull for some +months. A striking feature was a complete amnesia, not merely for the +stupor but also for his trial and entrance to the prison. At the age of +42, he was again incarcerated. A practically identical picture again +developed, with recovery when his environment was changed, and with a +similar amnesia. Recovery seemed to be complete and there were no +hysterical stigmata. The interesting features of this case are that a +typical stupor seems to have been precipitated by imprisonment, while +the retroactive amnesia covering a painful period of the patient's life +reminds one of hysteria. + +A case which is more difficult to interpret is reported briefly by +Seelig.[20] A man of 20 with bad inheritance tried to steal 100 marks. +When sent to jail he became ill shortly before his trial was due and was +sent to a hospital. There he seemed anxious, was shy, and gave slow +answers, with initial lip motions and had to be urged to take hold of +objects. All this sounds more like a pure depression than a stupor. But +he also had paralogia. This might make one think of a Ganser reaction on +the background of depression. S., however, calls it an hysterical +stupor, although he agreed with Moeli that it was hard to differentiate +from a catatonic state. + +Lwenstein[21] reports an interesting case of a dgnr who had had +hysterical attacks. He suddenly developed stupor symptoms, which lasted +with interruptions for nearly two years. After recovery and during the +interruptions the patient explained his mutism, refusal to swallow, his +filthiness and general negativism as all occasioned by delusions. He was +commanded by God to act thus, the attendants were devils, and so on. He +spoke, too, of being under hypnotic influence. In addition there were +other delusions such as that he had killed his brother. The attack came +on with the belief that he was going to die, otherwise none of the ideas +were typical of the stupors we have studied. Another incongruous symptom +was that he did not seem to be really apathetic, he reacted constantly +to the environment. The author comments on the absence of senseless +motor phenomena, such as would be expected in a "catatonic." His +complete memory of the psychosis also speaks against the usual form of +stupor. It seems possible that this psychosis was neither hysterical nor +a benign stupor in our sense, but, rather, an acute schizophrenic +reaction such as one occasionally sees. From the account which +Lwenstein gives, one gathers that the patient was absorbed in a wealth +of imaginations. + +Gregor[22] tells of a stupor which is unusual in that it consisted only +of symptoms connected with inactivity, which did not affect the +intellectual processes. The patient was a rubber worker who suddenly +developed a depression with self-accusation and convulsions. She was +soon admitted to a clinic and then showed mutism and catalepsy. Later +she became totally immobile with no apparent psychic reactions, and +soiled. Gregor studied pulse, respiration and respiratory volume in +their reflex manifestations and found nothing unusual. Next he tried to +discover if there were voluntary alterations in respiration. He +discovered that the respiratory curve could be changed by calling out +words to her, by odors associated with suggestions, menaces, etc. [This +is suggestive of the dissociation of affect, which we have discussed.] +After two months she recovered, _with complete recollection of the +stupor period_. It was then proven that the absence of reactions was not +the same as the lack of perception of stimuli. + +Froederstrm[23] reports a case that suggests hysteria, where the stupor +lasted for 32 years. A girl at the age of 14 fell on the ice, had a +headache, went to bed and stayed there for 32 years. She lay there +immobile, occasionally spoke briefly and took nourishment, when it was +put at a definite place at the edge of the bed. At first (according to a +late statement of her brothers) this consisted only of water but was +soon changed to two glasses of milk a day. After being in this state for +ten years she was placed in a hospital for two weeks, where she was +mute, did not react to pin pricks and had to be fed. It seems that at +home she secretly looked after herself, for she kept her hair and nails +in condition. Sometimes she sat up and stared at the ceiling. + +After attending to the patient for 30 years, her mother died. The +patient cried for several days when told of it, and after this she took +nourishment of her own accord. Two years later a brother died. Again she +cried on hearing the news. Her father, who looked after her when the +mother was dead, also died. Then a governess came into the home, who +noticed that furniture was moved about when she was alone. + +At the age of 46 she suddenly woke up and asked at once for her mother. +She claimed total amnesia for the period of her stupor, including the +stay at the hospital. She could summon memories of her childhood, +however. Her brothers she did not recognize and said, "They must be +small." She recalled the fall on the ice and coming home with headache, +toothache and pain in the back. Her general knowledge was limited but +she could read and write. Her expression and appearance was that of a +young person, only her atrophic breasts and the fat on her buttocks +betraying her age. She had been well for four years at the time the +report was made. + +He thinks that a certain tendency to exaggeration and simulation speak +for hysteria. We would be more inclined to view the fact that she looked +after herself in spite of complete amnesia as evidence of hysteria. + +Another protracted case suggestive of hysteria is that reported by +Gadelius.[24] The patient was a tailor, 32 years old, who had always +been rather taciturn and slow. A year before admission he began to have +ideas of persecution and to shun people. Then he developed a stereotyped +response, "It is nice weather," whenever he was addressed. A month +before admission inactivity set in. He would sit immobile in his chair +with closed eyes and relaxed face; he resisted when an attempt was made +to put him to bed. His color was pale. + +He was taken to hospital on November 1, 1882, where he was observed to +be immobile and to have little reaction to pin pricks. When a limb was +raised, it fell limply. However, he would leave bed to go to the toilet. +Tube-feeding became necessary, but when the tube was inserted in his +nose, he woke up. He then showed an amnesia not merely for his illness +but for his whole life: he did not know his father, that he was married +or that he had a mother. Towards the end of November, he became limp +again and answered, "I don't know" to most questions. In December, +however, he improved again and for a few months these variations +occurred. From April, 1883, to May, 1886, he was in deep stupor, almost +absolutely immobile and close to being completely anesthetic even with +strong Faradic currents. Towards the end of this period he walked about +_whenever he thought he was not watched_. He was very cautious about +this and became motionless any time he became aware of observation. +(Gadelius thinks this was not simulation but the expression of an +automatism on the basis of a vague fixed idea.) + +This condition persisted apparently for five years more, by the end of +which time the anesthesia had turned into a hyperesthesia. A year later +he began to eat. It was now found that he had an amnesia for his illness +and former life, so that he did not even recognize a needle or pair of +scissors. He knew that he was born in the month of February and retained +some facility in calculation, in speech, walking and usual motions. Then +he regained all his memories and resumed his trade as tailor. He was +discharged in June, 1893, nearly eleven years after admission. + +It seems safe to say that elements at least of hysteria appear in this +history, such as the profound retroactive amnesia and appearance of +simulation in the conduct of the patient. Accurate and rapid grasp of +the environment is necessary for such a watch as he kept on the eye of +his attendants. Mental acuity of this grade combined with amnesia looks +more like an hysterical than a manic-depressive process. + +Leroy[25] describes a case much like ours which is interesting from a +therapeutic standpoint. The patient was a woman who passed from a severe +depression with hallucinations and anxiety into a long stupor, from +which she recovered completely. There was no negativism and no affect, +although the latter appeared so soon as contact began to be established. +When well she had a complete amnesia for the onset of the psychosis. +Leroy attributed the recovery, in part at least, to the thorough +attention given the patient. Kraepelinian rigidity is seen, however, in +the author's refusal to regard the case as "circular" because of the +lack of all cyclic symptoms. He takes refuge in the meaningless label +"Mental Confusion." + +An important group of cases is that of the stupors occurring during +warfare. Considering stupor as a withdrawal reaction, it is surprising +there were so few of them, although partial stupor reactions as +functional perpetuation of concussion were very common. The editor saw +several typical cases in young children in London who passed into long +"sleeps" apparently as a result of the air raids. Myers[26] has given +us the best account of stupors in actual warfare. A typical case was +that of a man who was found in a dazed condition and difficult to +arouse. He could give little information about himself, could neither +read nor write and never spoke voluntarily. A week later his speech was +still limited and labored and no account of recent events could be +obtained from him. Under hypnosis he was induced to talk of the accident +which had precipitated this disorder. He became excited in telling his +story, evidently visualizing many of the events. In several successive +sances, more data were obtained and a cure effected. Myers points out +that in all his cases there was a mental condition which varied from +slight depression to actual stupor, all had amnesias of variable extent +and all had headaches. The mental content seemed to be confined to +thoughts of bombardment, with a tendency for the mind always to wander +to this topic. The author thinks that pain is a guardian protecting the +patient from too distressing thoughts. An effort to speak would cause +pain in the throat of a case of mutism and, sometimes, when a +distressing memory was sought after under hypnosis, physical pain would +wake the sleeper. His view is that pains tend to preserve the mutism and +amnesia, so that there are "inhibitory processes" causing the stupor, +which prevent the patient from further suffering. He does not find +either in theory or experience reason to believe that these conditions +are the result of either suggestion or "fixed ideas." He thinks it +natural that the last symptom of the stupor to disappear should be +mutism, as speech and vision are the prime factors in communicating with +environment. [As has been noted frequently in this book, mutism is a +common residual symptom of the benign stupor.] Myers believes that in +nearly every instance mutism follows stupor and is merely an attenuation +of the latter process. When deafness is associated with mutism, he +thinks it is often due merely to the inattention of the stuporous state. + +In this connection we should mention that Gucci[27] points out that +stupor patients with mutism of long duration may, when requested, read +fluently and then relapse again into complete unreactiveness towards +auditory impressions. This, we would say, is probably an example of a +more or less automatic intellectual operation occurring when the patient +is sufficiently stimulated, although he cannot be raised to the point of +spontaneous verbal productivity. + +As these scattered reports about benign stupors are so unsatisfactory, +one naturally turns to text-books. Little more appears in them. +Kraepelin treats stupors occurring in manic-depressive insanity as +falling into two groups, the depressive and manic. The former seems to +be nearer to our cases, judging by the statements in his rather sketchy +account. He regards stupor as being the most extreme degree of +depressive retardation. [This possibility has been discussed in the +chapter on Affect.] His description seems perhaps to include cases which +we would regard as perplexity states or absorbed manias. Activity is +reduced, they lie in bed mute, do not answer, may retract shyly at any +approach, but on the other hand may not ward off pin pricks. Sometimes +there is catalepsy and lack of will, again there may be aimless +resistance to external interference. They hold anything put into their +hands, turning it slowly as if ignorant of how to get rid of it. They +may sit helpless before food or may allow spoon-feeding. Not rarely they +are unclean. As to the mental content, he says they sometimes utter a +few words, which give an insight into confused delusions that they are +out of the world, that their brains are split, that they are talked +about, or that something is going on in the lower part of the body. The +affect is indefinite except for a certain bewilderment about their +thoughts and an anxious uncertainty towards external interference. +Intellectual processes suffer. They are disoriented and do not seem to +understand the questions put to them. An answer "That is too +complicated" may be made to some simple command. Kraepelin thinks that +the disorder is sometimes more in the realm of the will than of +thinking, for one patient could do a complicated calculation in the same +time as a simple addition. After recovery the memory for the period of +the psychosis is poor and quite gone for parts of it. Occasionally there +may be bursts of excitement, when they leave the bed; they may scold in +a confused way or sing a popular song. + +His manic stupor is a "mixed condition," a combination of retardation +with elated mood. The condition is different from the depressive stupor +in that activity is more frequent, either in constant fumbling with the +bed clothes or in spasmodic scolding, joking, playing of pranks, +assaultiveness, erotic behavior or decoration. The affect is usually +apparent in surly expression or happy, or erotic, demeanor. They are +usually fairly clear and oriented and often with good memory for the +attack but with evasive explanations for their symptoms. One cannot make +any classification of the ideas he quotes, but it is apparent from all +his description that the minds of these "manic stupors" are not a blank +but rather that there is a fairly full mental content. + +Wernicke, unhampered by classifications of catatonia and +manic-depressive insanity with inelastic boundaries, calls all stupor +reactions akinetic psychoses with varying prognosis. He does not make +Kraepelin's mistake of confusing the apathy of stupor with the +retardation of depression, stating distinctly that the processes are +different. + +Bleuler also has grasped this discrimination. He points out that the +thinking disorder in what he terms "Benommenheit" (dullness) +differentiates such conditions from affectful depression with +retardation. He writes, of course, mainly of dementia prcox,[28] but +makes some remarks germane to our problem. In the first place he denies +the existence of stupor as a clinical entity, except perhaps as the +quintessence of "Benommenheit", it is the result of total blocking of +mental processes. Consequently, he says, one can observe the external +features of stupor in all akinetic catatonics, in marked depressive +retardation, when there is a lack of interest, affect or will, in +autism, with twilight states, as a result of negativism or, finally, +when numerous hallucinations distract the patient's attention into a +world of fancy. He notes that in all stupors (with the exception, +perhaps, of "Benommenheit") the symptoms may disappear with appropriate +psychic stimulation or that some reaction, no matter how larval, may be +observed. He speaks, for instance, of the visits of relatives waking the +patient up. + +His only real group is "Benommenheit," which he separates out as a true +clinical entity. This seems to correspond roughly with our "Partial +Stupors." It is essentially an affectless, thinking disorder, usually +acute, sometimes chronic, occurring among schizophrenics. He believes +that it is the result of some organic process (intracranial pressure or +toxin). Activity is much reduced or absent; they have poor +understanding, answer slowly or confusedly; their actions are sometimes +as ridiculous as those of people in panic (e.g., throwing a watch out +of the window when the house is on fire); the defect is best seen in +writing, for large elisions are found in sentences. He was able to +analyze only one case and she retained her affect; it was even labile +and marked. One suspects that such a case might, perhaps, not really +find a place in the "Benommenheit" group even as Bleuler himself +describes it. + +With the exception of Kirby, whose work has already been discussed in +the introduction, we have been able to find only one author who has +attempted any symptomatic discrimination of the recoverable and +malignant catatonic states. Raecke[29] made a statistical study and +found that 15.8% recovered, 10.8% improved, 54.4% remained in +institutions, while 30% died. With the etiology mainly exogenous 20% +recovered and 14.3% improved. A good outcome was seen in 30.2% of +hereditary cases, while only 22.7% did well in the non-hereditary group. +His most important contribution is in his formulation of good and bad +symptoms. He thinks that dull, apathetic behavior with uncleanliness and +loss of shame are not so unfavorable as has been thought. Malignant +symptoms are grimacing with prolonged negativism but without essential +affect anomaly, decided echopraxia and echolalia and protracted +catalepsy. We would agree with this, although command automatisms have +not been prominent either in our benign or malignant stupors. + +Two writers have made special observations that should be confirmed and +amplified before their significance can be established. Whitwell[30] +thinks that in addition to a diminished activity of the heart there +exists a pathological tension. Ziehen says that he also has frequently +seen angiospastic pulse-curves in exhaustion stupor or acute dementia, +but that other pulse pictures may be seen as well. Any such studies +should be correlated rigorously with the clinical states before they can +have any meaning. Wetzel[31] tested the psychogalvanic reflex in stupors +and in normal persons who simulated stupors. He found them different. + +Only one publication has come to our attention in which an attempt is +made at psychological interpretation of various symptoms in stupor. +Vogt[32] derives much from a restriction of the field of consciousness. +Only one idea is present at a time, hence there is no inhibition and +impulsiveness occurs. Similarly, if the idea appear from without, it, +too, is not inhibited, which produces the suggestibility that in turn +accounts for catalepsy. Stereotypy and perseveration are other evidences +of this narrowness of thought content. Negativism is a state, he says, +of perseverated muscular tension. [This would apply only to muscular +rigidity.] So far as it goes, this view seems sound. Of course it +leaves the problem at that interesting point, Why the restriction of +consciousness? + +If stupor be a psychobiological reaction, it should occur, occasionally, +in organic conditions just as the deliria of typhoid fever may contain +many psychogenic elements. Gnauck[33] reports such a case. The patient, +a woman, was poisoned by carbon dioxide. At first there was +unconsciousness. Then, as she became clearer, it was apparent that she +was clouded and confused. She soiled. Neurological symptoms were +indefinite; enlargement of the left pupil, difficult gait and +exaggerated tendon reflexes. Months later she was still apathetic, +although her inactivity was sometimes interrupted by such silly acts as +cutting up her shoes. After five months she recovered with only +scattered memories of the early part of her psychosis. What seems like a +typical stupor content was recalled, however. She thought she was +standing in water and heard bells ringing. + +Stupor-like reactions are not infrequent in connection with or following +fevers. Bonhoeffer[34] describes a type that follows a febrile +Daemmerzustand of a few hours or a day at most. The affect suddenly +goes, disorientation sets in. Although outbreaks of anxiety may be +intercurrent, the dominant picture is of stupor. Reactions are slowed, +often there is catalepsy. Sometimes there is a retention defect and +confabulation to account for the recent past. Again the retention may be +good. In the foreground stands a strong tendency to perseveration. This +may affect speech to the point of an apparent aphasia or produce +paragraphia. Plainly organic aphasia and focal neurological symptoms are +sometimes seen. + +As Knauer[35] has gone thoroughly into the question of the febrile +stupors, the reader is referred to his paper for a digest of the +literature on this topic. Mention has already been made in Chapter IX to +this publication, where the close resemblance of these rheumatic, to our +benign functional, stupors has been noted. Discrimination seems to be +possible only on the basis of delirium-like features being added in the +organic group. + + +FOOTNOTES: + +[C] This chapter has been written mainly from material in Dr. Hoch's +notes which was manifestly incomplete. No claim is made for its +exhaustiveness. + + _The Editor._ + +[13] Dagonet, M. H.: "De la Stupeur dans les Maladies Mentales et de +l'Affection mentale dsigne sous le Nom de Stupidit." _Annales +Medico-Psychologiques_, T. VII, 5e Serie, 1872. + +[14] Newington, H. Hayes: "Some Observations on Different Forms of +Stupor, and on Its Occurrence after Acute Mania in Females." _Journal of +Mental Science_, Vol. XX, 1874, p. 372. + +[15] Clouston: "Mental Diseases." J. & A. Churchill, 1904. + +[16] Stern: "Ueber die akuten Situations-psychosen der Kriminellen." +Abstracted, _Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate Bd. +V, S. 554. + +[17] Wilmanns, K.: "Statische Untersuchungen ber Gefngnisspsychosen." +_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 847. + +[18] Kutner: "Ueber katatonischer Zustandsbilder bei Degenerierten." +_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 375. + +[19] Chotzen: "Fall von degenerativem Stupor." Abstracted, _Zeitschr. f. +d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 1077. + +[20] Seelig: "Psychiatrischer Verein in Berlin, 1904." _Neurol. +Centralbl._, 1904, S. 421. + +[21] Lwenstein: "Beitrag zur Differentialdiagnose des katatonische u. +hysterische Stupors." _Allg. Zeitschr. f. Psychiatrie_, Bd. LXV. + +[22] Gregor: "ber die Diagnose psychischer Prozesse im Stupor." Leipzig +Meeting, 1907. Reported in _Neurol. Centralbl._, 1907. S. 1083. + +[23] Froederstrm: "La Dormeuse d'Okno. 32 ans de Stupeur, Gurison +complte. Nouvelles Iconographies de la Salptrire," 1912, No. 3. +Reviewed by E. Bloch, _Neur. Centralbl._, 1913, S. 852, and by Forster, +_Zeitschr. f. d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 510. + +[24] Gadelius: "Ett ovanligt fall af stupor med nra 9-arig oafbruten +tvangsmatning; uppvaknande; total amnesi; helsa" (_Hygiea_, 1894, LVI., +Part 2, No. 10, p. 355). Abstracted by Walker Berger, _Neurol. +Centralbl._, 1895, S. 186. + +[25] Leroy: "Un cas de stupeur, guri au bout de deux ans et demi." +_Bull. de la Soc. Clin. de Md. Ment._, III, 276, 1910. Abstracted in +_Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate, Bd. II, S. 495. + +[26] Myers, Charles S.: "Contributions to the Study of Shell Shock." +_Lancet_, January 8, 1916, pp. 65-69. _Lancet_, September 6, 1916, pp. +461-467. + +[27] Gucci, R.: "Sopra una particolarit del mutismo per stupore +communicazione preventive." _Archivio italiano per le malattie nervose_, +1889, XXVI, 69-108. Reviewed in _Neurol. Centralbl._, 1889, S. 659. + +[28] "Dementia Prcox oder Gruppe der Schizophrenie" Aschaffenburg's +"Handbuch der Psychiatrie." + +[29] Raecke: "Zur Prognose der Katatonie." _Arch. f. Psychiatrie_, Bd. +XLVII, 1, 1910. + +[30] Whitwell: "A Study of the Pulse in Stupor." _Lancet_, Oct. 17, +1891. Reviewed by Ziehen, _Neurol. Centralbl._, 1892, S. 290. + +[31] Wetzel: "Die Diagnose von Stuporen." Baden-Baden Meeting of May, +1911. Reported in _Neurol. Centralbl._, 1911, S. 886. + +[32] Vogt, Ragner: "Zur Psychologie der Katatonischen Symptome." +_Centralbl. fr Nervenheilkunde_, 1902, S. 433. + +[33] Gnauck, R.: "Stupor nach Kohlenoxydvergiftung" (_Charit-Annalen_, +1883, p. 409). Reviewed by Moeli, _Neurol. Centralbl._, 1883, S. 237. + +[34] Bonhoeffer: "Die Symptomatischen Psychosen," 1910. + +[35] Knauer, A.: "Die im Gefolge des akuten Gelenkrheumatismus +auftretenden psychischen Storungen." _Zeitschr. f. d. ges. Neurol. u. +Psychiatrie_, Bd. XXI, S. 491-559. + + + + +INDEX + + +absorption, 163 + +activity, reduction of, 36, 100, 120 + +acute dementia, 251 + +adaptation, 107, 192 + +adrenalin, 180 + +affect, 9, 22, 32, 44, 113, 116, 117, _123_, 170 + +affect, dissociation of, 128, 201, 205, 237 + +affect, inappropriate, 216, 237 + +affect, poverty of, 234 + +affect, shallow, 127 + +affectlessness, 171, 172 + +affects, combination of, 245 + +agitation, 156 + +akinesis, 121 + +akinetic psychoses, 4, 274 + +albuminuria, 40 + +allied to dementia prcox, 236, 260 + +allied to manic-depressive, 236, 260 + +allopsychic, 135 + +ambivalence, 147 + +amnesia, 9, 24, 68, 70, 267, 269 + +anergic or unconscious stupor, 258 + +anergic stupor, 255, 256 + +anesthesia, 196, 212, 268 + +anger, 118, 139 + +angiospastic, 276 + +animal, turning into, 171 + +Antus, 190 + +apathy, 36, 48, 112, 122, 123, 151, 152, 163, 181, 195, 225, 237 + +apathy, resemblance to absorption, 202 + +anxiety, 122, 123, 126, 137, 153, 162, 166, 198, 226 + +apoplexy, 224 + +arteriosclerotic dementia, 80 + +attention, 195 + +atypical features, explanation of, 200 + +autoerotism, 199 + +automatism, 268 + + +Baillarger, 252 + +behavior, 195 + +"Benommenheit," 67, 273, 274 + +bewilderment, 79, 112, 120, 126 + +Bleuler, 67, 273 + +blocking, 163 + +blood-pressure, 181 + +blushing, 9 + +Bonhoeffer, 277 + +boredom, 247 + +bowels, interest in, 217 + +brain tumor, 5 + +breath, holding, 62 + +Brierre de Boismont, 252 + +burial, 111, 192 + + +Calculation, 23, 24 + +Calvary, 111 + +Cannon, 180 + +Cases + Adele M. (Case 24), 220 + Alice R., 135, 140, _192_ + Anna G. (Case 1), _6_, 47, 48, 68, 74, 77, 109, 127, 136, 140, 145, + 147, 183 + Anna L. (Case 16), 135, _149_, 158 + Anna M., 135 + Annie K. (Case 5), _24_, 69, 72, 105, 110, 111, 136, 139, 141 + Bridget B., 135 + Caroline de S. (Case 2), _11_, 68, 109, 141, 178, 193 + Catherine H. (Case 23), _216_ + Catherine M. (Case 18), _158_ + Catherine W. (Case 25), _221_ + Celia C. (Case 17), _155_ + Celia H. (Case 19), _167_ + Charles O., 143, 144, 178 + Charlotte W. (Case 12), _83_, 106, 112, 113, 116, 127, 136, 141, 144, + 166, 201 + Emma K., 71, 140 + Harriett C., 138 + Helen M., 130 + Henrietta B., 138, 140 + Henrietta H. (Case 8), _42_, 74, 77, 105, 106, 110, 111, 115, 136 + Isabella M., 136, 144, 147 + Johanna B., 135, 138 + Johanna S. (Case 13), _91_, 120, 127, 136 + Josephine G., 138 + Laura A., 71, 77, 135, 138, 140, 142, 193 + Maggie H. (Case 14), 71, 96, 109, 140, 194 + Margaret C. (Case 10), _55_, 75, 78 + Mary C. (Case 7), _39_, 42, 71, 74, 77, 121, 136, 138, 178, 194 + Mary D. (Case 4), _20_, 47, 69, 70, 71, 74, 76, 109, 136, 145 + Mary F. (Case 3), _14_, 68, 105, 110, 111, 115, 140, 142, 164, 183 + Mary G., 140, 141 + Meta S. (Case 15), _99_, 109, 127, 135 + Nellie H. (Case 22), _214_ + Pearl F. (Case 9), _51_, 75, 142 + Rose S. (Case 21), _210_ + Rose Sch. (Case 6), _35_, 74, 75, 145 + Rosie K. (Case 11), _62_, 75, 105, 112, 178 + Winifred O'M. (Case 20), _207_ + +catalepsy, 13, 21, 31, 32, 36, 86, 94, 95, 102, 115, 128, _143_, 144, +145, 147, 209, 211, 235, 239 + +catatonia, 4, 5, 50, 128, 205, 236, 261 + +catheterization, 85, 86, 102 + +cemetery, 105, 112 + +childbirth, 159 + +childhood, 188, 195 + +Chotzen, 262 + +Christ, 86, 115 + +Christian Science, 150 + +circular psychosis, 5, 126 + +circulation, 180 + +Clark, 184 + +clouding, 67 + +Clouston, 258 + +cocoon, 109 + +coffin, 88, 106, 114 + +coma, 176, 223 + +concussion, aerial, 224 + +confusion, 163 + +constipation, 92 + +convent, 117 + +convulsive attacks, 15 + +crime, 248 + +crucifix, 88 + +crucifixion, 86, 106, 114, 161 + +crustaceans, 148 + +cut-up idea, 94 + +cyanosis, 32, 63, 180 + + +Dagonet, 3, 249, 250, 253, 254, 258 + +death, feigned, 5, 83, 137, 196, 246 + +death, mutual, 192 + +death, projected, 198 + +death, relation with affect, 110 + +death ideas, 3, 46, 47, 50, 52, 58, 65, 83, 97, _104_, 107, 109, 110, +111, 114, 115, 119, 122, 136, 137, 138, 152, 153, 156, 159, 163, 166, +187, 190, 191, 192, 199, 212, 225, 235, 240 + +death of others, 192 + +deep stupor, _1_, 6, 41, 199 + +deep stupor, explanation of, 197 + +Delasiauve, 253 + +delirium, 176 + +delusional stupor, 255, 256 + +delusions, 165 + +dlire mlancholique, 252 + +dementia prcox, 4, 5, 62, 123, 127, 128, 205, 225 + +depression, 5, 117, 123, 137, 156, 236, 253 + +depression, differentiation of, 48, 124, 226 + +dermatographia, 102, 180 + +deterioration, 210 + +diabetes, 224 + +diarrhea, 45, 64, 178 + +dissociation, 225 + +distress, 119, 122, 154, 156, 162 + +dreams, 161, 190 + +drooling, 132, 181 + +drowning, 87, 192 + + +Earth, 107, 111, 190 + +echolalia, 275 + +echopraxia, 275 + +ecstasy, 91, 162, 191 + +_lan vital_, 123 + +elation, 44, 91, 123, 127, 151, 157 + +electric chair, 85, 110, 119 + +electricity, 150 + +emaciation, 8, 32, 58 + +emotion, 62 + +emotion, inconsistency of, 126 + +emotions and contact with reality, 164 + +energy, 187, 194 + +epilepsy, 5, 183, 199, 224, 242, 254 + +epileptic aura, 184 + +epileptic confusion, 80 + +epileptic deterioration, 80 + +erotic, 161 + +erotic ideas, 90 + +Esquirol, 251 + +Etoc-Demazy, 251 + +Euripides, 2 + +excretion, habits of, 230 + +extroversion, 195 + + +family visits, 232 + +father, 104, 109, 110 + +fear, 111 + +fever, 8, 13, 26, 32, 38, 40, 45, 64, 102, 160, _176_, 235, 241 + +filthiness, 210 + +fire, 151, 157 + +flippancy, 129 + +flushing, 27, 127, 128, 180 + +food, refusal of, 99, 104 + +Forel, 182 + +Froederstrm, 265 + + +Gadelius, 267, 268 + +Ganser reaction, 263 + +Georget, 251 + +German psychiatry, 259 + +Gnauck, 277 + +giggling, 206 + +God, 115, 160, 162 + +Golden Age, 187 + +Gregor, 265 + +Gucci, 271 + +guilt, 157 + + +hair, loss of, 32, 58, 180 + +heat production and loss, 179, 181, 242 + +Heaven, 87, 88, 104, 106, 108, 109, 111, 114, 115, 117, 118, 160, 162, +166, 171, 191, 240 + +Hell, 240 + +Hoch, 164 + +hypermia, 8 + +hyperesthesia, 268 + +hypochondria, 225, 253 + +hypomania, 243 + +hypnotism (see mesmerism), 145, 213 + +hysteria, 3, 135, 184, 225, 264, 267, 269 + + +ideational content, 82, 235 + +immobility, 85, 94, 196 + +immorality, 150 + +impulsiveness, 50, 113, 128, 172 + +impurities in stupor reaction, 66 + +inaccessibility, 141 + +inactivity, 17, 30, 40, 48, 56, 62, 88, 97, 102, 123, _132_, 152, 163, +194, 225, 234, 238 + +inactivity, patients' explanation of, 134 + +incest ideas, 209 + +inconsistency of reaction, 134, 214, 215, 245 + +incontinence (see _wetting_ and _soiling_), 52, 57 + +indifference, 123, 124, 142 + +infantile reactions, 196 + +infections, 5, _178_, 241 + +insight, 157 + +insomnia, 39 + +instinct of self-preservation, 188, 191, 198 + +interest, 99, 195 + +internal secretions, 178 + +internal thoughts, 163 + +interruptions of stupor, 130, 197, 238, 244 + +introversion, 164, 227 + +involuntary nervous system, 178, 180 + +involution melancholia, 129, 195, 225, 226 + + +jaundice, 21 + +Jung, 107 + + +Kahlbaum, 4, 260 + +Kirby, 4, 6, 164, 234 + +Knauer, 175, 278 + +Kraepelin, 4, 260, 269, 271, 272, 273 + +Kutner, 262 + + +laughter, 56, 141 + +Leroy, 269 + +leucocytosis, 8, 13, 40, 64, 178 + +levels, principle of, 198, 244 + +Lwenstein, 264 + + +MacCurdy, 2, 184 + +make-up, mental, 5 + +malignant stupors, _205_ + +mania (or manic), 5, 126, 137 + +mania, absorbed, 125, 226, 245 + +manic content, 166 + +manic-depressive insanity, 149, 167 + +manic-depressive insanity, mixed conditions in, 202 + +manic-depressive insanity, pathology of, 174 + +manic episodes, 191 + +manic stupor, 125, 245, 253 + +marriage, 160, 169 + +masturbation, 196, 209, 219 + +melancholic or conscious stupor, 258 + +memory (see thinking disorder), 40, 67, 168, 195 + +menstruation, 8, 56, 61, 100, 168, _182_, 236, 242 + +mesmerism, 86, 114, 117, 141, 144 + +Meyer, Adolf, 260 + +Meyer, E., 261 + +midday nap, 247 + +mixed conditions, 202, 273 + +Moeli, 264 + +Moses, 108 + +mother's body, 108 + +movement, spontaneous, 133 + +muscular resistiveness, 224 + +mutism, 10, 22, 31, 57, 62, 88, 104, 124, 134, 209, 271 + +mutual death, 165, 192, 196, 248 + +Myers, 270, 271 + +mystics, 3 + +mythology, 107, 108, 190, 240 + + +negativism, 5, 31, 52, 56, 65, 128, _138_, 139, 199, 209, 225, 235, 238, +243, 276 + +negativism, explanation of, 196 + +nephritis, 224 + +neuropsychic defect, 174 + +neurotic, 150 + +nervous, 159 + +Newington, 3, 254, 255, 257 + +Nirvana, 166, 188, 200, 248 + +nourishment, 229, 242 + + +OEdipus, 165 + +oestrous cycle, 182 + +onset, 96 + +onset, depressive, 99 + +ophthalmic disease, 230 + +Orestes, 2 + +organic delirium, 175 + +organic dementia, 67 + +organic stupor, 223 + +orientation (see thinking disorder), 9, 53, 154, 156, 159, 170, 245 + +Osiris, 108 + + +pain, 133 + +Papanicolaou, 182 + +paragraphia, 80 + +paralysis, feeling of, 105 + +paralysis, general, 5, 254 + +partial stupor, _34_, 206 + +perplexity, 125, 152, 153, 154, 155, 156, 160, 162, 164, 165, 169, 172, +208, 226, 245 + +perplexity, differentiation of, 227 + +perseveration, 145, 148, 276 + +personality, 1 + +perversity, 138 + +physical disease, 175 + +physical symptoms, _174_, 176 + +Pinel, 249, 251 + +poison, 97, 172 + +primitive ideas, 108 + +prison, 105, 169 + +prognosis, 4, 5, _206_ + +prostitution, 157, 161 + +psychoanalysis, 161 + +psychobiological reaction, 246 + +psychogalvanic reflex, 276 + +psychological explanation, 186 + +psychological factors, 175 + +pulse, 63, 92, 128, 180 + + +Rank, 107 + +reality, 107, 187 + +recuperation, 189 + +rebirth, _107_, 110, 114, 115, 119, 120, 121, 122, 187, 189, 190, 191, +240 + +regression, 187, 188, 191, 192, 194, 198, 199, 243 + +religious visions or ideas, 2, 162 + +resentment, 98 + +resistiveness, 54, 97, 102, 112, 127, 129, 133, 141, 147, 156, 211, 225 + +respiration, 180 + +resurrection, 159 + +restlessness, 53, 120, 169 + +retention of urine, 224, 230 + +rheumatism, 175 + +rigidity, muscular, 142, 179 + +Romberg sign, 262 + +rousing, 176 + + +sadness, 111, 113, 121, 122, 124 + +St. Catherine of Siena, 2 + +St. Paul, 2 + +saliva, 30, 63, 181 + +scattered speech, 207, 208 + +schizophrenia, 67, 214 + +seclusiveness, 207 + +secondary stupor, 259 + +Seelig, 263 + +self-injury, _50_, 57 + +sexual excess, 251, 253, 258 + +sexual ideas, 209, 219 + +sexual sensations, 209 + +ship, 87, 106, 118 + +sick, 136 + +skin, dry, 180 + +skin, greasy, 43, 180 + +sleep, 188, 189, 247 + +slowing of thought, 125 + +slowness, 85, 119, 160 + +smearing of feces, 142 + +smiling, 127 + +social status, 236 + +soiling, 30, 132, 172, 196, 225, 230, 235 + +somatopsychic, 135 + +sphincters, control of, 133 + +spirits, 89 + +spoiled child reaction, 129, 139 + +starvation, 182 + +stereotypy, 276 + +Stern, 261 + +stimulation, mental, 231, 246 + +Stockard, 179, 182 + +stubbornness, 142 + +stupidity, 93 + +stupor, diagnosis of, _223_ + hysterical, 225 + malignant, _205_, 206 + organic, 223 + reaction, _35_, 236 + relation to manic-depressive insanity, 173 + +sudden mental loss, 71 + +suggestibility, 145, 198, 276 + +suicidal impulses, _50_, 84, 104, 116, 118, 128, 172, 230, 235, 240 + +suicide, 188 + +sulkiness, 129 + +sullenness, 142 + +suprarenals, 242 + +swallowing, 133 + +sweating, 63, 102, 179, 180 + +swimming movements, 94 + +syncopal attacks, 64 + + +tears, 95, 98, 117, 128, 153 + +tense of ideas, 116 + +thinking disorder, 22, 31, 37, 39, 41, 45, 48, 59, _67_, 75, 124, 125, +148, 152, 157, 235, 239, 247 + +thinking disorder, explanation of, 195 + +tongue, coated, 13 + +toxins, 175 + +trauma, 5, 224 + +treatment, _229_ + + +ulceration of eyes, 133 + +unconscious ideas, 163 + motives, 186 + +unconsciousness, physiological, 199, 224, 277 + +underground, 240 + +understanding, 67 + +uneasiness, 93, 94, 95, 121 + +unfaithfulness, 97 + +unhappiness, 192 + +urine, retention of, 31 + + +Villermay, 250 + +Vogt, 276 + +vomiting, 45 + + +water, 94, 95, 106, 107, 114, 120 + +weakness, 137, 160 + +wealth, 169 + +wedding ring, 117 + +weight (see emaciation), 38, 52, 61 + +Wernicke, 3, 273 + +wetting, 30, 40, 132, 151, 170, 172, 196, 225, 230, 235 + +Wetzel, 276 + +whining, 171, 225 + +Whitwell, 276 + +Wilmanns, 261 + +womb, 108 + +worry, 110 + +writing, 27 + + +Ziehen, 276 + + + + +[Transcriber's Note: + + +The following corrections have been made: + +p. 1: antequated to antiquated (antiquated methods) + +p. 11, 97, 100: period to colon (Under Observation:) + +p. 53: extra "when" removed (from "In June, 1914, when she was seen +smiling at times." to "In June, 1914, she was seen smiling at times.") + +p. 64: period to colon (Physical condition during the stupor:) + +p. 84: 24 italicized to match other dates (October 24) + +p. 91: missing blank line added between Case 12 and 13 + +p. 93: aswer to answer (in answer to questions) + +p. 145: diaeresis added to coperation to match other instances + +p. 150: fatiguable to fatigable (nervous and fatigable) + +p. 153: phenomenom to phenomenon (unusual phenomenon for a stupor +patient) + +p. 159: comma added (correcting his grammar, and cried easily.) + +p. 161: missing "in" added (appeared in the statement that her father) + +p. 171: missing open quote added (she wants to go "to the river,") + +p. 198: funadmental to fundamental (most fundamental symptoms) + +p. 211: salivia to saliva (drooling saliva) + +p. 220: inaccesibility to inaccessibility (disinterestedness and +inaccessibility) + +p. 252: dimunition to diminution (just as well in the diminution) + +p. 256: or to of (relaxation of sphincter muscles) + +p. 262, Footnote 19: v. to u. (Zeitschr. f. d. ges. Neur. u. +Psychiatrie) + +p. 265, Footnote 23: Zeitsch. to Zeitschr. to match other instances +(Zeitschr. f. d. ges. Neur. u. Psychiatrie) + +p. 271, Footnote 27: Archivo to Archivio (Archivio italiano per le +malattie nervose) + +p. 280, Index: catherization to catheterization + +p. 282, Index: ophtalmic to ophthalmic (ophthalmic disease) + +Irregularities in capitalization (e.g. Dementia vs. dementia) and +hyphenation (e.g. off-hand vs. offhand) have not been corrected. A +repetitive sentence on p. 46 (Then she became stupid, although neither +sad nor happy. Then, she claimed, she got stupid, but neither sad nor +happy.), and two spaced em-dashes on p. 87 have also been retained. +Minor punctuation errors (e.g. missing period, missing close or open +quote where intended placement is clear) have been corrected without +note. The abbreviations "p.m.", "e.g." and "i.e." have been +standardized, with no space. + +In the Latin-1 and ASCII versions, oe/OE ligatures have been changed to +oe/OE.] + + + + + +End of the Project Gutenberg EBook of Benign Stupors, by August Hoch + +*** END OF THIS PROJECT GUTENBERG EBOOK BENIGN STUPORS *** + +***** This file should be named 30065-8.txt or 30065-8.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/3/0/0/6/30065/ + +Produced by Bryan Ness, S.D., and the Online Distributed +Proofreading Team at http://www.pgdp.net (This book was +produced from scanned images of public domain material +from the Google Print project.) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Benign Stupors + A Study of a New Manic-Depressive Reaction Type + +Author: August Hoch + +Release Date: September 22, 2009 [EBook #30065] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK BENIGN STUPORS *** + + + + +Produced by Bryan Ness, S.D., and the Online Distributed +Proofreading Team at http://www.pgdp.net (This book was +produced from scanned images of public domain material +from the Google Print project.) + + + + + + +</pre> + + +<h1 class="intro">BENIGN STUPORS</h1> + +<p class="center phead">THE MACMILLAN COMPANY</p> + +<p class="center sm">NEW YORK BOSTON CHICAGO DALLAS<br /> +ATLANTA SAN FRANCISCO</p> + +<p class="center phead">MACMILLAN & CO., <span class="smcap">Limited</span></p> + +<p class="center sm">LONDON BOMBAY CALCUTTA<br /> +MELBOURNE</p> + +<p class="center phead">THE MACMILLAN CO. OF CANADA, <span class="smcap">Ltd.</span></p> + +<p class="center sm">TORONTO</p> + +<div class="tp"> +<h1 class="tpg"> +<span class="wider">BENIGN STUPORS</span><br /><br /> + +<span class="tpsub"><i>A STUDY OF<br /> +A NEW MANIC-DEPRESSIVE REACTION TYPE</i></span></h1> + +<p class="center auth">BY<br /> +<span class="med">AUGUST HOCH, M.D.</span><br /> + +<span class="sm">LATE DIRECTOR OF THE PSYCHIATRIC INSTITUTE OF THE +NEW YORK STATE HOSPITALS, WARD'S ISLAND, NEW +YORK. LATE PROFESSOR OF PSYCHIATRY, CORNELL +UNIVERSITY MEDICAL COLLEGE, NEW YORK</span></p> + +<p class="center">New York<br /> +<span class="med">THE MACMILLAN COMPANY</span><br /> +1921</p> + +<p class="center wee"><i>All rights reserved</i></p> +</div> + +<div class="copy"> +<p class="center sm">PRINTED IN THE UNITED STATES OF AMERICA</p> + +<p class="center sm copy"><span class="smcap">Copyright, 1921,<br /> +By THE MACMILLAN COMPANY</span><br /> +Set up and printed. Published July, 1921.</p> + +<p class="center sm">Press of<br /> +J. J. Little & Ives Company<br /> +New York, U. S. A. +</p> +</div> + +<div class="ded"> +<p class="center">TO<br /> +MY FORMER COLLEAGUES<br /> +IN THE<br /> +NEW YORK STATE HOSPITAL SERVICE</p> +</div> + +<p><!-- Page vii --><span class='pagenum'><a name="Page_vii" id="Page_vii">[vii]</a></span></p> + +<h2>EDITOR'S PREFACE</h2> + +<p>A word should be said as to the origin and history +of this book. When the late Dr. Hoch became Director +of the Psychiatric Institute of the New York +State Hospitals in 1910, he found there an interest +in just the kind of psychiatric research which it was +his ambition to further. His predecessor, Adolf +Meyer, had developed the conception that the +psychoses should be looked on as psychobiological +reactions rather than rigid nosological entities and +had inculcated the habit of scrupulously thorough +examination and record of what the patient said and +did. Meyer had broken away from the sterile habit +of making diagnoses in accordance with the set terms +used to label symptoms; and his work and that of +his assistants thus led to a collection of valuable +material which could serve as a useful starting point +for the keen clinical investigation of Hoch. Specifically, +attention had already been fixed on the +study of the so-called functional psychoses, comprising +what are generally termed Dementia Prcox and +Manic-Depressive Insanity. An urgent problem in +this field was to separate different reaction types in +order to discover which were recoverable and which +chronic or progressive. In order to understand +psychological reactions, interrelation rather than<!-- Page viii --><span class='pagenum'><a name="Page_viii" id="Page_viii">[viii]</a></span> +mere coincidence of symptoms must be studied and, +to aid in this, free use was made of the fundamental +principles of unconscious mentation as exposed in +the theories of Freud and his followers.</p> + +<p>Almost at the outset it had been discovered that +many patients presented clinical pictures that would +not fit into existing diagnostic pigeon holes. Dr. +George H. Kirby, whose skill and industry had made +the most valuable contributions to the archives of +the Institute, published in 1913 a brief paper in +which he pointed out, not only that many cases with +"catatonic" symptoms recovered, but also that clinically +the behavior of stupor showed it to be related +to manic-depressive insanity as well as dementia +prcox. Dr. Hoch took up the problem at this point. +Using Dr. Kirby's material and adding to it his +earlier observations as well as current cases, he endeavored +to work out the essentials of the stupor reaction. +It was his ambition to describe stupor not +only in its psychiatric bearing but also as a life +reaction.</p> + +<p>The significance of this task is to be realized only +when one considers the general import of the functional +psychoses. They are, biologically, failures +of adaptation. The chronic and deteriorating cases +give up the struggle permanently, while the temporary +insanities lay bare the soul of man as he catches +a glimpse of unreality but turns back to face the +world as it is. When one realizes that emotional +disturbances are characteristic of the benign psychoses, +it is easy to imagine how much such studies<!-- Page ix --><span class='pagenum'><a name="Page_ix" id="Page_ix">[ix]</a></span> +may ultimately illuminate the problems of normal +life.</p> + +<p>The technical value of this work to psychiatry is +more immediate. Kraepelin laid the foundations for +systematic classification with his dementia prcox +and manic-depressive groups. But the rigidity of +the latter, allegedly descriptive, term has confused +the problem of classifying many benign psychoses. +It was Hoch's ambition to prove that, although elation +and depression were the commonest mood +anomalies in this group, they had no more theoretic +importance than anxiety, distressed perplexity or +apathy. These other moods, although less frequent, +are just as characteristic of the psychoses in this +group. In other words, the name "Anxiety-Apathy +Insanity" would be as appropriate, theoretically, +as Kraepelin's term. In 1919 Hoch and +Kirby published a report on the perplexity cases. +This present book was designed to show that the +symptom complex centering around apathy is as distinct +as that which is recognized by all psychiatrists +as mania with its predominant characteristic of +elation.</p> + +<p>In 1917 ill health forced Dr. Hoch to resign from +his official duties. He retired to California with the +purpose of adding to psychiatric literature the +fruits of his long experience and unrivaled judgment. +His first task was this book. In the midst of +this work came a sudden collapse. As I had been in +close touch with his researches, coperating in +psychological speculations, and was free to devote<!-- Page x --><span class='pagenum'><a name="Page_x" id="Page_x">[x]</a></span> +some time to it, he asked shortly before his death +that I complete the book. This obligation is incommensurate +with the debt I owe for years of inspiration, +tuition and criticism.</p> + +<p>The task has been mainly literary. I found the +first five chapters practically completed, while it has +not been difficult, as a rule, to discover from his +copious notes what his intentions were as to the +details of the following chapters. I have been +greatly aided by the assistance of Dr. Adolf Meyer +and of Dr. Kirby. The latter has been good enough +to read the entire manuscript, making invaluable +suggestions and criticisms.</p> + +<p class="ralign"> +<span class="smcap">John T. MacCurdy.</span> +</p> + +<p>New York.</p> + +<p><!-- Page xi --><span class='pagenum'><a name="Page_xi" id="Page_xi">[xi]</a></span></p> + +<h2>TABLE OF CONTENTS</h2> + +<table cellspacing="3" summary="Table of Contents"> + +<tr><th align="left" colspan="2" class="toc">CHAPTER</th><th class="toc">PAGE</th></tr> + +<tr><td></td><td class="smcap pad-l">Editor's Preface</td><td align="right"><a href="#Page_vii">vii</a></td></tr> + +<tr><td align="right">I.</td> <td class="smcap pad-l">Introduction and Typical Cases of Deep +Stupor</td> <td align="right"><a href="#Page_1">1</a></td></tr> + +<tr><td align="right">II.</td> <td class="smcap pad-l">The Partial Stupor Reactions</td> <td align="right"><a href="#Page_34">34</a></td></tr> + +<tr><td align="right">III.</td> <td class="smcap pad-l">Suicidal Cases</td> <td align="right"><a href="#Page_50">50</a></td></tr> + +<tr><td align="right">IV.</td> <td class="smcap pad-l">The Interferences with the Intellectual +Processes</td> <td align="right"><a href="#Page_67">67</a></td></tr> + +<tr><td align="right">V.</td> <td class="smcap pad-l">The Ideational Content of the Stupor</td> <td align="right"><a href="#Page_82">82</a></td></tr> + +<tr><td align="right">VI.</td> <td class="smcap pad-l">Affect</td> <td align="right"><a href="#Page_123">123</a></td></tr> + +<tr><td align="right">VII.</td> <td class="smcap pad-l">Inactivity, Negativism and Catalepsy</td> <td align="right"><a href="#Page_132">132</a></td></tr> + +<tr><td align="right">VIII.</td> <td class="smcap pad-l">Special Cases: Relationship of Stupor to +Other Reactions</td> <td align="right"><a href="#Page_149">149</a></td></tr> + +<tr><td align="right">IX.</td> <td class="smcap pad-l">The Physical Manifestations of Stupor</td> <td align="right"><a href="#Page_174">174</a></td></tr> + +<tr><td align="right">X.</td> <td class="smcap pad-l">Psychological Explanation of the Stupor +Reaction</td> <td align="right"><a href="#Page_186">186</a></td></tr> + +<tr><td align="right">XI.</td> <td class="smcap pad-l">Malignant Stupors</td> <td align="right"><a href="#Page_205">205</a></td></tr> + +<tr><td align="right">XII.</td> <td class="smcap pad-l">Diagnosis of Stupor</td> <td align="right"><a href="#Page_223">223</a></td></tr> + +<tr><td align="right">XIII.</td> <td class="smcap pad-l">Treatment of Stupor</td> <td align="right"><a href="#Page_229">229</a></td></tr> + +<tr><td align="right">XIV.</td> <td class="smcap pad-l">Summary of the Stupor Reaction</td> <td align="right"><a href="#Page_234">234</a></td></tr> + +<tr><td align="right">XV.</td> <td class="smcap pad-l">The Literature of Stupor</td> <td align="right"><a href="#Page_249">249</a></td></tr> + +<tr><td></td><td class="smcap pad-l">Index</td> <td align="right"><a href="#Page_279">279</a></td></tr> +</table> + +<p><!-- Page 1 --><span class='pagenum'><a name="Page_1" id="Page_1">[1]</a></span></p> + +<h1 class="ch1">BENIGN STUPORS</h1> + +<h2>CHAPTER I<br /> +<span class="sm">INTRODUCTION AND TYPICAL CASES OF DEEP STUPOR</span></h2> + +<p>The fact that psychiatry lags in development and +recognition behind other branches of medicine is due +in part to the crudity of its clinical methods. The +evolution of interest in science is from simple, +obvious and tangible problems to more intricate and +impalpable researches. Refined laboratory work has +been done in psychiatric clinics, particularly along +histopathological lines, but clinical studies follow +antiquated methods. The internist does not say, +"The patient has sugar in his urine, therefore he +has diabetes and therefore he will die." He finds a +glycosuria and looks for its cause. If this symptom +is found to be related to others in such a way as to +justify the diagnosis of diabetes, a therapeutic +problem arises, that of adjusting the chemistry of +the body. The prognosis depends not on the disease +but the interreaction of the organism and the morbid +process. Both in diagnosis and treatment an individual +factor, the patient's metabolism, is of prime +importance. Now in psychiatry, although the personality +is diseased, this personal factor has been<!-- Page 2 --><span class='pagenum'><a name="Page_2" id="Page_2">[2]</a></span> +almost entirely neglected. Text-books furnish us +with composite pictures which are called diseases, +not with descriptions of reactions brought about by +the interplay of personal and environmental factors. +Educated people are not satisfied with novels that +fail to depict real characters. Clinical psychiatry, +however, has been content with the dime-novel type +of character delineation. This is all the more disappointing, +inasmuch as the study of insanity should +contribute largely to our knowledge of everyday life. +This defect can only be remedied by looking on every +case as a problem in which the origin of each symptom +is to be studied and its relation traced to all +other symptoms and to the personality as a whole. +This is an ambitious task and we do not pretend to +any great achievement, merely to a beginning.</p> + +<p>No better psychoses could be chosen for a preliminary +effort than benign stupors. Every psychiatrist +has seen them, although they are wrongly diagnosed +as a rule, and they play no small rle in the world's +history. Euripides represents Orestes as having a +stupor which is pictured as accurately as any modern +psychiatrist could describe an actual case.<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a> St. +Paul is chronicled as falling to the ground, being +thereafter blind and going without food or drink for +three days. While apparently unconscious he had +a religious vision. St. Catherine of Siena had several +unquestionable stupors, which are fairly well<!-- Page 3 --><span class='pagenum'><a name="Page_3" id="Page_3">[3]</a></span> +described. In fact the mystics in general seem to +have had communion with God and the saints most +often when they seemed unconscious to bystanders.<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a> +The obsession with death, which seems so intimate +a part of the stupor reaction, is a fundamental theme +in poetry, religion and philosophy. The psychology +of this interest is, speaking broadly, the psychology +of stupor. So, from a general standpoint, our problem +is related to the study of one of the most potent +ideas which move the soul of man.</p> + +<p>Psychiatrically, stupors have long remained an +unsolved riddle. In the century prior to 1872 (See +the digest of Dagonet's publication in <a href="#CHAPTER_XV">Chapter XV</a>) +French psychiatrists wrote some good descriptions +of stupor and offered brilliant, though sketchy generalizations +about the condition. Two years later +an English psychiatrist (Newington, See <a href="#CHAPTER_XV">Chapter +XV</a>) improved on the French work. Little light has +been thrown on the subject since then. The researches +of the later French School showed that +stupor often occurs in the course of major hysteria, +but this left many of these episodes obviously not +hysterical. When serious attempts were made at +classification, this ubiquitous symptom complex was +hard to handle. Wernicke wisely refrained from +attempting more than a loose descriptive grouping. +He called all conditions with marked inactivity and<!-- Page 4 --><span class='pagenum'><a name="Page_4" id="Page_4">[4]</a></span> +apathy "akinetic psychoses" and said that some +recovered, some did not. Taxonomic zeal began to +blind vision when Kahlbaum formulated his "Catatonia" +and included stupor in the symptom complex. +The condition which we call stupor occurs in the +course of many different types of mental disease. +It is true that it is frequent in catatonia but is not +exclusively there. Mongols have black hair and +straight hair, but one cannot therefore say that any +black and straight haired man is a Mongol. Fortunately +Kahlbaum prevented serious error by leaving +the prognosis of his catatonia open. When Kraepelin +included it in his large group of Dementia +prcox, however, it implied that stupor could not +be an acute, recoverable condition.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a> He unquestionably +advanced psychiatry greatly but his scheme was +too ambitious to be accurate. Many observers saw +patients, classified as dements according to Kraepelin's +formul, return, apparently normal, to normal +life. Finally Kirby<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a> published a series of cases +which showed decisively that this classification was +too rigid.</p> + +<p>Since his paper is the foundation for this present +study, it should be reviewed carefully. He first +points out that Kraepelin's "Dementia prcox"<!-- Page 5 --><span class='pagenum'><a name="Page_5" id="Page_5">[5]</a></span> +includes much more than it should with its inevitably +bad prognosis. He shows how others have found +patients with catatonic symptom complexes proceed +to recovery and speaks of these symptoms occurring +in epilepsy and even in frankly organic conditions, +such as brain tumor, general paralysis, trauma and +infections. Kirby's first claim is that there are +probably fundamentally different catatonic processes, +deteriorating and non-deteriorating. Lack +of knowledge has prevented us from understanding +the meaning of the symptoms and hence making the +discrimination. He points out that stupor seems to +represent an attitude of defense, similar to feigned +death in animals, and that in a number of his cases +it was clear that the stupor symbolized the death of +the patient. Apparent negativism, he found to be +often a consciously assumed attitude of aversion +towards an unpleasant emotional situation. In +cases where there had been no prodromal symptoms +pointing definitely to dementia prcox the outcome +was almost always good. To discriminate the cases +with good outlook from those with bad, he discerned +no difference in the stupors themselves, but observed +that the mental make-up and initial symptoms +differed sufficiently for diagnosis to be made. +His most important point is, perhaps, that these +benign stupors showed a definite relationship to +manic-depressive insanity in that some patients +passed directly from stupor to typical manic excitement, +while in others a "catatonic" attack replaced +a depression in a circular psychosis.</p> + +<p><!-- Page 6 --><span class='pagenum'><a name="Page_6" id="Page_6">[6]</a></span> +Kirby introduces, then, the idea of stupor being a +type of reaction which can occur either in dementia +prcox or in manic-depressive insanity. The matter +cannot be left there, in fact it raises new +problems: what constitutes the reaction? how are +the various symptoms interrelated? are they different +in deteriorating and acute cases? what is the +teleological significance of the reaction? if it be an +integral part of the manic-depressive group, how +does it affect our conceptions of what manic-depressive +insanity is? More than five years have been +spent in endeavors to answer these questions and the +results of the study are now presented.</p> + +<p>Naturally the first point to be settled is: what +constitutes the stupor reaction itself. We can say at +the outset that it is seen in the purest form in benign +cases, hence they make up the material of this book. +To discover the symptoms of the disorder one +cannot do better than to study them in their most +glaring form in deep stupors, where consistently +recurring phenomena may be assumed to be essential +to the reaction.</p> + +<div class="blockquot"> +<a name="ChapI_Case1" id="ChapI_Case1"></a> +<p><span class="smcap">Case 1.</span>—<i>Anna G.</i> Age: 15. Admitted to the Psychiatric +Institute July 25, 1907.</p> + +<p><i>F. H.</i> The mother and two brothers were living and said to +be normal. The father died of apoplexy when the patient was +seven.</p> + +<p><i>P. H.</i> The patient was sickly up to the age of seven, but +stronger after that. It is stated that she got on well at school, +though she was somewhat slow in her work. She was inclined +to be rather quiet, even when a child, a bit shy, but she had +friends and was well liked by others. After recovery she made<!-- Page 7 --><span class='pagenum'><a name="Page_7" id="Page_7">[7]</a></span> +a frank, natural impression. She was always rather sensitive +about her red hair. She began to work a year before admission +and had two positions. The last one she did not like very well, +because, she alleged, the girls were "too tough."</p> + +<p>Three weeks before admission she came home from work and +said a girl in the shop had made remarks about her red hair. +She wanted to change her position, but she kept on working +until six days before admission. At that time her mother kept +her at home as she seemed so quiet, and when the mother took +her out for a walk she wanted to return, because "everybody +was looking" at her. For the next two days she cried at times, +and repeatedly said, "Oh, I wish I were dead—nobody likes +me—I wish I were dead and with my father" (dead). She also +called to various members of the family, saying she wanted to +tell them something, but when they came she would only stare +blankly. For a day she followed her mother around, clung to +her, said once she wanted to say something to her, but only +stared and said nothing.</p> + +<p>Four days before admission she became quite immobile, lay in +bed, did not speak, eat or drink. She also had some fever.</p> + +<p>The patient herself, when well, described the onset of her +psychosis as follows: She knew of no cause except that her +brother, some time before the onset (not clear how long), was +run over by an automobile and had his foot hurt. She claimed +that while still working she lost her ambition, lost her appetite, +did not feel like talking to any one; that when she went out with +her mother it merely seemed to her that people stared at her. +The day before she went to the Observation Pavilion her cousin +came to see her, and she thought she saw, standing beside this +cousin, the latter's dead mother. She also thought there was a +fire, and that her sister was sweeping little babies out of the +room. Then, she claimed, she felt afraid (this still on the day +before going to the Observation Pavilion) because she had repeated +visions of an old woman, a witch. This woman said, "I +am your mother, and I gave you to this woman (i.e., patient's +real mother) when you were a baby." She also was afraid her +mother was "going away."</p> + +<p>At the <i>Observation Pavilion</i> she was described as constrained, +staring fixedly into space, mute, requiring to be dressed and fed.</p> + +<p><!-- Page 8 --><span class='pagenum'><a name="Page_8" id="Page_8">[8]</a></span> +<i>Under Observation:</i> 1. For five months the patient presented +a marked stupor. She was for the most part very inactive, +totally mute, staring vacantly, often not even blinking, so +that for a time the conjunctiv were dry. She did not swallow, +but held her saliva; did not react to pin pricks or feinting +motions before her eyes. Sometimes she retained her urine, +again wet and soiled the bed. Often there was marked catalepsy, +and the retention of very awkward positions. As a rule +she was quite stiff, offering passive resistance towards any interference. +She had to be tube-fed at first. Later she was +spoon-fed, and then would swallow, in spite of the fact that during +the interval between her feeding she would let saliva collect +in her mouth. For a time she had a tendency to hold one +leg out of bed, and when it was put back would stick the other +out. Sometimes she walked of her own accord to the toilet chair, +but on one occasion wet the floor before she got there.</p> + +<p>During the first month after admission, this stupor was interrupted +for two short periods by a little freer action: she walked +to a chair, sat down, smiled a little, fanned herself very naturally +when a fan was given to her, though even then did not +speak.</p> + +<p>There was, as a rule, no emotional reaction, but after some +months she several times wept when her mother came, though +without speaking. Once when taken to the tub she yelled.</p> + +<p>Her <i>physical condition</i> during this stupor was as follows: She +menstruated freely on admission, then not again until she was +well. Several times she had rises of temperature to 102 or 103 +with a high pulse and respiration; again a respiration of 40, +with but slight rise of temperature, though the pulse had a tendency +to go to 130 and over. She was apt to show marked skin +hypermia wherever touched. With the fever there was found +a leucocytosis of from 11,900 to 15,000, with marked increase of +polynuclear leucocytes (89%). She got very emaciated, so that +four months after admission she weighed 68 lbs. (height 5' 2").</p> + +<p>2. About five months after admission she was often seen smiling, +and again weeping, and she began to talk a little to the +nurses, though not to the doctors. She also began to eat excessively +of her own accord, and rapidly gained weight, so that<!-- Page 9 --><span class='pagenum'><a name="Page_9" id="Page_9">[9]</a></span> +by January she weighed 98 lbs., a gain of 30 lbs. in two +months. Yet she continued to be sluggish.</p> + +<p>3. For two more months she was apathetic and appeared disinterested, +often would not reply, again, at the same interview, +she would do so promptly and with natural voice. This condition +may be illustrated by the summary of a note made on January +29, 1908, which is representative of that period. It is stated +that she sat about apathetically all day, appeared sluggish, but +was fairly neat about her appearance and cleanly in her habits. +There was at no time any evidence of affect, except when asked +by the examiner to put out her tongue so that he could stick a pin +in it she blushed and hid her face. When asked whether she +worried about anything, she denied this. When questions were +asked, she sometimes answered promptly and in normal voice, +again simply remained silent in spite of repeated urging. On +the whole, it seemed that simple impersonal questions were answered +promptly; whereas difficult impersonal questions or questions +which referred to her condition were not answered at all. +She proved to be oriented. Thus she gave the day of the week, +month, year, the name of the hospital, names of the doctors and +nurses promptly. She also counted quickly and did a few simple +multiplications quickly. But she was silent when asked +where the hospital was located, how long she had been here, +whether she was here one or six months, how she felt. Questions +in regard to the condition she had passed through, or involving +difficult calculations, she did not answer. However, +some questions regarding her condition asked in such a way that +they could be answered by "yes" or "no" were again answered +quite promptly. Thus when asked whether her head felt all +right she said, "Yes, sir." (Is your memory good?) "Yes." +(Have you been sick?) "No, sir." (Are you worried?) "No."</p> + +<p>4. This apathy cleared up too, so that by the middle of March +she was bright, active and smiled freely. With the nurses she +was rather talkative and pleased, though this was not marked. +Towards the physician only was she natural and free. She then +gave the <i>retrospective account</i> of the onset detailed above. When +questioned about her condition she claimed not to remember the +Observation Pavilion, although recalling vaguely going there in +a carriage. She was almost completely amnesic for a consider<!-- Page 10 --><span class='pagenum'><a name="Page_10" id="Page_10">[10]</a></span>able +part of her stay in the Institute. She claimed it was only +in November or December that she began to know where she was +(five months after admission). In harmony with this is the fact +that she did not recall the tube- and spoon-feeding which had +to be resorted to for about four months of this period. No +ideas or visions were remembered. As to her mutism she said, +"I don't think I could speak," "I made no effort," again "I did +not care to speak." She claimed that she remembered being +pricked with a pin but that she did not feel it. She remembered +yelling when taken to the tub (towards end of the marked +stupor) and claimed she thought she was to be drowned.</p> + +<p>When she went home (March 24, 1908) she got into a more +elated condition. She was talkative, conversed with strangers +on the street, said to her mother that she was now sixteen years +old and wanted "a fellow." When the mother would not allow +her to go out, she said it would be better if they both would jump +out of the window and kill themselves. She then was sent back +to the hospital. In the first part of this period after her return, +she was somewhat elated and overtalkative, though she did not +present a flight of ideas, and was well behaved. She soon got +well, however, and was discharged, four months after her readmission, +fully recovered.</p> + +<p>After that, it is claimed, she was perfectly well and worked +successfully most of the time with the exception of a short period +in the spring of 1909, when she was slightly elated.</p> + +<p>In 1910 she had a subsequent attack, during which she was +treated at another hospital. From the description this again +seems to have been a typical stupor (immobility, mutism, tendency +to catalepsy, rigidity). According to the account of the +onset sent by that hospital (it was obtained from the mother), +this attack began some months before admission, with complaints +of being out of sorts, not being able to concentrate and fearing +that another attack would come on. Finally the stupor was said +to have been immediately preceded by a seizure in which the +whole body jerked. She made again an excellent recovery.</p> + +<p>The patient was seen about two years after this attack, and +described the development of the psychosis as follows: She +claimed she began to feel "queer," "nervous," "depressed," got +sleepless. Then (this was given spontaneously) she suddenly<!-- Page 11 --><span class='pagenum'><a name="Page_11" id="Page_11">[11]</a></span> +thought she was dying and that her father's picture was talking +to her and calling her. "Then I lost my speech." As after the +first attack, she claimed not to have any recollection of what went +on during a considerable part of the stupor but recalled that +she began to talk after her brother visited her. It is not clear +how she was during the period immediately following the stupor.</p> + +<p>She made a very natural impression and came willingly to +the hospital in response to a letter and was quite open about giving +information.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 2.</span>—<i>Caroline DeS.</i> Age: 21. Admitted to the Psychiatric +Institute June 10, 1909.</p> + +<p><i>F. H.</i> The father died of apoplexy when patient was nine. +The mother had diabetes. A paternal uncle was queer, visionary.</p> + +<p><i>P. H.</i> The patient was always considered natural, bright, had +many friends, and was efficient.</p> + +<p>Some months before admission the patient's favorite brother, +who is a Catholic, became engaged to a Protestant girl, and +spoke of changing his religion. The family and the patient were +annoyed at this, and the patient is said to have worried about +it, but was otherwise quite natural until seven days before admission. +Then, at the engagement dinner of the brother, the +psychosis broke out. She refused to sit down to the table, and +then suddenly began to sing and dance, cry and laugh and talk +in a disconnected manner. Among other things, she said "I +hate her," "I love you, papa" (father is dead), "Don't kill me." +She struck her brother. She was in a few days taken to the +Observation Pavilion.</p> + +<p>The patient stated after recovery that what worried her was +that the brother would marry a Protestant and that he would +leave home (favorite brother).</p> + +<p>At the <i>Observation Pavilion</i> she was excited, shouted, screamed, +laughed, called out "Don't kill me," again "Brother, brother," +"You are my brother" (to doctor).</p> + +<p><i>Under Observation:</i> 1. On admission, and for two weeks, the +patient presented a marked excitement, during most of which +she was treated in the continuous bath. She tossed about, threw +the sheets off, beat her breasts and abdomen, put her fingers +into her mouth, bit the back of her hands, waved her arms about,<!-- Page 12 --><span class='pagenum'><a name="Page_12" id="Page_12">[12]</a></span> +sometimes with peculiar gyration, etc., at the same time shouting, +singing, again praying, laughing or crying, sometimes fighting +the nurses and resisting them. She also talked quite a little as +a rule, but there were periods when, although excited, she would +not talk or answer questions. She was very little influenced in +her talk by the environment. When on one occasion asked if she +had any trouble, she said: "No—I don't want, somebody else +gave me a book—all right I love myself, Uncle Mike too—all +right too—all right I am in Bellevue—I love everybody except +the Jews all right, all right—give me water, give me milk, give +me seltzer—white horse uncle—Holy Father, he is killing me, +I want my mother," or "Wait a minute, say, that's a lie—oh no, +Holy water—no I didn't wash the water away—oh, she forgets, +I am sick—mother why don't you come—look at the baby, they +knocked my head against the wall—wait a minute, isn't that terrible?—I +was married—I was so—I forgot—April fool—I kiss +you seven kisses and one more—I love papa and mamma, I like +others too—I am papa's angel child—yes I confess I love him, +but I don't want to die myself." On another occasion, when +asked where she was, she said: "I am at the ball—I am going +to Heaven—don't shoot me" (affectless). (Why are you afraid?) +"Because you see—high water (in the tub)—white horse." +(What about the water?) "My name is Caroline—if you love +me, father, tickle me under my feet," or, rolling her eyes up, +"Oh, isn't that awful, that ring, that diamond, that is the key +to Heaven."</p> + +<p>2. For about ten days she was somewhat different. She became +quieter and at first lay muttering unintelligibly, saying +some things about being killed, but speaking little, often restlessly +tossing about and tremulous. She had to be tube-fed. On one +day (July 1) she smiled more and talked more, said to the +physician "You have been arrested for me—you arrested the +first man that I ever—New York State—let me see that book" +(note pad). Then she went on: "Oh, I am all apart—diamonds—they +didn't know—must I keep them clean?—what is your +name?—that is another thing I would like to know." But when +asked what house she was in she said: "This is the same Ward's +Island" and then added, "How long have I been here?—there is +my picture up there (register), who is that? (listening) it's Ida<!-- Page 13 --><span class='pagenum'><a name="Page_13" id="Page_13">[13]</a></span> +..." She began to sing softly. Then again she whined. +"O mamma, mamma!" When asked how long she had been +here, she said: "Since Decoration Day, when my father went +in my sister's house, nobody could catch up with me—somebody +blackened her eyes." When asked whether she was sick, she +said "No, insane."</p> + +<p>Although, as was stated, she said at one time, "This is the +same Ward's Island," usually questions regarding orientation +were not answered, as she gave few relevant replies, but she repeatedly +said spontaneously that she was in "Hoboken or Bellevue," +and called the nurse by the name of a former teacher. A +few days after this state had developed she had a fever. Once +this rose to 104. The fever lasted two weeks, coming down +gradually. It was associated with a leucocytosis of 15,000 on +June 29 (no differential count) and with coated tongue. No +Widal (two examinations). No diazo (July 1).</p> + +<p>3. Then while the temperature still lasted she developed a +stupor which persisted for about a year. During this time her +temperature rose to 100 without ascertainable cause. She lay +for the most part motionless, changing her position but rarely; +her expression was stolid; she retained and drooled saliva, wet +and soiled herself. She never answered any questions; showed +no interest whatever. At times she was quite stiff and very resistive +but never cataleptic. Her extremities were cold and cyanotic. +She had to be tube-fed throughout. During this time +she lost much hair.</p> + +<p>After some months she occasionally gazed about furtively, or +later watched everything when unaware of being observed; at +this time she also smiled occasionally at amusing things, or perhaps +said "yes" or "no" to questions, but usually was stolid when +interrogated.</p> + +<p>Then about nine months after admission, while in the condition +just described, she developed a lobar pneumonia. During +it she remained the same. But during convalescence she began +to speak and eat.</p> + +<p>4. A period followed lasting six months during which she was +up and about, but sat or stood around a good deal. On the +other hand, she helped the nurses a little when urged. Her +face was often stolid, again she looked about. At times (even<!-- Page 14 --><span class='pagenum'><a name="Page_14" id="Page_14">[14]</a></span> +nearly to the end) she drooled and soiled. She said little. At no +time was she resistive. On other occasions she smiled or laughed, +not always on provocation, or she showed little playful tendencies, +such as throwing a pillow about the room, tearing leaves from the +plants, taking the doctor's arm and walking down the hall, asking +him to kiss her. At such times she often looked quite bright, +keen, alert and amused. Towards the end she would give at +times playful answers, such as "I came to-day," or "This is the +Hall of Fame." This tapered off, so that by December, 1910, +she was perfectly well.</p> + +<p><i>Retrospectively</i>, the patient claimed not to remember the upset +at the dinner, or what happened afterward, although recalling +the trip to the Observation Pavilion. She denied any +memory of the journey to the hospital, but could tell what ward +she came to. How well the condition after that was recalled, +was not inquired into, except that she could or would not explain +further the utterances during the first period. For the stupor +period it is stated that she remembered many external facts, but +it is not clear in which period they occurred.</p> + +<p><i>Catamnestic Note.</i> May, 1913: She has worked efficiently, and +is said to have been perfectly well.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 3.</span>—<i>Mary F.</i> Age: 21. Admitted to the Psychiatric +Institute June 28, 1902.</p> + +<p><i>F. H.</i> The mother died when the patient was five. The father +was living, an alcoholic and reckless man. Four brothers and +sisters died in infancy.</p> + +<p><i>P. H.</i> The patient was the only surviving child. She was +brought up in a convent and orphan asylum until 11, when +her father remarried. At 12 she had to go to work, hence she +had but little education. She was bright, efficient, well liked +by her employers (in one position five years). As to her peculiarities, +she was thought to be, perhaps, a little headstrong, +and was also described as always very exact, rather quick-tempered +and inclined to be irritable when crossed.</p> + +<p>She was married six months before admission and had a <em>baby +three weeks before admission</em>. The husband stated that when +the father found out she was pregnant, he spoke of killing him. +He frequently upbraided both husband and wife, though he lived<!-- Page 15 --><span class='pagenum'><a name="Page_15" id="Page_15">[15]</a></span> +with them. Even after the child was born he continued to be +disagreeable.</p> + +<p>The patient was rather low spirited and quieter after her marriage. +She worried over her illegitimate pregnancy and the scolding +from her father. But nothing was thought of all this, and +it did not interfere with her activity. The birth was normal. +She had no flow, no unfavorable symptoms, and sat up on the +twelfth day. She is said to have appeared natural mentally.</p> + +<p>A week before admission the family returned from the christening, +having left the patient apparently well. They now found +her sitting in her chair, limp, with closed eyes, giving no answer +to questions. Only after about twenty minutes could she be +aroused. After her father had given her milk with whiskey in +it, she claimed he had poisoned her. In the evening she was +bright and lively, singing and dancing with the others, but in +the night she woke up her husband, seemed frightened, said +somebody was in the room and that he should get a priest as she +was going to die. The husband went to sleep again. The next +forenoon the patient claimed she had been frightened all night +and thought her father was going to kill her husband.</p> + +<p>On the second day, while sitting at breakfast, she groped about +for the bread plate for some time and then said she had been +blind for a short time. During the day she had frequent spells +in which she would close her eyes, become perfectly quiet and +difficult to rouse. Sometimes at the beginning of these spells +she would say "I am going." She was then taken to her aunt +and walked there, a distance of a few blocks. She was there for +two days before going to the Observation Pavilion. In this time +she is said to have been quiet for the most part, often apparently +sleeping or staring. Once she said she was "rather dirty, +filthy." Once she tried to get out of the window, said it was a +door and that she wanted to get out and take a walk. Above +all, she had, in these two days, repeated peculiar seizures which +the aunt and the husband described as follows: When sitting +on a chair she would close her eyes, clench her fists, pound the +side of the chair, get stiff, slide on the floor, then thrash her +arms and legs about and move the head to and fro. She frothed +at the mouth. After the attack, which lasted a few minutes, she +breathed heavily for a while. Once she wiped off the froth<!-- Page 16 --><span class='pagenum'><a name="Page_16" id="Page_16">[16]</a></span> +with a handkerchief and gave the latter to the aunt, saying +"Burn that, it is poison." Before the attack she sometimes said +that it got dark over her eyes and that her face felt funny, again +that she had a pain in the stomach which worked towards her +right shoulder. There was no cry in the beginning of the attack, +but once she wet herself.</p> + +<p>After recovery the patient herself told the development of her +psychosis thus:</p> + +<p>There was trouble between the father and the husband, and +she was afraid of her father. On the day of the christening she +took sick: a queer feeling came over her and she wondered +whether she was going to die, "Then I seemed to lose myself, and +when I came to I found my family standing around me." Her +father gave her whiskey and she thought it was poison. "That +night I had spells of dancing and singing, it must have been +something I took, perhaps the liquor." The same night she was +frightened, thought her father might do some harm, and had a +vision of a person in white standing at her bed. After that she +had repeated spells in which she knew nothing until "I came to +again." "It was a queer trembling."</p> + +<p>At the <i>Observation Pavilion</i> she was described as in a state of +"intense mental depression," taking no interest in things going +on about her. She spoke, however; said she wanted to die, that +she had imagined her father had given her poison, that every +one was against her, and that people were talking about her.</p> + +<p>1. <i>On admission</i> the patient had a slightly elevated temperature, +which soon subsided, full breasts but without inflammation. +Sordes were not mentioned.</p> + +<p>For a few days she was essentially somewhat restless, getting +out of bed, disarranging her clothes, wandering about—all in a +rather deliberate, aimless way, sometimes vaguely resistive, again +with free movements. She looked, dazed, sometimes stared +straight ahead and looked "dreamy." Occasionally there was a +tendency to close her eyes. With the restlessness she looked at +times "a little apprehensive," or shrank away when approached. +She spoke slowly, with initial difficulty, but answered quite a +number of questions. The mental content of this period was +displayed in the following utterances: She would ask for a +priest, or say "Have I done something?" or "Do people want<!-- Page 17 --><span class='pagenum'><a name="Page_17" id="Page_17">[17]</a></span> +something?" or, when asked why she was here, she said "I have +done damage to the city, didn't I?" (What have you done?) +"I don't know." Or she spoke of people watching her. When +asked the day, she said "Judgment Day," yet she knew the month. +Once when asked what the place was she said, "This is the hereafter." +When asked what had happened at home, she said: +"Voices told me I was to be killed." She was not clearly oriented, +called the place Bellevue, asked "Isn't this a hospital?" yet again +said, "Ward's Island, where they work." On the day of admission +she thought she came "the day before," but knew she had come +in a boat. When asked her address, she said slowly, "Didn't I +live at, etc.," giving the address correctly. To the physician she +said, "Are you my brother?" And on another occasion, "My +God! You are Charlie" (brother). It was difficult to get her +to eat, and she had to be spoon-fed.</p> + +<p>2. Then she became more preoccupied, the restlessness was +much less in evidence, it became necessary to tube-feed her, she +retained her urine, answered a few questions, and when asked where +she was, she said, "Calvary, ain't it?" (What house?) "Heaven, +ain't it?" She still called the physician by the name of her +brother. After a few days this gave way to a more marked +stupor which lasted nearly two years. This was characterized +most frequently by a complete inactivity. She usually lay or +sat motionless, sometimes with mouth partly open, letting the flies +crawl over her face, gazing in one direction, soiling, wetting, +resisting moderately or markedly any interference, and had to be +tube-fed. But this was not the invariable state. The most +constant feature was her mutism, but even that was a few times +interrupted. Thus, when after a visit from her uncle (towards +the end of July, 1902) she tried to get out of the window and +was prevented, she swore at the nurse. Or in August, 1902, +when she got into another patient's bed and was taken out, she +resisted and said promptly: "I think it is a damned shame I +can't get into my own bed." But this was the extent of her talk +for a year and a half. Nor was she always totally inactive. In +the middle of July, 1902, she sometimes tried to get out of bed, +wandered about, got into other patients' beds. It was on such +an occasion that the above incident happened. In August, 1902, +she sometimes tried to get out when the door was opened, and<!-- Page 18 --><span class='pagenum'><a name="Page_18" id="Page_18">[18]</a></span> +we have seen that she tried to get out of the window, but she did +not change her placid expression at such times. Her motive was +not known. On two occasions towards the end of 1902, when +she was taken to a dance and was made to take part, she waltzed +with considerable animation but did not speak. This was quite +striking in that these incidents occurred in a setting of marked +inactivity (i.e., a condition in which she had to be pushed to the +table, pushed to the closet). She did not soil any more, but +she sometimes drooled and had to be spoon-fed. However, on a +third occasion when this was tried, she had to be dragged around. +Finally, though her facial expression showed at times a preoccupied +staring, she more often looked around, sometimes quite +freely and often looked up promptly enough when accosted. But +there was very little evidence of any affect at any time. We have +seen that twice she swore a little when opposed. On another +occasion she slapped a patient when the latter helped her. Twice +she was seen crying a little without apparent provocation, but +she did not laugh, and the only suggestion of pleasurable emotion +was that at the two dances mentioned she could be led into a +certain animation. Usually, even when she got less resistive +towards the end, she was essentially apathetic.</p> + +<p>Once in January, 1903, she could be made to write her name +but wrote her maiden name. In the end of 1903 she improved +gradually (a condition not well observed), so that by December +she answered some questions in a low tone. Even in April, 1904, +she was still described as apathetic, though she had begun to do +some work.</p> + +<p>3. Then she improved markedly and began to work, looked +after herself in a natural way, spoke freely, was entirely oriented +and her mood generally presented nothing striking. But her +mental attitude was still peculiar when she was questioned. She +seemed somewhat inattentive, sulky, sneering. Thus, when asked +why she was here, she said, "You will have to ask those who +brought me here."</p> + +<p>She denied ever having been pregnant, said the nurses on the +ward had spoken of her having had a child and that they had +showed her a child (one was born on that ward about August, +1903) but that it was not hers. She thought it was wrong for +the nurses to speak on the ward of her having been pregnant.<!-- Page 19 --><span class='pagenum'><a name="Page_19" id="Page_19">[19]</a></span> +Again questioned about her marriage, she first said she had not +been married, again that she was married "a year ago" (was in +the hospital then). Again she spoke of her husband as her +"gentleman friend," claimed she called herself Mary M. (maiden +name) until a girl friend wrote her a letter addressed to Mrs. F. +From then on, she called herself by her married name. But she +thought that probably they sometimes spoke of her marriage in +fun. If she were Mrs. F. she would be living in Mr. F.'s house.</p> + +<p>On June 29, when again asked about her marriage, she said +she was to have been married in December (correct date). (Were +you?) "So they say." (Do you remember it?) "In a way." +(When was the baby born?) "You will have to ask somebody +more superior to me, more experienced." Then, when further +questioned about the age of the baby, she said, "The baby I saw +in the ward was about a year old," and she claimed not to +remember ever having a baby. When asked why she had come +here she said, "Well, I don't know, perhaps you know better, +through sickness I guess," and later: "Well, don't you ever get +a cold and want doctors to examine you?" (What kind of a +place?) "This is a nice place for sensible people who have +enough knowledge to know and realize what they come for." But +she knew the name of the place, the date, the names of persons.</p> + +<p>Questioned about the trouble with her father or her husband's +trouble with him, she denied it, "If he did (sc. have any trouble), +I don't remember." About her not speaking, she said, in answer +to questions, "I didn't know what I was here for, what was the +object in keeping me here"; and to other questions about her +condition, "I don't know, those who examined me can tell you +more about that." Finally, she said in reply to the question, +why she came here, "I don't remember <em>unless it was through fire</em>," +but would not explain what she meant.</p> + +<p>In the beginning of July, she again said that she had no recollection +of her marriage.</p> + +<p>She then improved a great deal and finally appeared very +natural, gave the retrospective account noted in the history, had +a clear appreciation of the fact that she was married and had a +child. She claimed that she had previously forgotten about her +marriage and thought she was still merely keeping company with +Mr. F. She claimed not to remember coming to the hospital,<!-- Page 20 --><span class='pagenum'><a name="Page_20" id="Page_20">[20]</a></span> +did not know what ward she came to, who the doctor and nurses +were, in fact claimed that it was about a year before she knew +where she was. But she remembered having been tube-fed. She +could not say why she did not speak. But she appreciated that +she had been ill.</p> + +<p>Ten years after discharge the husband, in answer to an inquiry, +stated that she had been perfectly well and had had no trouble +at three successive childbirths.</p></div> + +<div class="blockquot"> +<a name="ChapI_Case4" id="ChapI_Case4"></a> +<p><span class="smcap">Case 4.</span>—<i>Mary D.</i> Age: 20. Admitted to the Psychiatric +Institute September 17, 1907.</p> + +<p><i>F. H.</i> The grandfather and the father of the patient were +alcoholics. The father died three years before the patient's +admission; he was killed in an accident. The mother stated that +she herself was nervous, but she made a normal impression.</p> + +<p><i>P. H.</i> The patient was described as bright at school and +efficient in her work as a dressmaker, but she was rather quiet, +inclined to stay at home and had not much inclination to consort +with the other sex. She was rather proud. As an example of +this is stated the fact that she was always somewhat sensitive, +because the family lived in the basement of the house in which +her mother was janitress. She did not menstruate until 16. It +was about this time that her father was killed in an accident. +She was considerably upset by this, talked a good deal about the +way he was killed, but did not break down. The patient on +recovery stated that it worried her because the father died without +having any chance to get a priest.</p> + +<p>Six weeks before admission the patient was given a vacation, +as there was not work enough in the shop, but she worked at +home.</p> + +<p>Two or three weeks before admission her appetite failed somewhat, +and ten days before admission, without any appreciable +cause, she began to sleep badly, seemed somewhat nervous, became +a little "fidgety" and said she worried because her mother had to +work so hard. Later she began to speak about people saying that +the ambulance would come for her and she heard voices saying +"You will be dead." It is not known in what emotional setting +these remarks were made. Her mother took her to a dispensary. +On the way she asked the mother where she was going and said<!-- Page 21 --><span class='pagenum'><a name="Page_21" id="Page_21">[21]</a></span> +"I can't tell the number and I don't know where I am going. I +think I am losing my mind." She also said she could not understand +any more what she read. She was put to bed. She then +talked less, appeared stupid, and was inclined to refuse food.</p> + +<p>Four days before admission she claimed that she could see her +dead father beckoning to her, again she said a certain young man +was God. She was sent to the Observation Pavilion. On the +day she went there she was reported to have shown a slight +jaundice.</p> + +<p>The patient, after her recovery, added to the above account of +the mother, that about two weeks before admission, for no reason +which she could state, she began to feel quiet, and that after that +her father's death began to prey on her mind, and that later she +had a vision of her father. She claimed that in this period she +had no fear but that her head felt dizzy and her vision +seemed dim.</p> + +<p>At the <i>Observation Pavilion</i> the patient was described as constrained, +refusing food, mute, resistive of attention, sometimes +muttering to herself and having the appearance of uneasiness.</p> + +<p><i>Under Observation:</i> 1. On admission the patient had a slight +jaundice, which disappeared in a few days, and the bile test in +the urine was negative on admission. She was rather thin, but +otherwise in good physical condition. Her temperature was 99.2.</p> + +<p>For three months the patient was very inactive, moving very +little. She had to be dressed and undressed, when taken out of +bed. She often was markedly constrained, either lying with her +head raised from the pillow, or for long periods of time holding +her arms or hands in rather constrained positions on her body. +But there was at no time any catalepsy when tested by moving +her arms. In the beginning, however, before she lay so persistently +with her head raised, she was found holding it up from +the pillow after her hair had been fixed. Again, she did not +correct other, rather uncomfortable, positions in which she had +been left. There was also at times a slight or occasionally a +somewhat more marked resistance in her arms and neck, but this +never amounted to a pronounced resistance. She sometimes did +not react to pin pricks, sometimes flinched a little, never warded +off the pin, indeed she would put out her tongue repeatedly when +asked to do so in order to have a pin stuck into it. She very<!-- Page 22 --><span class='pagenum'><a name="Page_22" id="Page_22">[22]</a></span> +often wet and soiled, once even immediately after she had been +taken to the closet, on which occasion she did not urinate. Her +face was usually dull, vacant and immobile, but sometimes, when +questioned or when something obtrusive happened, a little puzzled. +Occasionally she looked slowly about or followed people +with her eyes. There was no evidence of any affect as a rule, +but not infrequently she smiled, even quite freely at times, when +the physician came to her or on other appropriate occasions. For +example, once when a nurse came into the ward whom she had +known outside she flushed and smiled a little. Once when the +mother came to see her a few tears appeared, the only time this +occurred.</p> + +<p>Although for the most part immobile, when she did move, she +was distinctly slow. When asked to do certain things, she usually +did not comply, but now and then, after urging, would show her +tongue after delay, or merely open her mouth; or she would +bring the hand forward slowly when the physician offered his +hand in greeting. Once she fumbled with her braids slowly. +When out of bed, she stood about aimlessly or sometimes walked +somewhat slowly.</p> + +<p>She was almost entirely mute, but a few times she returned a +greeting quite promptly, or on another occasion (September 23) +she said quite promptly, when asked how she felt, "I feel better. +I took off my clothes" (correct—she had been up and put to bed +again). Again she sometimes answered simple questions by +"yes" or "no," though sometimes in a contradictory and rather +aimless manner, but promptly enough. Once she said to her +mother, "I can't, I have to remain here." There were some other +replies which we shall presently take up. Several times it was +possible to make her write. On these occasions she wrote her +name promptly, or might write only after much delay or stopping +in the middle of a word.</p> + +<p>This leads us to her capacity to think, the defect of which was +perhaps most clear in her writing. Thus, though having been +told to write her name, and having written it quickly enough, +when, immediately after it, she was asked to write her address or +the name of the hospital, she had to be urged much, and then +wrote each time merely a repetition of her name, this time much +more slowly. On October 13, when she was asked to write her<!-- Page 23 --><span class='pagenum'><a name="Page_23" id="Page_23">[23]</a></span> +name, she wrote it correctly; then for the address she wrote the +house number correctly, but for 90th street she wrote "90theath"; +and, urged again for the address, she added "Dr. Wyeth." Again +when asked to write the word "watch" she was slow, and finally +put down "10." When on October 23 she was asked to write +"Manhattan State Hospital," she wrote "Manhatt Hhospshosh," +and for "Ward's Island" (which she was told), "Ww Iland." +Then she was asked to write "I wish to go home." She wrote +"I wish to go home, go West." Here again the first part was +written promptly.</p> + +<p>We now can add some of the other replies which she gave. +Once she was asked "Do you know where you are?" She +promptly said, "Yes." (Where?) No reply. On another +occasion, at the initial examination, she said she was home or +"in papa's house." Once when asked "Do you know me?" she +said "Yes." (What is my name?) "Miss D." (her name). On +the occasion on which she had stated that she had taken off her +clothes, she was asked "Where have you taken off your clothes?" +She made the irrelevant reply, "That was the girl the one I had."</p> + +<p>2. Then she improved somewhat. On January 5 she walked +about a little more, though slowly, and still looked slightly +puzzled when questioned. She spoke more readily, counted +promptly though once stopped in the middle of the exercise. In +calculation she multiplied correctly 3 7, but for 4 9 repeated +the 21, and when given 9 9 she did not answer. A few days +later, though she lay again motionless with her head raised as +before, and, as she had sometimes done, smiled brightly when +accosted, she gave few replies, but when asked to write down +the month she slowly wrote "December." Asked to write it the +second time, she did it promptly. She also replied promptly by +saying "Yes" when asked whether Christmas, and again whether +New Year's, had passed, but did not reply to the questions how +long ago Christmas, or how long ago New Year's, had occurred. +On January 23 she was decidedly more free and prompt in her +replies, yet she still wet and soiled (in fact this did not cease +until the end of the month, when great improvement occurred). +At this time she gave quite a number of calculations promptly, +about an equal number wrongly. She knew where she was, knew +the names of a number of people about her, but thought she had<!-- Page 24 --><span class='pagenum'><a name="Page_24" id="Page_24">[24]</a></span> +been here about two weeks (four months), and gave the year +and the date, the latter as the 28th of January. When then told +that it was Thursday, January 23, and that she must remember +it, and asked five minutes later what she had been told, she again +said "January 28" and left out Thursday. To some questions +to which she did not know the answers, since she had an amnesia +for the time of their occurrence (the incidents of coming here), +she simply remained silent. Even on February 7, when she was +much freer, helped the nurses, and said herself she was "smarter," +she had difficulty in thinking, said she was 17 (21), gave the date +of her birth correctly, but the current year as 1909 (1908) and +still insisted she was 17. She then did the calculations on paper, +and with considerable difficulty got correctly "22." But she +could not straighten out the discrepancy. At that time, also, +she still wrote "Hospitital," calculated even simple multiplications +with some mistakes, could not get the point of a story, and to +retention tests gave poor results. Indeed, even seven days later, +when she wrote a very rational letter and appeared quite natural, +she made some omissions in her writing, and a few mistakes in +spelling.</p> + +<p>However, she now improved rapidly, and by March 31 she +made a very natural impression, was frank, free, had good insight, +calculated well, etc., understood a story, retention was good.</p> + +<p>She then gave the retrospective account embodied in the history, +and in addition told that she had no recollection of going to the +Observation Pavilion, the coming here, or the first part of her +stay, including presentation of the case at a staff meeting, a +physical examination and a blood examination, and she claimed +for a long time not to know where she was, "I was in a kind +of dazed condition." She also said she could not understand +the questions which were asked her. This probably refers, +however, to the second part, i.e., the partial stupor lasting for +two months. She did not "feel like talking," the limbs "felt +stiff-like."</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 5.</span>—<i>Annie K.</i> Age: 22. Admitted to the Psychiatric +Institute January 7, 1907.</p> + +<p><i>F. H.</i> The father was an alcoholic, who died when patient was +a child. A paternal aunt had a nervous breakdown, with recovery. +The mother appeared to be normal.</p> + +<p><!-- Page 25 --><span class='pagenum'><a name="Page_25" id="Page_25">[25]</a></span> +<i>P. H.</i> The mother stated that the patient was a rather delicate +child. She attended school irregularly, never felt much interest +in it, and was always glad to be at home and help the mother +take care of the other children. On the other hand, she is said +to have been quite lively, rather a tomboy, with a temper. She +left school at 14; learned dressmaking for a year, but did not +get along well. Then she took several other positions, which +she held for about a year, getting on pretty well.</p> + +<p>She married at 20. Her husband never supported her well and +often beat her. She had to borrow money to get along and +worried much. During pregnancy she seemed to worry more, +had crying spells, and often seemed absorbed in thought.</p> + +<p>Three weeks before admission she gave birth to a child. The +labor was somewhat difficult, but she had no fever. She got up +on the tenth day, and then seemed to lose all interest, did not +attend to the baby, said she was not strong enough. She sat +about, appearing depressed. The mother then took her and the +baby to her house. There she sat or walked about, said very +little. But she repeatedly came to her mother, said she had +something to tell her, or that she had "done something," although +she could never be induced to say what. Once she came to her +and said, "You are not going to die." She often moaned. +Finally, she claimed a neighbor had been saying she was poisoning +the baby.</p> + +<p>The patient herself gave, after recovery, the onset as follows: +When she married she knew her husband was not what he should +be, but not that he was so bad as he proved to be. He was a +gambler, did not support her, and this caused her much worry. +When she became pregnant, eight months after marriage, this +increased her worry, and throughout the pregnancy she spoke +much to a neighbor about her worries, and said she did not know +how she could manage, pay the doctor, and the like, but she did +not say much about it to her mother (because the latter would +have made such a fuss about it, or would have said, "It serves +you right"). Then the childbirth came. This further accentuated +her worries. She felt her difficult circumstances, wondered how +she could get the necessary money, "I lay there worrying." And +she claimed she did not sleep at all. About her statement, mentioned +by the mother, that she had done something, she said that<!-- Page 26 --><span class='pagenum'><a name="Page_26" id="Page_26">[26]</a></span> +she thought she had poisoned the child by giving it fennel tea, +and that she thought a neighbor who visited her said she had +poisoned it. She was then put to bed again, and one night she +had a vision of her father. This frightened her. She thought +this meant he had come for her and she wanted to die.</p> + +<p>At the <i>Observation Pavilion</i> she was dull, staring, resisting +attempts at passive motions.</p> + +<p><i>Under Observation:</i> 1. There was nothing noteworthy in her +physical condition, except for a rise of temperature to 100 +occasionally during the first month of her admission. For the +first four months she was often found lying in bed with her head +half raised from the pillow, or standing or sitting about in +constrained positions, immobile, frequently she let saliva collect +in her mouth. She usually wet and sometimes soiled the +bed. Sometimes, when sitting in a constrained position, she let +herself gradually slide on the floor. She often began to feed +herself when urged, but would not finish, and had to be spoon-fed, +as a rule. She was never tube-fed. She was often quite stiff +and showed marked resistance. This was manifested either when +passive motions were tried, at which times she usually resisted +passively, i.e., she became more tense; or when there broke +through a more active aggression and she would strike. Above +all, the opposition showed itself towards the nurses' attention; +in this she also showed either a passive, aimless opposition and +stiffness, or a more active one; but even in the latter an open +show of angry affect, or plain irritation, though present at times, +was by no means constant. When it was present, she would strike +quite aimfully; once she struck the nurse and said, "You are the +cause of it all," and once, when the nurse tried to give her some +milk, she said, in an irritated tone, "I wonder people would not +let me alone some time." Again, she bit a patient who tried to +hold her. On another occasion she quickly jumped up and pulled +the hair of a patient who evidently disturbed her by her noisy +shouting. As was stated, she usually wet the bed, resisted being +taken to the toilet, or when taken there, would not urinate or +defecate, but would do so as soon as she was returned to bed; +or she urinated while standing. The same perverse opposition +was seen when she would refuse a glass of milk, but grab it when<!-- Page 27 --><span class='pagenum'><a name="Page_27" id="Page_27">[27]</a></span> +it was taken away and then refuse to let go. She often would +grasp the bedclothes or other things and hold on aimlessly.</p> + +<p>She rarely spoke, answered almost no questions, complied, as +a rule, not even with the simplest commands. To pin pricks she +did not react except at times by flushing. But she did not stare, +rather looked about, and was at times easily attracted by noises +or happenings about her, and would then look in that direction +not without some interest. Often there was then an expression +of bewilderment. Her mood, however, was, as a rule, apathetic, +but at times, as stated, she showed some anger. Once she wept, +and a few times she smiled or snickered. As a rule, this happened +without appreciable cause. But once, when a cheering +remark was made, she smiled; or, when her picture was taken (to +show the peculiar constrained attitude with the head raised from +the pillow), she laughed loudly.</p> + +<p>Although she spoke rarely, she made a few utterances in the +first few days. Thus she suddenly said: "I want to see Mr. N.—what +I said to him was not right," or "Listen! there are the +priests calling," or "You are all faking—it is me that done it—they +are all dressing up downstairs," or "I told you she was not +able to nurse the baby," or "I have nobody, I am lost—I want to +know the truth—my mamma," or she called her sister, "They are +dead since last night."</p> + +<p>Even during the more stuporous state she could, a few times, +be made to write a little. Then she either wrote very slowly and +not more than a letter, or if she wrote more, it was remarkably +mixed up. Thus when asked to write the date, she wrote, "Jane +(mother's name) to me to Chrichst," or when asked to write her +name: "Annie take you ktusto."</p> + +<p>As to her orientation, nothing could be made out as a rule. +At first, however, a few weeks after admission, she spoke correctly +of the month as January and spoke of the Island. When +at that time she was asked if she had a baby, she said, in an +annoyed tone, "I don't know."</p> + +<p>2. In the beginning of May, i.e., four months after entrance, +her condition changed somewhat, and for two months she presented +the following state: She stood about, or walked around +slowly, usually with her arms folded. She had a tendency to +stand near the door. She had to be assisted in dressing, pushed<!-- Page 28 --><span class='pagenum'><a name="Page_28" id="Page_28">[28]</a></span> +rather than led to her meals, and urged to eat. For the most +part, she would not answer questions, but would either smile in +a sneering way, or just walk away, or say, "Oh, don't bother me," +or "I don't want to talk," and generally her attitude was rather +sulky. Nor was this only towards the physicians but towards +the husband, sister and child as well. When on May 17 the +sister came, she would not speak to her but said "Go away." +The baby she simply pushed away sulkily when it was brought +to her. To the husband she said on May 31, "Go away, you +stink." In the first part of this period, she presented some +bursts of elation, on one occasion turned somersaults, indulged +in a few pranks with laughter, or once, when a knock at the door +was heard, she called out "Holy gee, cheese it, the cop." But +these occurred only in the first part of the period. On June 1 +she spoke to the nurse, said, "What is the matter with these +people, they must be crazy," asked to go home, and was then +by the nurse found to be oriented, and to know the names of +people around her. But when she was asked about the baby +she would not answer, and questioned whether she was not married, +she said "I don't know." Yet when the physician desired to +talk to her, she was just the same as before and remained so for +two more weeks. Another somewhat isolated occurrence was +when on June 18 she spoke a little to the physician, but she sat +in a constrained position when taken into the office and answered +many questions by "I don't know," namely, those regarding her +condition and feelings, the questions about orientation, about her +mother's address, and her child's age; but when asked how long +she had been married she said correctly "Two years."</p> + +<p>At the beginning of July she improved quite rapidly, and on +July 5 appeared fairly free and gave a fair retrospective account, +with some urging, and it was thought that she smiled somewhat +too freely. However, on July 27, she seemed perfectly well, had +normal insight, and then gave the second retrospective account, +which, together with the first, will now be taken up.</p> + +<p><i>Retrospectively:</i> She claimed to remember things at home, +and at both interviews said she recalled being taken to the +Observation Pavilion. While there she thought she knew where +she was, remembered that she did not talk. She had a feeling she<!-- Page 29 --><span class='pagenum'><a name="Page_29" id="Page_29">[29]</a></span> +was going to die and said "I thought I would die if I kept still." +However, the transfer to this hospital was vague in her mind, as +was the entrance on the ward, and she claimed not to have known +for quite a while where she was. She added that she used to +wonder where she was, how she had gotten here, and how she +could get out, and thought the questions which were asked were +queer. Individual occurrences, too, specifically inquired into were +not recollected, such as an examination in a special room. Of +the mixed-up writing at the end of the second week, she had no +recollection even when it was shown to her. She did not recall +having her picture taken (with eyes open) two months after +entrance. Yet a sudden angry outburst ten weeks after admission +was remembered. She stated that she struck the patient because +the latter annoyed her by her shouting. She had a general recollection +of being stiff, having her head raised, and of soiling and +drooling, but could not account for it. She felt stubborn. She +also claimed not to have been hungry and not to have felt pin +pricks.</p> + +<p>In regard to ideas which she had, she claimed to be afraid at +first that she would be cut up. She remembered repeated visions +of her father at night, also once of her dead aunt, who said +"Come to me." She thought she was in a cemetery, all the family +were dead, the baby dead. In the beginning, too, she sometimes +heard a priest whom she had known, say "Be good and God will +look after you."</p> + +<p>In regard to the later period, she recalled that she got up in +May and felt cross. She did not answer because she did not +want to be bothered. She pushed the baby away because she +did not think it belonged to her, the husband because she did +not like him. (She did not think she was not married.) She +evidently remembered the visits, thought she knew where she +was, knew she stood near the door "because I wanted to go home." +Besides the idea that the baby was not hers, she recalled none, +and thought she had no hallucinations.</p> + +<p>She was discharged perfectly well six months after admission +to the hospital. Soon after that, she left the husband, once had +him arrested in 1908 and sent to the workhouse. She was again +examined in 1913, and was found to be perfectly well, and she +stated she had been well since the discharge.</p></div> + +<p><!-- Page 30 --><span class='pagenum'><a name="Page_30" id="Page_30">[30]</a></span> +These five cases will have to suffice for the present. +They were given in full in spite of the fact that we +shall leave out of our present considerations the +history of the cases and certain of the stages, and +confine ourselves to that stage of each case which is +best qualified to give us a good general survey of the +essential features of the stupor reaction.</p> + +<p>These phases are: stage 1 of Case 1, lasting five +months; stage 3 of Case 2, lasting one year; stage 2 +of Case 3, lasting two years; stage 1 of Case 4, +lasting three months; stage 1 of Case 5, lasting four +months.</p> + +<p>We gather from these descriptions that the essentials +of the stupor reaction are (1) more or less +marked interference with activity, often to the point +of complete cessation of spontaneous and reactive +motions and speech; (2) interference with the intellectual +processes; (3) affectlessness; (4) negativism.</p> + +<p><i>Inactivity:</i> There is a complete cessation or more +or less marked diminution of all spontaneous or reactive +movements. This includes such voluntary +muscle reflexes as contain a psychic component. For +instance, there is, often, an interference with swallowing +(letting saliva collect and drooling), winking, +and even with the inhibitory processes used in holding +urine and feces (soiling and wetting). Often +there is no reaction to pin pricks or feinting motions. +The inactivity also often interferes with the taking +of food so that spoon-feeding or tube-feeding has to +be resorted to. The patient may keep his eyes cov<!-- Page 31 --><span class='pagenum'><a name="Page_31" id="Page_31">[31]</a></span>ered +or stare vacantly, the face often presenting a +remarkably immobile wooden, or stolid, expression. +Complete mutism is the rule. When activity is not +totally interfered with, those movements which are +present may be slow. The patient may have to be +pushed around and be able to take a few steps, but +soon relapses. More often they are of normal rapidity. +Speech then may also be slow and low, but +usually shows no change except for the fact that it +is diminished in amount. Sometimes awkward positions +are assumed and retained, and there may be +catalepsy.</p> + +<p><i>Negativism:</i> A common symptom is perverse +resistiveness. It may consist in a marked stiffening +of the body which is assumed spontaneously or appears +only when attempts at interference are made, +or there may be a more active turning away or even +a direct warding off, sometimes with scowling or +anger or even swearing and striking. Retention of +urine, which is seen at times, should, perhaps, be +mentioned here. Now and then we find that a patient +is put on the toilet and cannot be induced to urinate +or defecate, while soiling and wetting occur at once +on returning to bed.</p> + +<p><i>The intellectual processes:</i> Little is known about +the intellectual processes from direct observation in +these more pronounced cases, except for the fact +that in Case 5 questions or obtrusive occurrences +sometimes produced a somewhat puzzled facial expression. +Moreover, the patient retrospectively +stated that she was unable to understand the ques<!-- Page 32 --><span class='pagenum'><a name="Page_32" id="Page_32">[32]</a></span>tions, +which points to marked difficulty in apprehension. +We also find that occasionally there is +evidence of an interference with the intellectual +processes which showed itself in what may be called +"paragraphic" writing when the patient could be +induced to write. Above all, we see that retrospectively +very little is remembered of what took place +during the stupor, even of such obtrusive events as +the moving from one ward to another, tube-feeding, +physical examination, the presentation at a staff +meeting, and the like.</p> + +<p><i>Affect:</i> Complete affectlessness is an integral +part of the stupor reaction. Modification of the +statement will later be mentioned. The patient is +indifferent so far as his basic condition is concerned, +and it is only by certain stimuli that at times emotional +reactions can be elicitated, some tears at a +visit of a relative, an appropriate smile at a joke or +a comical situation when the stupor is not too deep +or an angry reaction called forth by interference.</p> + +<p><i>Catalepsy:</i> Waxy flexibility or merely a tendency +to maintain artificial positions is a frequent but not +an essential symptom.</p> + +<p><i>Physical Condition:</i> Not infrequently we find in +the beginning or in the course of the stupor an elevation +of temperature to 101, 102 or even 103. In +one case we found a marked cyanosis in the extremities. +Case 2 showed marked loss of hair. Gain in +weight is never observed and marked emaciation is +the rule. This we may attribute to the refusal of +food.</p> + +<p><!-- Page 33 --><span class='pagenum'><a name="Page_33" id="Page_33">[33]</a></span> +A perusal of these cases, then, shows that the +dominant (and well-nigh exclusive) symptoms of the +stupor are inactivity, apathy, negativism and disturbance +of the intellectual functions. Benign +stupor can be defined as a recoverable psychosis +characterized by these four symptoms. The meaning +of such vague physical manifestations as the low +fever is not clear.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> MacCurdy has discussed the psychological phenomenon of a +dramatist depicting a psychosis correctly in "Concerning Hamlet +and Orestes." <cite>Journal of Abnormal Psychology</cite>, Vol. XIII, No. 5.</p></div> + +<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> Many of these states seem to be hysterical rather than +manic-depressive stupors, but so far as the unconsciousness goes, there +is probably as much psychological as symptomatic resemblance between the +two types of reaction.</p></div> + +<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> Kraepelin recognizes, of course, the occurrence of stupor +symptoms or states in the course of manic-depressive psychoses. It is +stupor as a clinical entity, as a separate psychosis, that he regards as +one form of the catatonic, and therefore of the dementia prcox, +reaction.</p></div> + +<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> Kirby, George H.: "The Catatonic Syndrome and Its Relation +to Manic-Depressive Insanity." <cite>Jour. of Nervous and Mental Disease</cite>, +Vol. 40, No. 11, 1913.</p></div> +</div> + +<p><!-- Page 34 --><span class='pagenum'><a name="Page_34" id="Page_34">[34]</a></span></p> + +<h2>CHAPTER II<br /> +<span class="sm">THE PARTIAL STUPOR REACTIONS</span></h2> + +<p>The cases thus far considered, namely, those of +marked stupor, are fairly well known and have been +studied by others. Less well known and formulated, +but even more important from a practical as well +as from a theoretical point of view, are what may be +called partial stupors.</p> + +<p>The reader has noted that the states of deep +stupor described in the last chapter, did not end +abruptly with a sudden return to health or a sudden +change to another type of psychosis. They all +gradually passed away, not by the disappearance of +one symptom after another, but by the attenuation +of all. Sometimes a more or less stable condition +persisted for months, in which there was no stupor +in a literal, clinical sense but when apathy, inactivity, +interference with the intellectual functions and +negativism all existed. Had these been the only +states observed in these patients, there might have +been some ground for doubt as to the diagnosis. As +it was, it was clear that we were dealing with mild +stages of stupor. When a psychiatrist meets with +an undeveloped manic state, he calls it a hypomania +and does not hesitate to make this diagnosis in the<!-- Page 35 --><span class='pagenum'><a name="Page_35" id="Page_35">[35]</a></span> +absence of complete development into a florid excitement. +This procedure is not questioned, because the +manic <em>reaction</em> as distinguished from a <em>mania</em> is well +recognized. We believe that there is just as distinctive +a <em>stupor reaction</em> which may be exhibited +either in deep stupors or what we may term partial +stupors. Theoretically, complete apathy, inactivity, +etc., make up the clinical picture of a deep stupor. +When these symptoms appear rather as tendencies +than as perfect states, a partial stupor is the product. +That partial stupors occur as well-defined +psychoses, developing and disappearing without the +appearance of deep stupor, we shall attempt to show +in the following three typical cases:</p> + +<div class="blockquot"> +<p><span class="smcap">Case 6.</span>—<i>Rose Sch.</i> Age: 30. Admitted to the Psychiatric +Institute August 22, 1907.</p> + +<p><i>F. H.</i> Both parents were living (father 74, mother 68), as +were two brothers and two sisters. All were said to be normal.</p> + +<p><i>P. H.</i> Nothing was known of the patient's early characteristics, +except that she herself said she was slow at learning in +school and did not have much of an education. But when well +she made by no means the impression of a weak-minded person. +The husband had known her for ten years. He married her +eight years before admission, by civil process, keeping this from +his own family because he was a Jew and she a Christian. He +said that this undoubtedly worried the patient at times and that +she often asked him when he would take her to his family. The +patient herself later also said that this used to worry her. +Finally, one and a half years before admission she agreed, on +account of the children, to accept the Hebrew faith, and they +were then married in the synagogue. But he still did not take +her to his family.</p> + +<p>There were four pregnancies: the first child died; of the +survivors one was 8, a second 5 years old. Finally, a year before<!-- Page 36 --><span class='pagenum'><a name="Page_36" id="Page_36">[36]</a></span> +admission, she became again pregnant. During the pregnancy +one of the children had whooping cough and she herself was +thought to have caught it. The baby was born three months +before admission. It was a blue baby which died two days after +birth. The patient flowed heavily for three weeks and was taken +to a hospital, where she continued to flow intermittently for +some weeks more.</p> + +<p>Finally, three weeks before admission, a hysterectomy was +performed. Several days after this, when the sister-in-law visited +her, the patient begged her to take her home, said the doctor +wished to shoot her and to give her poison. Later the patient +confirmed this, saying that she thought they wanted to give her +saltpeter, and that she heard them say they wanted to shoot her.</p> + +<p>When taken home she refused food; gazed about, was absorbed, +seemed obstinate, and several times tried to jump out of the +window. Retrospectively the patient stated that she heard +children on the street call "Katie." She thought they meant her +child, heard that it was to be taken away from her, and a similar +idea again came out later in her psychosis, namely, that somebody +was going to harm her children.</p> + +<p>At the <i>Observation Pavilion</i> she appeared stupid, rather immobile, +her attention difficult to attract.</p> + +<p><i>Under Observation:</i> On admission the patient appeared sober, +impassive, moved very little, was markedly cataleptic, though not +resistive. On the other hand, her eyes were wide open and she +looked about freely, following the movements of those around her +not unnaturally. When questioned, she looked at the questioner +rather intently, and was apt to breathe a little more rapidly, and +made some ineffectual lip motions but no reply. To simple commands +she made slow and inadequate responses. She flinched +when pricked with a pin, but made no attempt at protecting +herself. She had to be spoon-fed. The catalepsy persisted only +for two days.</p> + +<p>After this she continued to show a marked reduction of activity, +moved very little, said nothing spontaneously, had at first to be +spoon-fed (later ate naturally enough). But she never soiled +herself and went to the closet of her own accord.</p> + +<p>Emotionally she seemed dormant for the most part, though for +the first few days she appeared somewhat puzzled, and one night<!-- Page 37 --><span class='pagenum'><a name="Page_37" id="Page_37">[37]</a></span> +when a patient screamed she seemed afraid and did not sleep, +whereas other nights she slept well. She answered only after +repeated questions and in a low tone. Very often, though her +attention was attracted easily enough, her answers were remarkably +shallow and also showed a striking off-hand profession of +incapacity or lack of knowledge. This was often without any +admission of depression or concern about her incapacity. She +would usually say "What?" or "Hm?" or repeat the question, +but most often would say, "I don't know," this even to very +simple questions. For instance, when asked, "What is your +name?" she answered, "My name? I don't know myself" (but +she did give her husband's name), or when asked to write her +name, she said, "I don't know how to write," or "Call Annie, she +will write my name." When requested to read or write (even +when asked for single letters), she would make such statements +as "I can't read." However, she finally named some objects in +pictures. This condition was characteristic of her for two weeks.</p> + +<p>Then her condition changed a little. She spoke a little more +freely but was similarly vague. The following interview of September +9, is characteristic: When asked how she was, she said, +"Belle." (Are you sick?) "No." (Is your head all right?) +"Yes." (Is your memory all right?) "Yes." (Do you know +everything?) "Yes." (Understand everything?) "Yes." (Are +you mixed up?) "No." (Do you feel sick?) "No." But when +asked where she was, how long she had been here, what the name +of the place was, what was the occupation of those about her, +she said, "I don't know." (How did you come here?) "I couldn't +tell how I came up here." (What are you here for?) "I am +walking around and sitting on benches," but finally, when again +asked what she was here for, she said, "To get cured." She now +gave and wrote her name and address correctly when requested, +also gave the names of her children. Yet when asked about the +age of the girl, said, "I don't know, my head is upside down." +When an attempt was made to make her repeat the name of the +hospital, or the date, or the name of the examiner, she did so +all right, but even if this was done repeatedly and she was asked +a few minutes later, she would say "I couldn't say," or "I forget +things," or "I have a short memory," or she would give it very<!-- Page 38 --><span class='pagenum'><a name="Page_38" id="Page_38">[38]</a></span> +imperfectly, as "Manhattan Island," or "Rhode Island" for +"Manhattan State Hospital, Ward's Island." (How is your +memory?) "All right." But when at this point the difficulty +was pointed out, she cried. (Why?) "Because I forget so +easily." All this was while her general activity was much reduced, +and she seemed to take very little interest in her surroundings.</p> + +<p>Then she improved somewhat, asked the husband some questions +about home, and on one occasion cried much and clung to +him and did not want to let him go without taking her. She +also began to work quite well, but still said very little spontaneously. +During this period when asked questions, she spoke freely +enough, but seemed somewhat embarrassed. What was still +quite marked were striking discrepancies in giving dates, and her +utter inability to straighten them out when attention was called +to them, as well as to her inability to supply such simple data +as the ages of her children. Her capacity was later not gone into +fully but it was certainly less defective on recovery than at this +time. She was rather shallow in giving a retrospective account +during this period. Even later, when she had developed a clear +insight and made, in respect to her activity and behavior, a +natural impression, she was not able to give much information +about her psychosis, although she apparently tried to do so.</p> + +<p>She was discharged recovered four months after admission, her +weight having risen from 93 lbs. on admission to 133 lbs. on +discharge. For the first two weeks of her stay in the hospital, +her temperature varied between 99 and 100.</p> + +<p><i>Retrospectively:</i> She said in answer to questions about her +inactivity and difficulty in answering that she did not feel like +talking, felt mixed up, could not remember well, did not want +to write.</p> + +<p>Before she was quite well she knew of her entrance to the +Observation Pavilion and her transfer to Ward's Island, of which +she could give some details, but thought she had been in the +Observation Pavilion two weeks instead of three days and in the +admission ward one month instead of a few hours. As to the +precipitating cause of the attack, she spoke of her flowing so +much after childbirth and of her operation.</p> + +<p><!-- Page 39 --><span class='pagenum'><a name="Page_39" id="Page_39">[39]</a></span> +She was seen again in March, 1913, when she seemed quite +normal mentally and claimed that she had been well ever since +leaving the hospital.</p></div> + +<p>With the exception of negativism, which appears +only in the anamnesis, all the cardinal stupor symptoms +are found in this history. Particularly noteworthy +is her intellectual deficiency which seemed +to be made up of a real incapacity plus a remarkable +disinclination for any mental effort whatever. It is +important to note that her attitude towards this +disability was usually one of indifference and that, +in general, there was no show of affect whatever. +Freedom of speech was the last thing for her to +regain.</p> + +<div class="blockquot"> +<a name="ChapII_Case7" id="ChapII_Case7"></a> +<p><span class="smcap">Case 7.</span>—<i>Mary C.</i> Age 26. Single. Admitted to the Psychiatric +Institute April 7, 1907.</p> + +<p><i>F. H.</i> The father had repeated attacks of insanity, from which +he recovered, but he died in an attack at the age of 60. A sister +also had a psychosis, from which she recovered.</p> + +<p><i>P. H.</i> The patient was rather quiet and easily worried. When +14 she had some dizzy spells, with momentary loss of consciousness. +After that time she had no such attacks, except after a +tooth extraction when about 24.</p> + +<p>The patient came to the United States six months before admission. +She went to live with a cousin who died a week after +she arrived at his house. She worried and said that she brought +bad luck. Then she took a position, where she was well liked, +but she was not particularly efficient. In this situation she often +felt homesick and lonely.</p> + +<p>Two weeks before admission an uncle died, which affected her +considerably. She spoke of his leaving three children, and would +not go to the funeral. Then she thought she was going to die. +She felt dizzy, weak, walked with a stooped position, was sleepless. +In the midst of this she suddenly felt frightened and walked<!-- Page 40 --><span class='pagenum'><a name="Page_40" id="Page_40">[40]</a></span> +into her mistress' room, to whom she complained that some one +was talking outside but could not tell what was said. She heard +shooting. Retrospectively, after recovery the patient said that +at that time she suddenly got "mixed up," and that her "memory +got bad."</p> + +<p>She was taken to a general hospital, where she thought there +was a fire, and screamed "Fire!" She was soon transferred to +the <i>Observation Pavilion</i>, where she appeared dazed, moving +slowly, yet showing a certain restlessness. She spoke of "the +boat" being shut up so that no one could go out. Again, she said +"The boat went down and all the people keep turning up." +Retrospectively the patient stated about this condition that she +remembered going to the general hospital but not her stay at the +Observation Pavilion. (The trip to the Manhattan State Hospital +was again clearer to her.) About the ideas she had at the time, +she remembered only that the room seemed to go around, and that +after she had come to the Manhattan State Hospital and was +clearer, she thought she was in Belfast, was on a ship, and that +people were drowning.</p> + +<p><i>Under Observation:</i> On admission she had a temperature of +100, a coated tongue, suffused conjunctiv. There were herpes +of the lower lip, a general appearance of weariness and exhaustion, +a flushed face, trace of albumen in the urine, which +was absent on the third day, no leucocytosis, but 41 per cent. +lymphocytes.</p> + +<p>Then and henceforth she was inactive and very slow in all her +movements; she never stirred spontaneously, and had to be pushed +to the toilet and to the table; she ate slowly. She did not speak +spontaneously, and her replies were very slow in coming. She +had to be urged considerably before she would speak and, as a +rule, she did not answer. On one occasion she was for a day +totally inactive and looked duller. That day and on a few other +occasions she wet the bed. There was at times an appearance +of dull bewilderment. When, soon after admission, asked +whether she felt cheerful or downhearted, she said "downhearted," +but this was the only time. Often she answered "I don't +know," when asked whether she was worried, and she could never +say what she was worried about. Again she directly denied +worry. Sometimes she smiled appropriately, and repeatedly,<!-- Page 41 --><span class='pagenum'><a name="Page_41" id="Page_41">[41]</a></span> +when asked how she felt, said, "I feel better." In answer to +questions as to how her head was, she replied several times, "My +memory is gone," also "I can't take in my surroundings," or "I +don't know where I am," or "I cannot realize where I am." +Again, she spoke of being dizzy and once said it was as though +the room went round. Sometimes she knew where she was or +knew names, again said "I forget," but she always was approximately +oriented as to time. There were no special ideas expressed +and no hallucinations, except in the very beginning when she still +thought at night, when she heard the boats on the East River, +that people were being drowned. She later, as stated above, said +she thought she was on a boat and people were being drowned.</p> + +<p>By June, i.e., two months after admission, she began rhythmical +swaying of the body, twisting of the fingers, or pulling out +some of her hair. She ascribed this behavior simply to "nervousness."</p> + +<p>On July 16, after a visit from her cousin, who said to her that +if she worked she would soon get better, she began spontaneously +to occupy herself somewhat. She became more active, said she +felt stronger and brighter, and that her memory was better. By +the beginning of August she was fairly free, but still spoke in a +rather low voice, although answering well. Her capacity to +calculate also remained poor. When asked about the more +inactive state, she said she had been afraid to stir. (What afraid +of?) "I didn't know where to go or what to do." Further, she +recalled that she had had a numb feeling in her tongue, could +not speak quickly, and that her mind had felt confused and "she +could not take in things." Further review with her of the earlier +period of her psychosis showed that there was a blank for +external events and most of the internal events during this time.</p> + +<p>She made a perfect recovery and was discharged August 7, +1907, four months after admission.</p></div> + +<p>This case, although very like the last, differs from +it in two particulars. For one day her symptoms +were sufficiently marked to suggest a deep stupor. +Secondly, her intellectual incapacity was not so +marked (always approximately oriented for time)<!-- Page 42 --><span class='pagenum'><a name="Page_42" id="Page_42">[42]</a></span> +and with this there was some subjective appreciation +of her defect. Apparently, however, this insight +did not cause her any worry. The affectlessness +was equally prominent in both of the foregoing +cases, the fact that Mary C. (Case 7) once admitted +feeling downhearted in response to leading questions, +having little significance in the face of her +expression, actions and usual denial of worry. It is +interesting to note that, during the bulk of her +psychosis, her only complaints were of mental hebetude +and dizziness. Possibly the latter was merely +an expression of her subjective confusion.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 8.</span>—<i>Henrietta H.</i> Age: 22. Admitted to the Psychiatric +Institute March 6, 1903.</p> + +<p><i>F. H.</i> The father stated that both parents were living and +well, also eight brothers and sisters.</p> + +<p><i>P. H.</i> The patient came to this country when she was a baby. +She was bright at school and industrious. From the age of 17 +on, she worked in a drygoods store and gave satisfaction. About +her mental make-up no data were available, except for the statement +that she always made a natural impression.</p> + +<p>When 21 (February, 1902), without known cause, she broke +down and was sent to the Manhattan State Hospital, but was +not observed in the Institute ward. She remained in the hospital +for three months. It was claimed that the attack came on suddenly +two days before she was sent away. She suddenly appeared +anxious, said something had happened and became excited. This +lasted for about a week, and then she was, as the description +says, "depressed and cataleptic." She remained in this condition +for about a month, during which time there was a slight rise +of temperature. Then she improved gradually and was discharged +three months after admission. After recovery from the +present attack the patient stated that during the first sickness +she had visions of dead friends.</p> + +<p>She was perfectly well in the interval.</p> + +<p><!-- Page 43 --><span class='pagenum'><a name="Page_43" id="Page_43">[43]</a></span> +Six days before admission she suddenly became excited, refused +to eat, and began to talk, repeating phrases over and over. Then +she became elated and excited.</p> + +<p>After recovery the patient described the onset of her psychosis +as follows: Six days before admission, after having been perfectly +well and without any known cause, she was feverish and +vomited, but slept well. Next day she felt nervous, and her +thoughts were clear. She constantly thought of dead friends, +heard them talking, when she tried to do anything the voices +said, "Don't do that." She also thought somebody wanted to +harm her people. Soon she started singing and felt happy.</p> + +<p>Then she was sent to the <i>Observation Pavilion</i>, where she appeared +to be in the same condition which was observed in the +Institute.</p> + +<p><i>Under Observation:</i> 1. On admission she was in good physical +condition, except for her skin seeming greasy. She presented for +nine days the following picture: She was essentially elated, +laughing, singing, jumping out of bed, good-natured and tractable, +and very talkative. Her productions showed a good deal of +sameness and a certain lack of progression. She spoke at times +in a rather monotonous voice, but again often in very theatrical +tones, with much, rather slow, gesturing. The following are +very representative samples:</p> + +<p>"I have been suffering from my own blood, my own blood sent +all away from home. I just came from Bellevue. I left here +last May (correct) a healthy girl. A sister is a sister—I wonder +why shorthand is shorthand, a stenographer is a stenographer +(seeing stenographer write)—a kind brother, Bill H.—why H. +his wife is a sister-in-law to us, she has four children—four +beautiful children—sister-in-laws and brother-in-laws—telephone +ringing (telephone did ring)—dear Lord, such a remembrance—remembrance +was remembrance, truth was truth—honesty is +honesty—policy is policy—if she married him, she is my sister-in-law +and he is my brother-in-law—Max knows me—she changed +her name to Mrs. R.—two children who are Rosie and Maud, if +names were given, names should not be mistaken—they are Julia, +Lillian—Rosie and Maud—why should wonders wonder and +wonders cease to wonder, why should blunders blunder and +blunders still blunder; sleep is one dream and dream means sleep<!-- Page 44 --><span class='pagenum'><a name="Page_44" id="Page_44">[44]</a></span>—if +move is moving, why not move?" When she accidentally +heard the word wine, she said "Guilty wine is not in our house—wine +is red and women are women, and women and wine and +wine and women and wine and song." Again, "You are not Mr. +Kratzberger, Mr. Steinberger, Mr. Einberger—you are not Mr. +Horrid or Mr. Storrid—perhaps you are Mr. Johnson or Mr. +Thompson—no, you are Dr. C." (correct).</p> + +<p>She was quite clear about her environment.</p> + +<p>Although the mood was throughout one of elation, on the +ninth day in the forenoon she cried at times, wanted to see her +mother, and spoke in a depressed strain (content not known). +A few hours after that she suddenly became quiet.</p> + +<p>2. Then for four days (March 14-17) she was markedly +inactive, though at times got out of bed. She looked about in a +bewildered manner, did not speak spontaneously, but could with +urging be induced to make some replies. She did this now fairly +promptly, now quite slowly. Questions were apt to bring on the +bewilderment. Thus, when asked where she was, she merely +looked more bewildered, finally said "Bellevue—I don't know," +and questioned who the doctor was whom she had called by name +in her manic state, she said, with some bewilderment, "Your face +looks familiar." (Where have you seen me?) "In New York." +She claimed to feel all right. There was no real affect. She +made the statement that at home she heard voices saying "You +will be killed."</p> + +<p>3. Henceforth this bewilderment ceased, and for 16 or 17 +days she was essentially inactive for the most part, for a short +time with a tendency to catalepsy and some resistiveness, and at +that time lying with eyes partly closed. As a rule she said +nothing spontaneously, but replied to some questions, usually +with marked retardation, again more promptly. She constantly +denied feeling sad or worried, repeatedly said she felt "better," +only on one occasion did she cry a little. When asked to calculate +she sometimes did it very slowly, again fairly promptly. The +simple calculations were usually done without error, the others +with some mistakes. As to her orientation the few answers +obtained showed that at times she knew the name of the place +and the day, again she gave wrong answers (Bellevue). Once +asked on March 23 for the day, she said April. She wrote her<!-- Page 45 --><span class='pagenum'><a name="Page_45" id="Page_45">[45]</a></span> +name promptly on one occasion, again a sentence slowly but +without mistakes. Once during the period she sang at night. +Once she suddenly ran down the hall but quickly lapsed into the +dull condition.</p> + +<p>On April 4, at the end of this period, she suddenly laughed, +again ran down the hall, said she had done nothing to be kept on +Ward's Island. But she quickly lapsed again into the dull state. +Later, on the same day, when the doctor was near, she said, in +a natural tone, "Thank God, the truth is coming out." (What +do you mean?) "That I have been trusting in a false name and +that Miss S. (the nurse) should not nurse me." Then she got +suddenly duller, calculated slowly and with some mistakes, +317=41, 419=56, and when asked to write Manhattan +State Hospital she wrote (not very slowly) "Mannahaton Hotspalne."</p> + +<p>4. Next day it was noted that she was more stuporous, and +she remained so for two weeks, now showing a decided tendency +to catalepsy and more resistance than before, though not marked, +except in the jaw. She lay often with head raised, sometimes +with eyes partly open, or staring in a dull, dreamy way, neither +soiling nor drooling, however; a few times she looked up when +spoken to sharply. There was no spontaneous speech. Usually +she did not answer at all, but a few times a short low response +was obtained. Once she wrote slowly a simple addition, put +down on paper. When, on one occasion, asked how she felt, she, +as before, said, "I feel better."</p> + +<p>5. Then, with the exception of a day at the end of the month, +when the more stuporous state was again in evidence, she returned +to her former condition without catalepsy or resistiveness and +without staring, but essentially with inactivity or slowness. She +now even dressed herself, answered slowly though not consistently, +but she again denied feeling troubled or sad, "I feel better."</p> + +<p>On July 7 she got brighter but was still rather slow. She then +even began to do some work. She again denied feeling sad.</p> + +<p>In a few weeks, while having a temperature of 102 with +vomiting and diarrhea, she suddenly got freer. She then said, +in answer to questions, that she did not speak because she was +not sure whether it would be right, again because she seemed to +lose her speech. She did not move because she was tired, had a<!-- Page 46 --><span class='pagenum'><a name="Page_46" id="Page_46">[46]</a></span> +numb feeling. She said she had not been sad, "but I had +different thoughts," "saw shadows on the walls of animals, living +people and dead people." She was not frightened, "I just looked +at them." People moved so quickly that she thought everything +was moved by electricity. She thought her head had been all +right.</p> + +<p>After a few days she relapsed into a duller state again, but +then got quite free and natural in her behavior. On August 28 +she gave a <i>retrospective</i> account of her psychosis, a part of +which has been embodied in the history. She had insight in so far +as she knew she had been mentally ill. She claimed to remember +the Observation Pavilion and her coming to the hospital, also the +incidents during the manic state, when she heard cannon and +thought a war was on, and voices she could not recognize nor +understand. Then she became stupid, although neither sad nor +happy.</p> + +<p>Then, she claimed, she got stupid, but neither sad nor happy. +She claimed to have known all along where she was, but felt +mixed up at times, her thoughts wandered and she felt confused +about the people. She thought she was in everybody's way, +thought others wanted to get ahead of her, did not speak because +she did not know if it were right or wrong, felt she might cause +disturbance if she answered. (It is not clear whether she had +complete insight into the morbid nature of these statements.) +She also claimed again that all along she "saw shadows on the +wall," "scenes from Heaven and Earth," "shadows of dead +friends laid out for burial." She had insight into the hallucinatory +nature of these visions. Sometimes she thought she was +dead also. She claimed that she began to feel better when these +shadows stopped appearing in June (the actual time of her improvement).</p> + +<p>She was discharged recovered a month later, after having been +sent to another ward.</p></div> + +<p>In this case, then, we find that the two months of +stupor were ushered in by a brief state in which, in +addition to the usual inactivity, there was a certain +bewilderment, increased by questions, while the<!-- Page 47 --><span class='pagenum'><a name="Page_47" id="Page_47">[47]</a></span> +orientation which in the preceding manic state had +been good became seriously interfered with. The +psychosis bordered on deep stupor for brief periods +when the inactivity seemed to be complete or she lay +in bed with her head raised from the pillow. On +the other hand, there were occasional sudden spells +of free activity even with a certain elation. She +could often be persuaded to answer questions or to +write, the slowness of this spoken or written speech +varying considerably. Her replies revealed the fact +that she was essentially affectless and that her intellectual +processes were interfered with, even to +the extent of paragraphic writing. We have, therefore, +here again features similar to those of the +preceding cases. In addition we must add as important +that this patient said retrospectively that she +thought she was dead, that she saw "shadows from +Heaven and Earth," "shadows of dead friends laid +out for burial," all this without any fear. We shall +see later that this is a typical stupor content.</p> + +<p>We will here include state 3 of Anna G. (See +<a href="#ChapI_Case1">Chapter I, Case 1</a>) who after the pronounced stupor +was for two months merely dull, somewhat slowed +and markedly apathetic. Although her orientation +was not seriously affected, there was considerable +interference with her intellectual processes, as +shown in her wrong answers or her lack of answers +when more difficult questions were asked.</p> + +<p>A similar picture was presented in state 2 of +Mary D. (See <a href="#ChapI_Case4">Chapter I, Case 4</a>.) Here, to be sure, +there were more marked stupor features in that the<!-- Page 48 --><span class='pagenum'><a name="Page_48" id="Page_48">[48]</a></span> +patient wet and soiled, in addition to occasional +spells when she lay with her head raised. But she +spoke and acted fairly freely (even while soiling). +By her replies she showed a considerable intellectual +inefficiency, although, like Anna G., her orientation +was not seriously disturbed. Here again there was +complete affectlessness.</p> + +<p>This gives us, therefore, five states which may be +analyzed for the symptoms of partial stupor. The +pictures of all five are unusually consistent. There +is inactivity, marked but not complete; poverty of +affect without perfect apathy; and a marked interference +with the intellectual processes. The last can +be studied better than in the deep stupors because +these partial cases are more or less accessible to +examination. There is a tendency for the patient to +think much of death either in the onset or during the +psychosis. Negativism seems much less prominent +than in the deep stupors.</p> + +<p>A natural criticism is that these cases merely had +retarded depressions. Although this topic will be +discussed fully in a later chapter, two differential +characteristics should be mentioned now. First, +depression is a highly emotional state in which the +sadness of the patient is as evident from his facial +and vocal expression as from what he says, while +these stupor reactions are by observation and confession +states of indifference. Secondly, there is no +such disturbance of the intellectual processes in depression +as is here chronicled. Let the retardation +once be overcome so that the will is exercised and<!-- Page 49 --><span class='pagenum'><a name="Page_49" id="Page_49">[49]</a></span> +no real defect is demonstrable. In our experience +the cases of apparent depression with intellectual +incapacity are found on closer study to be really +stupors as other symptoms show.</p> + +<p><!-- Page 50 --><span class='pagenum'><a name="Page_50" id="Page_50">[50]</a></span></p> + +<h2>CHAPTER III<br /> +<span class="sm">SUICIDAL CASES</span></h2> + +<p>An important "catatonic" symptom is a tendency +to sudden, impulsive, unexplainable acts. Such +actions occur occasionally in benign stupors and, +since we attempt an understanding of the reaction +as a whole, an effort should be made to study these +phenomena as well. The cases chosen showed persistent, +quite affectless, yet very impulsive attempts +at self-injury. They characterized the first of the +three cases throughout, were present in one stage +(the second) of the second patient, while in the last +for one day there was behavior which can be similarly +interpreted.</p> + +<p>Mention has been made of the prominence, approaching +universality, of the death idea in stupor. +This is a subject to be discussed in length presently, +but for the present we may say that there may be a +delusion of death with dramatization of that state +or a mere abandonment of the mental activities of +life. It is but a step from corpse-like behavior to +suicidal attempts, psychologically speaking, yet this +transition necessarily modifies the clinical picture, +since one necessitates inactivity and the other activity. +Secondarily, other atypical clinical features +appear, as will be seen.</p> + +<div class="blockquot"> +<p><!-- Page 51 --><span class='pagenum'><a name="Page_51" id="Page_51">[51]</a></span> +<span class="smcap">Case 9.</span>—<i>Pearl F.</i> Age: 24. Admitted to the Psychiatric Institute +July 26, 1913.</p> + +<p><i>F. H.</i> A paternal aunt was insane. Both parents died long +ago; the mother when the patient was a baby; the father when +she was a girl. She came to this country when 17. In this +country she had generally been a domestic. An older brother +and sister were also in America.</p> + +<p><i>P. H.</i> She was described as sociable, good-natured, bright +enough, not inclined to be depressed. She had little education. +There was no former attack.</p> + +<p>Four months before admission, the patient did not menstruate +but was said not to have worried about this. A month later she +began to show symptoms. She said she did not want to live, had +done something wrong but could not or would not say what it +was. Again she said a young man was going to sue her, a young +Jewish fellow whom she had seen only a few times. She talked of +turning on the gas. She also complained that people were looking +at her and that the food was poisoned.</p> + +<p>The patient after recovery gave the following version of the +onset: She had a position on 99th St. for 2 years. She liked +the people there and often went to see them later. Her next position +was in the Bronx. She was there for nine months. In the +same house lived "Harry." After the work she used to talk to +him in the yard and, after she left, she used to think of him and +long for him. But she denied, with a very natural attitude, that +she worried about him at the beginning of her psychosis. After +the position in the Bronx she went to one on 96th St., where +she was for four months. In the same house was a girl whom she +liked and who was lively. When she left, the patient left too. +This was a month before the psychosis began. When she left +there, she got word that her employer on 99th St. had developed +consumption and had to go out West, but did not worry over this +news, she claimed. She looked for another position and had one +for two weeks, but felt lonely, did not care to live. Then her +sister took her to her home. She thought people were looking +at her and were making remarks because she was not working. +During this time she had a dream one night in which her dead +mother appeared to her (in ordinary street clothes) and said to +her that she (the patient) "was going away." She woke up<!-- Page 52 --><span class='pagenum'><a name="Page_52" id="Page_52">[52]</a></span> +frightened. She was worried, thought she had not prayed enough +for her mother, and asked her sister to pray also and to give +money to the poor. She did not recall, or at any rate denied, +speaking of the young man suing her.</p> + +<p>She was then taken to a <i>private sanatorium</i>, where she was for +two months preceding her admission to this hospital. There she +was described as quiet, mute, tube-fed, resistive.</p> + +<p>When well, the patient said that in this sanatorium she was +first spoon-fed, cup-fed, later tube-fed, "I used to be scared of +them, they used to put a spoon way down my throat and I had no +appetite—I did not like them around me, they were mean to me. +They used to let me stand without clothes, used to spite me." "If +I did not want to dress myself, they used to hit me." "I used +to feel lonesome for home and I imagined my people were there +and that my sister passed the place without stopping." She was +afraid of the nurses, thinking they wanted to kill her.</p> + +<p>At the <i>Observation Pavilion</i> the patient was described as dull, +but brightening up under examination. She made few spontaneous +remarks, but in answer to questions said she was melancholy, +tired of life, because she was in love with a Gentile fellow who +refused to marry her. She also said "I get peculiar thoughts +that I am going to die."</p> + +<p><i>Under Observation:</i> The patient's condition lasted for about +two years. Much of the time she lay in bed, often with the covers +pulled over her, sometimes with her legs drawn up, again in a +more natural, comfortable position, or she sat up with her head +bowed. She obeyed almost no commands. For months she soiled +and wet herself, but never drooled. For a time she refused food +consistently, lost flesh and had to be tube-fed. For the most part +she said very little and, when one accosted her, she was apt to +turn away. A few times, when further urged, she swore at the +examiner. There was also persistent marked resistance towards +any interference, sometimes merely passive or quite often, especially +at first, with wriggling or severe scratching of her own +body. There was often with this evidence of irritation or she +moaned. Again she was described as quite affectless. One of +the most striking features throughout a large part of the course +were her suicidal attempts. She would try to strike her head +against the iron bedpost, throw herself out of bed, throw herself<!-- Page 53 --><span class='pagenum'><a name="Page_53" id="Page_53">[53]</a></span> +about generally, try to strangle herself with the sheets, try to +pull out her tongue, all of which seemed to be done with great +impulsiveness. Almost her only utterances had to do with death. +She said she wanted to die, wanted to drop dead, did not want +to live, wanted to kill herself, that she did not eat because she +wanted to die. When once she was found tossing about and +was asked whether she worried, she said "I know I am going to +die." (You mean you will be killed?) "I don't care."</p> + +<p>There were a few episodes which still have to be mentioned. +Quite early in the course of the stupor, when she was restless, +scratching herself and moaning, she once spoke quite freely. She +said "Give me that fellow (Harry), I don't care, I can't help it. +I must have him, even if it costs me my life." "I would feel +happy if I could get him. O God, I love him—I will never get +him even if I drop dead, I know I won't get him, the darling" +(cries). (What if you did get him?) "I know I would lose him +again." Then with shame she claimed she had had sexual relations +with him (when well, denied). At the same interview, when +the doctor sneezed, she said "Gesundheit." In June, 1914, +she was seen smiling at times. But the first was the only episode +when she spoke more freely, and the two occasions the only ones +when she showed a frank affect.</p> + +<p>The improvement commenced in April, 1915. Although still +very inactive, she sometimes began to laugh and sing and talk +a little to other patients. She also answered a few questions on +April 22, 1915. Thus, when asked whether she wanted to go +home, she said "No, I want to stay here." (Do you like it here?) +"Yes" (smiles), "I can't get no other place; I have got to like it +here." She smiled freely. To orientation questions, she knew +the place, month, but not the year.</p> + +<p>She continued inactive and above all diffident, but improved +steadily and, when examined by the writer on November 15, she +made a very natural impression and gave the retrospective account +of the onset embodied in the history. She was quite frank, +thanked the doctor for the interest he took in her case, and said +for example, "You know I never thought I would get well. I +quite gave up—I am very glad I am well now."</p> + +<p>When questioned about her stay here, the patient evidently +remembered much. She was able to say which wards she had<!-- Page 54 --><span class='pagenum'><a name="Page_54" id="Page_54">[54]</a></span> +been in and approximately how long she had been in each one. +She claimed that at first it "seemed strange." "I did not eat, I +did not want to eat, I used to tell them to poison me and that I +wanted to die, I was <em>disgusted</em>, I thought I would never go home." +She also says she felt <em>angry</em>, wanted to kill herself. She bit and +scratched "because I was nervous." She remembered talking +about Harry, "I said I was in love with him, I thought I wanted +to die because I could not have him." She also talked of having +been <em>stubborn</em>. Sometimes she felt like running to the river. She +also claimed she imagined people were false to her.</p> + +<p>In one of the wards she said she thought people were there on +her account, were waiting for her death. She did not care for +a time whether she died or not. She knew she tried to choke herself +occasionally. Asked how she behaved, she first said she was +quiet. (Were you not restless?) "I used to get tired and have +backache and roll around in bed." She also felt like running +away sometimes, wanted to get out of bed and wanted to walk +about. (What about going to the river?) "I used to say that." +She claimed not to have been mixed up at any time and to +remember everything. Remarkable is the fact that she claimed +she <em>did not worry at all</em>, "<em>I felt I was lost and would not worry.</em> +I used to worry at home and at Dr. M.'s (the private sanatorium) +but not here. Here I never worried, I did not care where I +went." She said she did not talk because she was bashful in the +presence of doctors, sometimes she felt afraid of them, afraid +they would kill her, put poison in her food when they fed her. +"When my people came, I said I did not want to live, wanted to +kill myself. I used to cry." Again asked why she did not talk, +she admitted she really did not know. Once she said she was +bashful because she soiled her bed. She did not want to go to +the closet because she was afraid of the nurse. She denied +hearing voices.</p></div> + +<p>In addition to the activity incidental to her attempts +at self-injury, this patient showed an unusual +degree of resistiveness and with this some affect, +for she appeared to be irritated and at times +moaned. Still more unusual were the appearances<!-- Page 55 --><span class='pagenum'><a name="Page_55" id="Page_55">[55]</a></span> +of delusions not associated with death but with a +vivid form of life, namely, a love affair. Occasionally +she spoke of her imaginary lover "Harry." +Another atypical feature was a fair memory for the +period when she was in stupor. She claimed to remember +much of her movements and this claim was +substantiated by her answers to questions after recovery.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 10.</span>—<i>Margaret C.</i> Age: 23. Single. Admitted to the +Psychiatric Institute November 13, 1913.</p> + +<p><i>F. H.</i> Heredity was absolutely denied. The mother is living +and made a natural impression. The father died at 65, nine +months before patient's admission, of cardio-renal disease. Two +brothers and one sister died of acute diseases. One sister died in +childbirth. Three brothers and one sister were said to be well.</p> + +<p><i>P. H.</i> The patient was bright and passed successfully through +high school. For seven years prior to the psychosis she worked +for the same company as clerk. She was described as efficient, +conscientious, systematic, though sometimes upset by her work; +as lively, talkative, cheerful, with somewhat of a temper and +easily hurt, also as quite religious. She was more attached to +her mother than to her father, but still more to her older sister, +whose death precipitated her psychosis. She never had any love +affair and was said not to have cared for men. Two months before +admission, when her favorite sister was confined, the patient +was quite worried about her, but relieved when she heard good +news. A few hours later, however, the sister died suddenly. +When the patient learned of the sister's death, she screamed, and +screamed several times at the funeral. She did not cry, said she +could not. After this she slept poorly, seemed nervous, went to +church more, but there was no other change. She continued to +work and, according to the employer, worked well.</p> + +<p>Nine days before admission she would not get out of bed in +the morning, said little and refused food. A few days later she +was induced to take a walk, but she seemed to have no interest +in anything. When she talked at all it was about her sister and<!-- Page 56 --><span class='pagenum'><a name="Page_56" id="Page_56">[56]</a></span> +of wanting to go to a convent. When asked to do anything she +said she would if it were God's will. She did not menstruate +after her sister's death. When practically recovered, the patient +attributed her breakdown to this tragedy. She added to the description +above given that, soon after losing her sister, she had +a fright at home. "It was the house in which my father died +and one day when I was in bed I thought somebody came in." +But she denied a vision and could not further explain.</p> + +<p>At the <i>Observation Pavilion</i> she was very inactive, so that she +had to be fed and cared for in every way, mute, often covering +her head with a sheet, turning away when questioned and resistive +when the physical examination was attempted. But at +times she smiled or laughed.</p> + +<p><i>Under Observation:</i> 1. For two months the patient was generally +inactive, sometimes lying in bed with her eyes tightly +closed, or with her face covered by the sheets or buried in the +pillow; or she sat inactive, staring, or with eyes closed, or her +head buried in her arms. On one visit she had to be brought into +the examining room in a wheel chair and lifted into another seat. +A few times she was observed holding herself very tense with her +head pressed against the end of the bed. But this inactivity was +often interrupted by her going quickly into various rooms to kneel +down, though she was never heard praying. Or she ran down the +hall for no obvious reason. Or, again, she was found lying on +the floor face down. She ate very poorly and had to be tube-fed +a considerable part of the time. When this was done, she sometimes +resisted severely, as she did in fact most nursing attentions. +Thus she soon began to struggle when her hair was combed. She +also resisted being taken to the toilet or being brought back. +She did not soil or drool, however, but sometimes seemed to be +in considerable distress before she finally literally ran to the +closet. This resistance just spoken of consisted chiefly in making +herself stiff and tense. Sometimes at the feeding she pulled up +the cover when preparations were made and held to it tightly. +Quite striking was the fact that with such resistance she sometimes, +though by no means always, laughed loudly, as she did +occasionally when she was talked to, or even without any external +stimulation. This laughter always was one of genuine merriment +and quite contagious, and by no means shallow or silly.</p> + +<p><!-- Page 57 --><span class='pagenum'><a name="Page_57" id="Page_57">[57]</a></span> +Usually the patient was totally mute. The exceptions occurred +mostly when her resistance was called forth. Thus one day when +fed she said, "I wish you people would have more to do," or on +another occasion, when she had resisted being brought into the +examining room, she said, "I will get out of here if I break a leg." +But once when the nurse accidentally tickled her, she said, "Since +I am ticklish, I must be jealous—I should worry." She also +answered very few questions and such responses as she made were +chiefly expressions of resentment. Thus, when one kept urging +her, she finally would say "stop," or after much urging "I am +going to hurt you pretty quick." Sometimes she said "Go away," +or "Let me alone." She was just as silent with the mother and +the priest as with the physicians. On one occasion she told the +nurse that the priest had told her to talk to the doctors, but +that she had nothing to say. Sometimes she did not even look +at the visitors, but turned away from them, as she did from the +physicians, but at one visit from a priest, though she scarcely +said anything, she held on to him when he was about to depart +and would not let him go. Throughout this period, since scarcely +any answers were given, nothing was known about her orientation, +except when on admission she gave a few answers. She then +thought she was at the Observation Pavilion, seemed unable to +tell even that the physician was a doctor, but knew the date. +When asked how she came to Ward's Island, she said "By ambulance." +The physical condition presented nothing of note, except +for a certain sluggishness of the skin with marked comedones.</p> + +<p>2. By <i>January</i>, 1914, the picture changed somewhat and she +then presented the following state for an entire year: The +mutism persisted and indeed became even more absolute, and she +began to wet and soil constantly. This commenced as what +seemed to be an act of spite as a part of her resistiveness, for +the first time she soiled she seemed to do it deliberately when the +nurses insisted that she allow them to put on a dress. Later +this explanation no longer held. Tube-feeding too was for the +most part necessary, the resistiveness continuing as before. But +the inactivity was broken into much more than before by constant +impulsive attempts to hurt herself in every conceivable way—by +bumping her head against the wall, putting her head under the +hot water faucet, trying to pound the leg of the bedstead on her<!-- Page 58 --><span class='pagenum'><a name="Page_58" id="Page_58">[58]</a></span> +foot, striking herself, pinching her eyelids, pulling out her hair, +trying to pick her radial artery, throwing herself out of bed, +knocking her head against the bed rail, etc. This was done in +silence but with what appeared a great determination that occasionally +showed itself in her face. She also sometimes scowled +and frowned. With the difficulty in feeding her and the constant +impulsive excitement in which bruises could not always be avoided +(once an extensive cellulitis developed in the arm which had to be +lanced), the patient got weak, emaciated and exhausted; much +of her hair fell out, although some she pulled out. It should be +stated that during this entire impulsive state she could not be +taken care of in the Institute ward, but was sent to a special +ward in the Manhattan State Hospital, where suicidal patients +are under constant watch. These impulsive attempts at self-injury +lessened only towards the end of the period. Her laughter, +which had been such a prominent trait, disappeared almost entirely +during this entire phase. With all this, the general resistiveness, +as has been stated, remained towards feeding or any +other interference. It was only in the beginning associated with +laughter as in the previous stage.</p> + +<p>Although there were, as a rule, no spontaneous remarks and +no replies, she on one occasion said spontaneously, probably +referring to her unsuccessful attempts to kill herself: "I can't +do it, I have no will." During the same period she once said: +"I don't want to eat, I don't want to get well, I want to do +penance and die."</p> + +<p>By <i>January</i>, 1915 (i.e., a year after the second phase had +commenced), she began to dress herself and eat, and also became +clean. But she remained for the most part very inactive, sitting +stolidly about all day and still without interest in her environment. +The impulsive attempts at killing herself disappeared. +Although she remained for months to come still inactive, she +gradually began to talk a little, began to play a little on the +piano, but said little to any one.</p> + +<p>By <i>August</i>, 1915, she still was inactive, shy, standing about, +or sitting picking her fingers, occasionally going to the piano, +but evidently unable to finish anything. She had to be coaxed +to come to the examining room and talked in a low tone. Often +she commenced vaguely to speak and then stopped and could not<!-- Page 59 --><span class='pagenum'><a name="Page_59" id="Page_59">[59]</a></span> +be made to repeat what she had been saying. Affectively she +was remarkably frank, sometimes a little surly, or she showed +a slight empty uneasiness. She could, however, be made to laugh +heartily at times, or did so spontaneously on very slight provocation.</p> + +<p>Some of her utterances were in harmony with her apparent +indifference. It was difficult to get her to say how she felt +even when thorough inquiries were made. Once she said, when +asked about worrying, "I don't worry," or again "I get angry +sometimes," or "I used to worry about my health, I don't now," +or, when asked what her plans were, she said directly: "I don't +care what happens." Again she said "I guess I am disagreeable," +or "I guess I am a crank." Another interesting indication +of her state was expressed in her repeated statement, "I +don't know what I want." But she was oriented in a way, +though not sure of her data. She would give most of her answers +with a questioning inflection, "This is the Manhattan State +Hospital, isn't it?" or she would say, "I don't know exactly where +I am, it's Ward's Island, isn't it?" and in the same way she gave +the day, date and year correctly. But she did not know the names +of the physicians. At that time she could give many data about +her family correctly, but was slow, even if correct, in calculation, +and, though she got the gist of a test story, she left out some +important details.</p> + +<p>A retrospective account at that time showed she was uncertain +about the Observation Pavilion, that she was not certain how she +came to Ward's Island, "On a boat, I believe." It was clear that +she did not remember the admission ward, about the Institute +ward (in which she had been for the first two and a half months +and in which she was again examined); she said it was familiar +to her, but she was not certain that she had been in it. About +the physician who saw most of her in these first two and a half +months, she said that his voice seemed familiar, and she asked +him whether he had tube-fed her (she had been tube-fed by him +many times), but she again said, "No, you are not the one," and +described as the man who had fed her the one who did it on the +second ward where she was for a year. But she knew that she +had been sent to the second ward, because she constantly tried +to injure herself. These injuries she recalled but was unable<!-- Page 60 --><span class='pagenum'><a name="Page_60" id="Page_60">[60]</a></span> +to say why she attempted them, "I suppose I didn't know what +I was doing." She claimed she heard voices and had "all sorts" +of imaginations, but could not be gotten to tell about them. +When it was difficult for her to give an answer, she was apt to +keep silent and then could be prodded without much success.</p> + +<p>In <i>October</i>, 1915, there was further improvement, inasmuch +as she began to converse some with other patients, played the +piano and seemed able to carry a piece through. She was put +in the occupation class and did quite well. At the interview +with the physician she was still apt to laugh boisterously at +slight provocation. Even now she had great difficulty in describing +her condition and at the examination was often still quite +vague. Thus, when asked how she felt, she said, "I do know I +feel ridiculous—sometimes I feel kind of angry—I don't know—they +say I am crazy but I am not, but I am hungry—I don't +know whether I am or not, I don't know what I can do well," +etc. This is quite characteristic. When asked whether she was +worried, she said: "I don't know, am I worried?—yes, a little +sometimes, I am to-day—I am so untidy—don't know what is +the matter with me." Again: "Sometimes I lose my speech—I +can't say what I feel, I don't know what it was." Later, half +to herself: "I don't know what is the matter with me—I don't +care anyway."</p> + +<p>In <i>December</i>, 1915, there was still further improvement, and on +the ward and in superficial conversation she made, towards the +end of the month, in many ways a natural impression, though +the laughter before described was still somewhat in evidence. +It usually came not without occasion, but was, as a rule, quite +out of proportion to the stimulus. She again said she could +not explain why she tried to injure herself, claimed she did not +feel it, and even claimed she did not remember doing it in the +Institute but only in the second ward.</p> + +<p>The defect in thinking which still remained is very difficult to +formulate. She was now entirely oriented, no longer with any +hesitation about the correctness of her information. She subtracted +7 from 100 very quickly and could from memory write a +long poem, but there was a certain vagueness about her which +partly may have been due to a still existing indifference. This +vagueness consisted chiefly in a difficulty of attention or in her<!-- Page 61 --><span class='pagenum'><a name="Page_61" id="Page_61">[61]</a></span> +capacity to grasp fully what was wanted. It is best illustrated by +a few examples: After she had been asked about the <em>onset</em> of her +sickness and she had said that what was on her mind then were +prayers for the salvation of her relatives, she was asked exactly +when it was that she thought of this; she answered "Now?" +(What period were we talking of, the present or past?) "The +present." (What did I ask you?) "About this period of my +sickness." (Which one?) "What sickness?" She said herself +at this point, "I am rather stupid" (quite placidly). Or again +she said she did not know why she pounded her head, but finally +said, "To get better and go home." (Do you think if you +pounded your head against the wall you would go home sooner?) +"I don't know—maybe." (How would it help you?) "You +mean to go to the city?" (Yes.) "I don't know." Again when +asked how her mind worked, she said, "Pretty quickly sometimes—I +don't know." (As good as it used to?) "No, I don't think +so." (What is the difference?) This had to be repeated several +times, at which she said, "There is no difference." (What +did I ask you?) "The difference." (The difference between +what?) "You did not say." Equally striking was the fact that +when she was jokingly told "If it snows to-night, we shall have +a black Christmas," she did not grasp the absurdity at once, +but in a rather puzzled way asked, "Why?"</p> + +<p>She was then discharged on parole, two years and one month +after admission. Soon after discharge her menstruation, which +had been absent throughout her psychosis, returned. On her +discharge she had regained her normal weight, and during the +two subsequent months gained fifteen pounds.</p> + +<p>She then recovered completely, so that three months after +discharge she made a very natural impression. She said, on +looking back over her state with impulsive excitement, that she +constantly had the idea that she wanted to punish herself, but +that <em>she did not know why</em>, and did not think she was sad or +worried.</p></div> + +<p>Considering only the second phase of the psychosis, +this deep stupor showed many interruptions, due +not merely to her suicidal efforts but also to her +resistiveness. The condition, too, was not so com<!-- Page 62 --><span class='pagenum'><a name="Page_62" id="Page_62">[62]</a></span>pletely +affectless as one expects a deep stupor to be. +In the first stage there was much sudden laughter, +reminding one of dementia prcox (except for its +never being shallow or silly) and this persisted into +the first part of the second phase. The actual attempts +at self-injury brought out emotion, for with +them she scowled and frowned as well as showing +considerable energy.</p> + +<p>To these may be added the following case. It is +not unlike the ordinary stupor in the fact that there +was intense inactivity and mutism with great tenseness. +The remarkable trait was, however, that for +a whole day she forcibly held her breath until she +got blue in the face. The case in detail is as follows:</p> + +<div class="blockquot"> +<p><span class="smcap">Case 11.</span>—<i>Rosie K.</i> Age: 18. Admitted to the Psychiatric +Institute January 24, 1907.</p> + +<p><i>F. H.</i> Both parents were living. The father was a loafer. +Nine brothers and sisters were said to be well, with the exceptions +of one brother who had an irritable temper, and of a +markedly inferior sister.</p> + +<p><i>P. H.</i> The patient was a Galician Hebrew, a shirtwaist operator. +Not much was known about her make-up, but it is certain +that she was a bright girl. The patient herself said after recovery +that her father was nagging her constantly with complaints +that she was not making enough money, although he himself did +not work and she contributed much to the support of her family. +She disliked him very much and claimed that all her relatives +worried her, except her mother.</p> + +<p>Nine weeks before admission a messenger came into the shop +where she worked and said, "Rosie, your father is dead" (the +message was intended for a fellow worker). In spite of the +fact that the matter was explained, she was upset and nervous +enough to be taken home. Though she continued to work for +over two weeks, she worried over many trivial matters and talked<!-- Page 63 --><span class='pagenum'><a name="Page_63" id="Page_63">[63]</a></span> +much about this. She also said that everything looked queer at +her home and complained of having difficulty in concentrating +her mind. Finally she became elated and talkative. Nothing is +known of any special ideas.</p> + +<p>At the <i>Observation Pavilion</i> she appeared to be typically +manic.</p> + +<p>Then she was sent to an institution where she remained for +six weeks. The report from there stated that she was for ten +days "elated, excited, talkative, with flight of ideas." Then her +condition suddenly changed to a marked reduction of activity, in +which she neither spoke spontaneously nor answered questions. +She "appeared to sleep," but was said to have talked to her +people. When interfered with, she was resistive and sometimes +let herself fall out of bed. On the other hand, she occasionally +wandered about at night. It should be added that during the +stupor an alveolar abscess developed which discharged pus. It +was washed out and healed.</p> + +<p>Then she was sent to the Manhattan State Hospital and admitted +to the service of the Psychiatric Institute.</p> + +<p><i>Under Observation:</i> 1. On the first day she lay in bed with +cyanotic extremities, weak pulse, grunting, moaning and not responding +in any way when examined. After this the moaning +and grunting ceased and she was essentially indifferent, and for +the most part kept her eyes closed. Often she wet and soiled +herself. She was resistive to any care or examination. She +would not eat, as a rule, but again gulped down milk offered her. +For a considerable time she had to be tube-fed. During the +early part of this stupor she once took a paper from the doctor, +examined it, and then gave it back without saying anything, or +again she peered around silently, or asked to go home, or again, +on a few occasions, answered a question or two or spoke some +unintelligible words. Orientation could not be established.</p> + +<p>2. After a few weeks she became more rigid, a condition which +continued for six months. She let saliva collect in her mouth, +and drooled. She had to be tube-fed. She lay very rigid, with +very pronounced general tension, with her lips puckered, hands +clenched, sometimes holding her eyes tightly closed, and often +with marked perspiration. For one day she held her breath until +she was blue in the face. On the same day she was extremely<!-- Page 64 --><span class='pagenum'><a name="Page_64" id="Page_64">[64]</a></span> +rigid, so that she could be raised by her head with only her heels +resting on the bed. Her eyes were tightly shut and she was in +profuse perspiration. Sometimes she interrupted this by a deep +breath, only again to resume the forcible holding of her breath. +On another day towards the end of the period, while quite stiff, +she kept grunting and screaming "murder." The soiling continued. +She never spoke.</p> + +<p><i>Physical condition during the stupor:</i> At first she had a coated +tongue, foul breath and a fetid diarrhea. The latter was +treated with high colonic flushing and mild diet. Urine normal—gynecologically +normal. General neurological and physical examination +not possible. At the same time she had for two weeks +a temperature which often reached 100 or a little above, a weak, +irregular but not rapid pulse, a leucocytosis of 17,500 and 80% +hemoglobin. When she began to refuse food and before she was +tube-fed regularly, she twice had syncopal attacks and lost considerable +flesh which was gradually regained under tube-feeding. +After the diarrhea she was habitually constipated. Cyanosis +of the extremities seemed to have been present only at first.</p> + +<p>3. Six months after admission she began to make very free +facial movements—winking, raising the eyebrows—and soon developed +an excitement with marked elation. She had to be kept +in the continuous bath, talked continuously, whistled, sang, was +markedly erotic towards the physician, careless in exposing herself +and often obscene in her talk. Most of her productions +were determined by the environment. She was therefore quite +distractible, very alert; sometimes she was meddlesome, again +irritable, irascible. The following illustrates her productions: +"Send for my husband, S.—He had one sister as big as that. +She likes candy.... My father is underneath and my mother is +on top because she is fat and he is skinny.... Wait till the +sun shines, Nellie—we will be happy, Nellie—don't you sigh, +sweetheart, you and I—wait till the sun shines by and by.... +Come in (as noise is heard)—I bet that is my husband—my name +is Regina K. (mother's name)—my mother's name is the same—I +got a little sister named Regina—she is my husband." When +she heard the word pain, she said, "Who says paint, Pauline used +paint, I used paint," etc.</p> + +<p><!-- Page 65 --><span class='pagenum'><a name="Page_65" id="Page_65">[65]</a></span> +Towards the end of August she had pneumonia, which did not +change her condition.</p> + +<p>By October she was well, having gradually settled down. She +had good insight.</p> + +<p><i>Retrospectively:</i> She laid very little stress on the false report +of the father's death. She claimed to remember being at the +Observation Pavilion, but to recall very little of the other hospital. +Unfortunately an inquiry was not made regarding her +memory during the stupor period under observation with the exception +of the fact that she said she wanted to die and therefore +refused food.</p> + +<p>She was seen in March, 1913, appeared perfectly well, and +stated she had been well during the entire interval.</p></div> + +<p>If this forced holding of the breath had been the +only anomaly, one would, perhaps, not be justified +in drawing any conclusions as to its significance. +But the deep stupor was interrupted again for a day +by grunting and screaming of "murder." This is +certainly indicative of a compulsive death idea and +retrospectively she spoke of having refused food in +order to die. The latter seems to indicate some +connection between her negativism and death. Consequently, +even if we regard the breath holding as +resistiveness, it would still be related to her idea of +dissolution. Her negativism went beyond ordinary +limits in that it affected the expression of the +face.</p> + +<p>When we consider these three cases together, we +see that what would otherwise have been deep +stupors with profound inactivity, were modified by +activity in two directions: suicidal and resistive. +Presuming that the symptoms of stupor are all interrelated, +we can see a reason why the affect should<!-- Page 66 --><span class='pagenum'><a name="Page_66" id="Page_66">[66]</a></span> +also have been altered. When one is modified, this +should influence the other. When the activity is +increased, the emotional concomitants of impulsive +acts tend to break through as well. Hence the +changes observed in these cases in facial expression +and tone of voice. It is noteworthy, too, that all +three showed a tendency for laughter to appear, as +if, the emotions once stirred, it was possible for +them to be exhibited in other than unpleasant forms. +So, too, it was possible for ideas unrelated to the +stupor picture, such as those of lovers, to occur +sporadically. Finally, since activity must imply +some contact with environment, the first of these +cases at least showed less interference with the intelligence +than is usual. In general, one may conclude +that any aberration from the pure type of +stupor tends to allow other impurities to appear.</p> + +<p><!-- Page 67 --><span class='pagenum'><a name="Page_67" id="Page_67">[67]</a></span></p> + +<h2>CHAPTER IV<br /> + +<span class="sm">THE INTERFERENCES WITH THE INTELLECTUAL +PROCESSES</span></h2> + +<p>This is one of the most interesting and important +of the stupor symptoms. We are accustomed to +think of the functional psychoses having symptoms +to do with emotions and ideas in the main, and, +conversely, that disorientation, etc., observed in such +cases is merely the result of distraction, poor attention +or coperation. But in stupor the deficit in +understanding, incapacity to solve simple problems +and failure of memory seem deep-rooted and fundamental +symptoms. So far is this true that Bleuler<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a> +looks on "schizophrenic" cases with this symptom +of "Benommenheit" as organic in etiology. It may +be said at the outset that we do not share this view +for many reasons. One at least may now be stated +as it seems to be final. In benign stupor purely +mental stimuli may change the whole clinical picture +abruptly and with this produce a change in the intellectual +functioning such as we never see in organic +dementias or clouded states. We find it more satisfactory +to attempt a correlation of this with the +other symptoms on a purely functional basis, as will +be explained later.</p> + +<p><!-- Page 68 --><span class='pagenum'><a name="Page_68" id="Page_68">[68]</a></span> +For the study of the interferences with the intellectual +processes during stupor reaction, we have +two sources of information: The first is derived +from the account which the patient is able to give in +regard to what he remembers as having taken place +around him or in his mind during the stupor period; +the second is the direct observation of partial stupor +reactions.</p> + +<h3>1. Information Derived from the Patient's Retrospective +Account</h3> + +<p>We will start with the cases of marked stupor mentioned +in Chapter I. Anna G.'s (Case 1) psychosis +commenced at home, and under observation lasted +with great intensity for five months. She remembered +only vaguely the carriage going to the Observation +Pavilion, had no recollection of the latter, +nor of her transfer to the Manhattan State Hospital +and of most of the stay at the Institute ward, including +the tube- or spoon-feeding which had to be +carried on for four months. She also claimed that +she did not know where she was until four or five +months after admission. She was amnesic for her +delusions and hallucinations. Of Caroline DeS. +(Case 2) we have no information. Of Mary F. +(Case 3), whose stupor began at home and under +observation lasted two years, we find that she had +no recollection of coming to the hospital, what ward +she came to, who the doctor and nurses were (with +whom she became acquainted later), in fact she<!-- Page 69 --><span class='pagenum'><a name="Page_69" id="Page_69">[69]</a></span> +claimed that for about a year she did not know +where she was. But she remembered having been +tube-fed (this took place over a long period). Mary +D.'s (Case 4) stupor also commenced at home, and +under observation lasted for three months. She had +no recollection of going to the Observation Pavilion, +of the transfer to Manhattan State Hospital, and of +a considerable part of her stay here, including such +obtrusive facts as a presentation before a staff meeting, +an extensive physical and a blood examination, +and she claimed not to have known for a long time +where she was. Annie K.'s (Case 5) stupor commenced +at home. Although she recalled the last +days there and some ideas and events at the Observation +Pavilion, the memory of the journey to +Ward's Island was vague, as was that of entrance +to the ward, and she claimed not to have known +where she was for quite a while. Specific occurrences, +such as the taking of her picture (with open +eyes two months after admission), an examination +in a special room, her own mixed-up writing (end of +second week) were not remembered. But it is quite +interesting that an angry outburst of another patient +within this same period, which was evidently +not recorded, is clearly remembered.</p> + +<p>We shall later show that when the patient comes +out of a stupor the condition may be such that, for +a time at least, retrospective accounts are difficult +to obtain. It must also be remembered that not infrequently +the more marked stupors may be followed +by milder states, and it is important, if we<!-- Page 70 --><span class='pagenum'><a name="Page_70" id="Page_70">[70]</a></span> +wish to determine how much is remembered, not to +confuse the two states or not to let the patient confuse +them. For example, Mary D. (Case 4), who +showed two separate phases, while she claimed not +to know of many external facts, also added that she +could not understand the questions which were +asked. From observation in other cases it seems +that in marked stupor any such recollection about +the patient's own mental processes would be quite +inconsistent. We have to assume, therefore, that this +remark referred in reality to the second milder +phase, for which, as we shall see, it is indeed quite +characteristic. It is not necessary to burden the +reader with other cases, all of which consistently +gave such accounts.</p> + +<p>We see, then, that in the marked stupor the intellectual +processes are regularly interfered with, as +evidenced by almost complete amnesia for external +events and internal thoughts. In other words, this +would indicate that the minds of these patients were +blank. Inasmuch as direct observation during the +stupor adduces little proof of mentation, we may +assume that such mental processes as may exist in +deepest stupor are of a primitive, larval order.</p> + +<p>Before we examine more carefully the milder +grades of stupor, it will be necessary to say a few +words about the retrospective account which the +patient gives of intellectual difficulties during the +incubation period of the psychosis. As a matter of +fact, we find that these accounts are remarkably +uniform. While some patients, to be sure, speak of<!-- Page 71 --><span class='pagenum'><a name="Page_71" id="Page_71">[71]</a></span> +a more or less sudden lack of interest or ambition +which came over them, others of them speak plainly +of a sudden mental loss. Mary. C. (Case 7) claimed +she suddenly got mixed up and lost her memory. +Laura A. spoke at any rate of suddenly having felt +dazed and stunned. Mary D. (Case 4) said she felt +she was losing her mind and that she could not understand +what she was reading. Maggie H. (Case +14) began to say that her head was getting queer. +We see from this that the interferences with the intellectual +processes may in the beginning be quite +sudden.</p> + +<p>In some instances a more detailed retrospective +account was taken, which may throw some light upon +the interferences with the intellectual processes with +which we are now concerned. Emma K., whose case +need not be taken up in detail, had a typical marked +stupor which lasted for nine months, preceded by a +bewildered, restless, resistive state for five days. +She was in the Institute ward for the first four +months, including the five days above mentioned; +later in another ward. When asked what was the +first ward which she remembered, she mentioned the +one after the Institute ward, and when asked who +the first physician was, she mentioned the one in +charge of the second ward. However, when taken +to the Institute ward, she said it looked familiar, and +was able to point to the bed in which she lay, though +somewhat tentatively. The same rousing of memory +occurred when the first physician, who saw her daily, +was pointed out to her. She remembered having<!-- Page 72 --><span class='pagenum'><a name="Page_72" id="Page_72">[72]</a></span> +seen him, and then even recalled the fact that he had +thrown a light into her eyes, but remembered nothing +else. This observation would seem to show that +with some often repeated or very marked mental +stimuli (throwing electric light into her eyes) a +vague impression may be left, so that it may at least +be possible to bring about a recollection with assistance, +whereas spontaneous memory is impossible. +In another instance, the patient was confronted +with a physician who had seen a good deal +of her. She said that he looked familiar to her, but +she was unable to say where she had seen him. Here +then again evidence that a certain vague impression +was made by a repeated stimulus.</p> + +<p>Another feature should here be mentioned, +namely, that isolated facts may be remembered +when the rest is blank. We have seen above +that Annie K. (Case 5), while very vague about +most occurrences, recalled a sudden angry outburst +in detail. Another patient, though the period of the +stupor was a blank, recalled some visits of her +mother. At these times, as she claimed, she thought +she was to be electrocuted and told her mother so, +"Then it would drop out of my mind again." These +facts are very interesting. We can scarcely account +for such phenomena in any other way than by assuming +that certain influences may temporarily lift the +patient out of the deepest stupor. In spite of the fact +that stupors often last for one or two years almost +without change, a fact which would argue that the +stupor reaction is a remarkably set, stable state,<!-- Page 73 --><span class='pagenum'><a name="Page_73" id="Page_73">[73]</a></span> +we see in sudden episodes of elation that this is not +the case, and other experiences point in the same direction. +A similar observation was made on a case of +typical stupor with marked reduction of activity and +dullness. A rather cumbersome electrical apparatus +(for the purpose of getting a good light for pupil +examination) was brought to her bedside. Whereas +before, she had been totally unresponsive, she suddenly +wakened up, asked whether "those things" +would blow up the place, and whether she was to be +electrocuted. During this anxious state she responded +promptly to commands, but after a short +time relapsed into her totally inactive condition. +We have, of course, similar experiences when we try +to get stuporous patients to eat, who, after much +coaxing may, for a short time, be made to feed themselves, +only to relapse into the state of inactivity.</p> + +<p>Such variations are paralleled, as we shall later +show, by a suddenly pronounced deepening of the +thinking disorder. We have already seen that the +onset may be quite sudden. All this indicates that, +in spite of a certain stability, sudden changes are +not uncommon. Finally, we know that, in spite of +the fact that stupor is an essentially affectless reaction, +certain influences may produce smiles or tears, +or, above all, angry outbursts, which again can +hardly be interpreted otherwise than by assuming +that those influences have temporarily produced a +change in the clinical picture, in the sense of lifting +the patient out of the depth of the stupor. All these<!-- Page 74 --><span class='pagenum'><a name="Page_74" id="Page_74">[74]</a></span> +facts suggest that inconsistencies in recollection are +correlated with changes in the clinical picture.</p> + +<p>As is to be expected, the cases with partial stupors +remember much more of what externally and internally +happened during their psychoses. Rose Sch. +(Case 6), who had a partial stupor during which she +answered questions but showed a great difficulty in +thinking, said retrospectively that she felt mixed up +and could not remember. Although she recalled +with details the Observation Pavilion and her transfer, +she was not clear about their time relations +(how long in the Observation Pavilion, how long in +the first ward). Mary C. (Case 7), whose activity +was not entirely interfered with and who showed +some thinking disorder, said retrospectively that she +could not take in things. Henrietta H. (Case 8), who +had a partial stupor, claimed to have known all +along where she was, but that she felt mixed up, +that her thoughts wandered and that she felt confused +about people. In the cases where a partial +stupor was preceded by a marked one, such as in +phase 2 of Anna G. (Case 1) and phase 2 of Mary +D. (Case 4), we have no retrospective account regarding +the partial stupor, because emphasis in the +analysis was naturally laid on the period comprising +the most marked disorder. However, we can gather +from the few cases at our disposal that the patients +retrospectively lay stress chiefly on their inability +to understand the situation.</p> + +<p>We finally have to consider the group of suicidal +cases. We have information only in regard to two<!-- Page 75 --><span class='pagenum'><a name="Page_75" id="Page_75">[75]</a></span> +cases, namely, Margaret C. (Case 10) and Pearl F. +(Case 9). In both of these, we find that a good many +things that happened during the period under consideration +were remembered, as were also the +patients' own actions. In Rosie K. (Case 11) we +have at least the evidence that she remembered her +own impulses, namely, that she refused food because +she wanted to die. In other words, in these partial +stupors with impulsive suicidal tendencies the interference +with the intellectual processes seems to be +moderate, and memory for external events not +markedly affected.</p> + +<h3>2. Information Derived from Direct Observation</h3> + +<p>The evidence can best be presented by considering +the details of some cases.</p> + +<p>Rose Sch. (Case 6) was remarkable, in connection +with the present problem, in her unusually poor +answers. She either merely repeated the questions, +or made irrelevant superficial replies, or said she did +not know, this even with very simple questions. +When better, too, though not quite well, she showed +striking discrepancies in time relations and incapacity +to correct them. It would seem that in this case +there was something more than an acute interference +with the intellectual processes, such as we are +here discussing. As a matter of fact, we have the +statement in the history that the patient herself said +she was slow at learning in school and had not much +of an education. A congenital intellectual defect<!-- Page 76 --><span class='pagenum'><a name="Page_76" id="Page_76">[76]</a></span> +and the attitude which it creates may, however, as +my experience has repeatedly shown me, very +greatly exaggerate an acute thinking disorder. The +case, therefore, while it shows us an unquestionably +acute interference with the intellectual processes, +does not give us useful information about its nature. +More information can be gathered from Mary D. +(Case 4). Even toward the end of her marked +stupor some replies were obtained chiefly by making +her write. When asked to write Manhattan State +Hospital, she wrote Manhatt Hhospshosh, and for +Ward's Island, Ww. Iland. Again, instead of writing +90th Street, she wrote 90theath Street. These +are plainly reactions of the path of least resistance +or, in these instances, of perseveration. Of the +same nature are some of her other replies in writing +or speaking. After she had been asked to write her +name, she was requested to add her address, or the +name of the hospital; she merely repeated the name. +Similarly, when asked whether she knew the examiner, +she said "Yes," but when urged to give his +name, she gave her own. In the partial stupor at a +time when she knew where she was, knew the names +of some people about her, the year and approximately +the date, she made mistakes in calculation and +could not get the point of a test story. Moreover, +she failed in retention tests without there being any +evidence of anything like a marked fundamental +retention disorder, such as we find in Korsakoff +psychosis. It seems that these results are best +termed defects in attention, which chiefly interfere<!-- Page 77 --><span class='pagenum'><a name="Page_77" id="Page_77">[77]</a></span> +with the apprehension of more difficult tasks. As +we shall see later, this seems to be rather characteristic +of these cases. Another point which should be +mentioned is the fact that her reaction to questions +which she was unable to answer (such as matters +which referred to her amnesic periods) was peculiar, +inasmuch as she did not only not try to think them +out, but seemed indifferent to her incapacity, simply +leaving the question unanswered. This too, as we +shall see later, is characteristic. Laura A., at a time +when she could be made to reply, merely repeated +the question, again a reaction of least resistance. +The same patient sometimes asked, "Where am I?" +Mary C. (Case 7) made similar queries. Although +she was at times approximately oriented, she would +say, "I don't know where I am," or "I can't realize +where I am," or more pointedly, "I can't take in my +surroundings." She often did not answer and sometimes +seemed bewildered by the questions. Henrietta +H. (Case 8) again showed some defect of +orientation and mistakes in calculation, and above +all, marked mistakes in writing (for Manhattan +State Hospital—Manhaton Hotspal). A special feature +here is that this occurred immediately after she +had been quite talkative, but suddenly had relapsed +into a dull state. Anna G. (Case 1), during the third +phase of her psychosis, showed the following: Although +she was approximately oriented and answered +promptly simple questions; e.g., about +orientation or simple calculation, she, like these +other patients, simply remained silent when more<!-- Page 78 --><span class='pagenum'><a name="Page_78" id="Page_78">[78]</a></span> +difficult intellectual tasks were required of her (more +difficult calculations); or when she was asked how +long she had been here (which involved data that +could not be available to her, owing to her amnesia); +or when questions were put to her regarding her +feelings or the condition she had passed through. +On the other hand, she sometimes gave appropriate +replies in the words "yes" or "no," but it was +difficult to say whether these answers did not also +represent the path of least resistance.</p> + +<p>We will finally take up the last phase of Margaret +C. (Case 10). Although she was entirely oriented, +there was a certain vagueness about her answers +which is difficult to formulate. She was telling about +the onset of her sickness and said that at that time +her mind was taken up with prayers about the salvation +of her relatives. She was asked exactly when +it was that she thought of this and she answered +"Now?" (What period are we talking about?) +"The present." (What did I ask you?) "About +this period of my sickness." (Which one?) "What +sickness?" She said herself at this point, "I am +rather stupid." Again when asked how her mind +worked, she said, "Pretty quickly sometimes—I +don't know." (As good as it used to?) "No, I +don't think so." (What is the difference?) "There +is no difference." (What did I ask you?) "The difference." +(The difference between what?) "You +did not say." In this the shallowness of her comprehension +and thinking is well shown, and it seems +here again perhaps justifiable to formulate the main<!-- Page 79 --><span class='pagenum'><a name="Page_79" id="Page_79">[79]</a></span> +defect as one of attention, which prevents completion +of a complicated process of comprehension. A +feature of further interest in this case is that automatic +intellectual processes, such as those necessary +for the writing of a long poem from memory, were +not interfered with.</p> + +<h3>Summary</h3> + +<p>In the most pronounced stupor we have evidently +a more or less complete standstill in thinking +processes. Practically no impressions are registered +and consequently nothing is remembered except +events that occurred in some short periods +when some affective stimulus, or a brief burst of +elation, lifts the patient temporarily out of the deep +stupor. It is impossible to say whether the statement +of a complete standstill has to be qualified. In +some stupors repeated environmental stimuli sometimes +make at least a vague impression, so that while +spontaneous recollection is impossible a feeling of +familiarity is present when the patient is again confronted +with this environment. This might be an +exception to the dictum of complete mental vacuity, +or it may be that there are somewhat less pronounced +stupor reactions. When more is perceived, +there is often a retrospective statement of having +felt mixed up, being unable to take in things, or, +directly under observation, the patient may say, "I +cannot realize where I am," "I cannot take in my +surroundings." In harmony with this is the fact +that questions often produce a certain bewilderment.<!-- Page 80 --><span class='pagenum'><a name="Page_80" id="Page_80">[80]</a></span> +In quite pronounced states in which some replies +can still be obtained, we find that the intellectual +processes may be interfered with to the extent of a +paragraphia, i.e., a remarkably mixed-up writing in +which perseveration (one form of following the path +of least resistance) plays a prominent part. This +same principle is also seen in such reactions as the +repetition of the question or the senseless repetition +of a former answer. These phenomena remind us +of what we see in epileptic confusions, in epileptic +deterioration and in arteriosclerotic dementia.</p> + +<p>In milder cases difficulties in orientation may be +more or less marked; or there may be incapacity to +think out problems, although the orientation is perfect. +The more automatic mental processes may +run smoothly (memory and calculation may be excellent) +and there may yet be a certain shallowness +in thinking, a defect of attention (a purely descriptive +term) which is most obvious in the patient's +inability to grasp clearly the drift of what is going +on or the meaning of complicated questions. I am +inclined to think that poor results in retention tests +are entirely due to this attention disorder, for we +have no evidence of any fundamental retention defect +such as we find in the totally different organic +stupors. From a practical point of view it is important +at this place to call attention to the fact +that such mild changes are particularly seen in end +stages. Even when pronounced negativistic tendencies +do not play a prominent rle, the patient is +then apt to be silent chiefly as a result of the residual<!-- Page 81 --><span class='pagenum'><a name="Page_81" id="Page_81">[81]</a></span> +disorder in the intellectual processes. Still more +striking are the conditions which are on a somewhat +higher level and in which the shallowness of the responses, +due to the residual disorder of attention, +together with the last traces of the affectlessness, +are apt to create the impression of a dementia. In +such cases the opinion is often held that the patient +has reached a defect stage from which recovery is +impossible, whereas a thorough knowledge of these +end stages teaches us that they are not only recoverable +but quite typical for the terminal phases of +stupor.</p> + +<p>Considering these data, especially those gathered +in the end stages, it would appear that there is no +tendency in this intellectual disorder associated with +the stupor reaction for any special side of mental +activity to be most prominently affected. It looks +rather as if it were a question of a general diminution +of the capacity to make a mental effort which in +its different intensities accounts for the symptoms.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> See <a href="#CHAPTER_XV">Chapter XV</a>.</p></div> +</div> + +<p><!-- Page 82 --><span class='pagenum'><a name="Page_82" id="Page_82">[82]</a></span></p> + +<h2>CHAPTER V<br /> + +<span class="sm">THE IDEATIONAL CONTENT OF THE STUPOR</span></h2> + +<p><i>Brief survey of the ideas associated with stupor:</i> +Having thus described the formal manifestations of +the various stupor reactions, it will now be interesting +to see what ideas seem to be associated with +these reactions. It is, of course, impossible to obtain +during a considerable part of the stupor any statement +of the patients' thoughts. We therefore have +to depend on their utterances during periods when +the inactivity temporarily ceases, or on the retrospective +account which the patient gives after the +stupor has completely disappeared; and as we shall +see, we also may obtain considerable information by +studying the ideas which occur in the period preceding +the stupor. These last may be autogenous +delusions or thoughts about actual events which precipitated +the psychosis.</p> + +<p>It is not likely that many observers have a very +clear conception about what sort of ideas to expect. +We have, as a rule, not been in the habit of paying +much attention to the content of delusions, hallucinations, +and the like. So far as we could judge, +therefore, the ideas expressed might be expected to +be fairly multiform, and it was distinctly interesting<!-- Page 83 --><span class='pagenum'><a name="Page_83" id="Page_83">[83]</a></span> +to us when we found a marked tendency for the +trends of ideas to remain within a certain small +compass.<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a> It was possible, to state this at once, to +show that in by far the majority of cases the same +set of ideas returned, and that these ideas had +among themselves a definite inner relationship, being +concerned with thoughts of "death." In isolated +instances other ideas were found as well, and +they will have to be discussed later. For the present +we shall take up more habitual content.</p> + +<p>In addition to the eleven cases already described, +it may be well to cite four others which present +material now of interest to us.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 12.</span>—<i>Charlotte W.</i> Age: 30. Admitted to the Psychiatric +Institute October 21, 1905.</p> + +<p><i>F. H.</i> The father was alcoholic and quick-tempered; he died +when the patient was a child. The mother was alcoholic and +was insane at 40 (a state of excitement from which she recovered). +A brother had an attack of insanity in 1915. A maternal +uncle died insane.</p> + +<p><i>P. H.</i> The patient was described as jolly, having many friends. +She got on well in school and was efficient at her work.</p> + +<p>She was married at 23 and got on well with her husband. +The latter stated, however, that she masturbated during the first +year of her married life. The first child was born without +trouble.</p> + +<p><i>First Attack at 25:</i> Two or three days after giving birth to +a second child, her mother burst into the room intoxicated. The +patient immediately became much frightened, nervous, and developed +a depressive condition with crying, slowness and inability +to do things. During this state she spoke of being bad and told<!-- Page 84 --><span class='pagenum'><a name="Page_84" id="Page_84">[84]</a></span> +her husband that a man had tried to have intercourse with her +before marriage. This attack lasted six months and ended with +recovery.</p> + +<p>When 29, a year before her admission, she had an abortion +performed, and four months later another. Her husband was +against this, but she persisted in her intention. Seven months +before admission she went to the priest, confessed and was reproved. +It is not clear how she took this reproof, but at any +rate no symptoms appeared until three weeks later, after burglars +had broken into a nearby church. Then she became unduly +frightened, would not stay at home, said she was afraid the burglars +would come again and kill "some one in the house." The +patient herself stated later, during a faultfinding period, that +at that time she was afraid somebody would take her honor away, +and that she thought burglars had taken her "wedding dress." +"Then," she added, "I thought I would run away and lead a bad +life, but I did not want to bring disgrace to the family."</p> + +<p>The general condition which she presented at this time is described +as one of apprehensiveness when at home. For this +reason she was for five weeks (it is not clear exactly at what +period) sent to her sister, where she was better. About a month +before the patient was admitted, the husband moved, whereupon +she got depressed, complained of inability to apply herself to +work, became slow and inactive, and blamed herself for having +had the abortion performed. She began to speak of suicide and +was committed because she bought carbolic acid. She later said +that while in the <i>Observation Pavilion</i> she imagined her children +were cut up.</p> + +<p><i>Under Observation</i> the condition was as follows:</p> + +<p>1. For the first three days the patient, though for the most +part not showing any marked mood reaction, was inclined at +times to cry, and at such times complained essentially that this +was a terrible place for a person who was not insane.</p> + +<p>2. On the fourth day the condition changed, and it will be +advisable to describe her state in the form of abstracts of each +day.</p> + +<p>On <i>October 24</i> the patient began to be preoccupied and to +answer slowly. A few days later she became distinctly dull, +walked about in an indifferent way or lay in bed immobile.<!-- Page 85 --><span class='pagenum'><a name="Page_85" id="Page_85">[85]</a></span> +Twice on <i>October 27</i> she said in a low tone and with slight distress, +"Give me one more chance, let me go to him." But she +would not answer questions. At times she lapsed into complete +immobility, lying on her back and staring at the ceiling. When +the husband came in the afternoon, she clung to him and said: +"Say good-by forever, O my God, save me." Again, very slowly +with long pauses and with moaning, she said: "You are going +to put me in a big hole where I will stay for the rest of my life." +<i>On October 28</i> she was found with depressed expression and +spoke in a rather low tone, but not with decided slowness as had +been the case on the day before. She pleaded about having her +soul saved; "Don't kill me"; "Make me true to my husband"; +once, "I have confessed to the wrong man the shame of my life." +Later she said she did not tell the truth about her life before +marriage. Again she wanted to be saved from the electric chair. +At times she showed a tendency to stare into space and to leave +questions unanswered.</p> + +<p>3. From now on a more definite stupor occurred, which is also +best described in summaries of the individual notes.</p> + +<p><i>Oct. 29.</i> Lies in bed with fixed gaze, pointing upward with +her finger and is very resistive towards any interference. She +has to be catheterized.</p> + +<p><i>Oct. 30.</i> Can be spoon-fed but is still catheterized. During +the morning she knelt by the bed and would not answer. At the +visit she was found in a rather natural position, smiling as the +physician approached, saying "I don't know how long I have been +here." Then she looked out of the window fixedly. At first +she did not answer, but, when the physician asked whether she +knew his name, she laughed and said, "I know your name—I know +my name." Then she would not answer any more questions but +remained immobile, with fixed gaze. When her going home was +mentioned, however, she flushed and tears ran down her cheek, +though no change in the fixedness of her attitude or in her facial +expression was seen.</p> + +<p><i>Nov. 1.</i> Lies flat on her back with her hands elevated. She +is markedly resistive.</p> + +<p><i>Nov. 2.</i> Free from muscular tension and more responsive. +When asked whether she felt like talking, she said in a whining +tone, "No, go away—I have to go through enough." Then she<!-- Page 86 --><span class='pagenum'><a name="Page_86" id="Page_86">[86]</a></span> +spoke of not knowing how long the nights and days were, of not +having known which way she was going. When asked who the +physician was she whimpered and said, "You came to tell me +what was right." She called him "Christ" and another physician +"Jim" (husband's name), though, later in the interview, she +gave their correct names. When asked about the name of another +physician, she said: "He looks like my cousin, he was +here, they all came the first night. I did not take notice who +it was till I went through these spirits, then I knew it was right."—She +paused and added: "My God—mother it was; she is here +on Earth, somewhere in a convent—Sister C. (who actually is in +a convent) she was here, too, I could hear her." She said they +all came to try to save her. When asked whether she had been +asleep, she said: "No, I wasn't asleep, I was mesmerized, but I +am awake now—sometimes I thought I was dead." (When?) +"The time I was going to Heaven." Again: "I went to Heaven +in spirit, I came back again—the wedding ring kept me on Earth—I +will have to be crucified now." (Tell me about it.) "Jim +will have to pick my eyes out—I think it is him. Oh, it is my +little girl." (Who told you?) "The spirits told me." Again: +"Little birds my children—I can't see them any more—I must +stay here till I die." (Why?) "The spirits told me—till I +pick every one of my eyes out and my brains too." When asked +what day it was, she said, "It must be Good Friday." (Why?) +"Because God told me I must die on the cross as he did." When +asked why she had not spoken the day before, she said that +"Jesus Christ in Heaven" had told her she should not tell anything, +"till all of you had gone, then I could go home with him, +because that is the way we came in and it was Jim too all the +time." Finally she said crossly, "Go away now, you are all +trying to keep me from Jim" (crying).</p> + +<p><i>Nov. 3.</i> Knelt by bed during the night. This morning lies +in bed staring, resistive, again she is markedly cataleptic. She +has to be spoon-fed, and is totally unresponsive. In the afternoon +she was found staring and resistive. Presently she said +with tears: "I am waiting to be put on the cross."</p> + +<p><i>Nov. 4.</i> Still has to be catheterized. She sits up, staring, +with expressionless face, but when asked how she felt she responded +and said feebly: "I don't know how I feel or how I<!-- Page 87 --><span class='pagenum'><a name="Page_87" id="Page_87">[87]</a></span> +look or how long I have been here or anything." (What is +wrong?) "Oh, I only want to go to a convent the rest of my +days." (Why?) "Oh, I have only said wrong things, I thought +I would be better dead, I could not do anything right." Later +she again began to stare.</p> + +<p><i>Nov. 5.</i> During the night she is said to have been restless and +wanted to go to church. To-day she is found staring, but not +resistive. When questioned she sometimes does not answer. She +said to the physician, "I should have gone up to Heaven to you +and not brought me down here." She called the physician +"Uncle James." Again she said, "I want to go up to see Jim." +Sometimes she looks indifferent, again somewhat bewildered.</p> + +<p><i>Nov. 6.</i> She eats better, catheterizing is no longer necessary. +She is found lying in bed, rigid, staring, resistive, does not answer +at first, later appears somewhat distressed, says "I want to +go and see Jim." (Where?) "In Heaven." She gave the name +of the place and of the physician, also the date.</p> + +<p><i>Nov. 8.</i> In the forenoon, after she had presented a rather +immobile expression and had answered a few orientation questions +correctly, she suddenly beckoned into space, then shook +her fist in a threatening manner. When later asked about this, +she said: "Jim was down there and I wanted to get him in." +(And?) "You was up here first." (And?) "I thought we +was going down down, up up—the boat— —you came in here +for—to lock Jim out so we wouldn't let him in." Later she said, +when asked whether anything worried her, "Yes, you are taking +Jim's place."</p> + +<p><i>Nov. 9.</i> During the night she is reported to have varied between +stiffness with mutism and a more relaxed state. Once, the +nurse found her with tears, saying "I want to go down the hall +to my sister—to the river," and a short time later with fright: +"Is that my mother?" Again she said: "Oh dear, I wish this +boat would stop—stop it—where are we going?" In the forenoon +she was quiet and unresponsive. In the afternoon she said +in a somewhat perplexed way, "We were in a ship and we were +'most drowned." (When was that?) "Day before yesterday +it must have been"—Again she said in the same manner: "It was +like water. I was going down. I could hear a lot of things." +She claimed this happened "to-day." "I saw all the people in<!-- Page 88 --><span class='pagenum'><a name="Page_88" id="Page_88">[88]</a></span> +here, it was all full of water," "I have been lying here a long +time—do you remember the time I was under the ground and it +seemed full of water and every one got drowned and a sharp +thing struck me?" "I was out in a ship and I went down there +in a coffin." When asked whether she had been frightened at +such times, she said: "No, I didn't seem to be, I just lay there." +She also said: "the water rushed in," and when asked why she +put up her arms, she said, "I did it to save the ship."</p> + +<p><i>Nov. 10.</i> She is still fairly free. She said that when she was +on the ship things looked changed, "the picture over there looked +like a saint, the beds looked queer." (How do things look now?) +"All right." (The picture too?) "The same as when I was +going down into a dark hole." When asked later in the day +where she was, she said, "In the Pope's house, Uncle Edward is +it?" but after a short time she added, "It is Ward's Island, +isn't it?"</p> + +<p><i>Nov. 11.</i> Inactive, inaccessible, but for the most part not +rigid.</p> + +<p><i>Nov. 14.</i> Varies between mutism with resistance and more +relaxed inactivity. To-day lies in a position repeatedly assumed +by her, namely, on her stomach with head raised, resistive towards +any interference, immobile face, totally inaccessible.</p> + +<p><i>Nov. 15.</i> Freer. She said: "One day I was in a coffin, that's +the day I went to Heaven." She also said she used to see "the +crucifix hanging there" (on the ceiling)—"not now but when I +was going to Heaven." (When was that?) "Over in that bed" +(her former bed). Later she added, "The place changed so ... +things used to be coming up and down (dreamily)—that was the +day I was coming up on the ship or going down." She is quite +oriented.</p> + +<p><i>Nov. 17.</i> Usually stands about with immobile face, preoccupied, +but she eats voluntarily.</p> + +<p><i>Nov. 24.</i> When the husband and sister came a few days ago +she said she was glad to see them, embraced them, cried and is +said to have spoken quite freely. To-day she speaks more freely +than usually. When asked why she had answered so little, she +said she could not bring herself to say anything, though she +added spontaneously, "I knew what was said to me." When +shown a picture of her cataleptic attitude with hands raised, she<!-- Page 89 --><span class='pagenum'><a name="Page_89" id="Page_89">[89]</a></span> +said dreamily, "I guess that must have been the day I went to +Heaven, everything seemed strange, things seemed to be going up +and down." (Did you know where you were?) "I guess that +was the day I thought I was on the ship." When the sister +spoke to her, she seemed depressed and said, "If only I had not +done those things I might be saved, if I had only gone to church +more."</p> + +<p><i>Dec. 3.</i> Seems depressed. She weeps some, says she is sad, +"There seems to be something over my heart, so I can't see my +little girls." Again: "I should have told you about it first—I +should not have bought it"—(refers to buying carbolic acid). +She wrote a natural letter but very slowly.</p> + +<p>4. There followed then a state lasting for six months, during +which the patient was rather inactive, preoccupied, even a little +tense at times. Sometimes she did not answer, again at the same +interview spoke quite promptly. For the most part the affect +was reduced, at other times she appeared a little uneasy, bewildered, +or again depressed. She said that sometimes a mist +seemed to be over her. Now and then spoke of things looking +queer and she asked, when the room was cleaned, "Why do they +move things about?" and she added irrelevantly: "I thought the +robbers broke into my house and stole my wedding dress and my +children's dresses" (refers to the condition during the onset of +her psychosis). In the beginning of this state, when asked +about the stupor, she spoke again of the "ship" and about going +"down, down," but also said that on one occasion she heard beautiful +music, was waiting for the last trumpet and was afraid to +move. Moreover, she had some ideas referring to the actual +situation which were akin to those in the more marked stupor +period. Although she admitted she was better, she said on December +8 that she still had queer ideas at times, "I sometimes think +the doctor is Uncle Jim" (long dead). She also spoke of other +patients looking like dead relatives, and added, "Are all the +spirits that are dead over here?" "We never die here, the spirits +are here." But after that date no such ideas recurred, in fact +this whole period seems to have been remarkably barren of delusions. +Exceptionally isolated ones were noted. Thus, on January +28 it is mentioned that she stated she sometimes felt so lonely, +and as though people were against her; and on February 13 she<!-- Page 90 --><span class='pagenum'><a name="Page_90" id="Page_90">[90]</a></span> +said she felt as though the chair knew what she was talking about. +It is also mentioned in January that she wept at times, but this +seems not to have been a leading feature at all. In March, when +asked why she was not more active and cheerful, her lips began +to quiver and she said, "Oh, I thought my children would be cut +up in Bellevue." "I don't know why I feel that way about them." +She sometimes cried when her friends left her.</p> + +<p>5. Then followed a week of a rather faultfinding, self-assertive +state, during which she demanded to be allowed to go home, saying +indignantly that she was not a wicked woman, had done nothing +to be kept a prisoner here; she wanted justice because another +patient had called her crazy. But in this period also she said +that after the robbery (at home) she felt afraid that her honor +would be taken away. When told that her husband had been +with her, she said "Yes, but I was afraid they would get into a +fight." (You mean you were afraid the other man would kill +him?) "No, he is not dead." She further talked of a disagreement +she had at that time with her husband, and that she felt +then like running away and leading a bad life, but thought of +the children. With tears she added: "I would not do anything +that is wrong. I have my children to live for." Quite remarkable +was the fact that she then told of various erotic experiences +in her life, though with a distinctly moral attitude and minimizing +them.</p> + +<p>6. On <i>June 16</i> another state was initiated with peculiar ideas, +the setting of which is not known, as she told them only to the +nurses. She said that she was not Mrs. W. but the Queen of +England, again that she was an actress, or again the wife of a +wealthy Mr. B., and that she was going to have a baby. But at +night she is said to have been agitated and afraid she was to be +executed. She asked to be allowed to go to bed again, then +stopped talking, and remained in this mute condition for about +a week. She often left her bed and went back again, remained +much with a perplexed expression. On one occasion she put +tinsel in her hair saying it was a golden crown.</p> + +<p>7. At the end of that time she became freer and more natural, +and remained so for three weeks. She occupied herself somewhat. +When asked what had happened in the condition preceding, +said she thought she was a queen or was to be a queen.</p> + +<p><!-- Page 91 --><span class='pagenum'><a name="Page_91" id="Page_91">[91]</a></span> +8. Towards the end of this period she had again three more +absorbed days, but when examined on the third of these days got +rather talkative and somewhat drifting in her talk on superficial +topics.</p> + +<p>9. Two days later she began to sing at night, kissed everybody, +said it was the anniversary of her meeting her husband, +again cried a little, and on the following morning began to sing +love songs, with a rather ecstatic mood, and at times stood in an +attitude of adoration with her hands raised. This passed over +to a more elated state, during which she smiled a good deal, often +quite coquettishly; she sang love songs softly; on one occasion +put a mosquito netting over her head like a bridal veil; or she +held her fingers in the shape of a ring over a flower pinned to +her breast. But even during this state she said little, only once +spoke of waiting for her wedding ring, and again, when asked +why she had been singing, said "I was singing to the man I love." +(Why are you so happy?) "Because I am with you" (coquettishly).</p> + +<p>This, however, represented the end of the psychosis. She improved +rapidly. At first she smiled rather readily, but soon began +to occupy herself and made a perfect recovery.</p> + +<p>She gave a rather shallow retrospective account about the last +phase: at first she said it was natural for people to feel happy +at times, and that she did not talk more because the inclination +was not there. The only point she added later was that she +held her fingers in the shape of a ring because she was thinking +of her wedding ring.</p> + +<p>She was discharged on <i>October 11</i>.</p> + +<p>The patient was seen again in <i>September, 1915</i>. She then stated +that she had been perfectly well until 1912, when she had a +breakdown after childbirth. (A childbirth in 1910 had led to +no disorder.) The attack lasted six months. She slept poorly, +lost weight, and felt weak, depressed, "my strength seemed all +gone." In <i>July, 1915</i>, following again a childbirth, she was for +about six weeks "despondent, weak and tired out."</p> + +<p>At the interview she made a very natural, frank impression, +and displayed excellent insight.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 13.</span>—<i>Johanna S.</i> Age: 47. Admitted to the Psychiatric +Institute January 23, 1904.</p> + +<p><!-- Page 92 --><span class='pagenum'><a name="Page_92" id="Page_92">[92]</a></span> +<i>F. H.</i> It was claimed that there was no insanity in the +family.</p> + +<p><i>P. H.</i> The patient was said to have been bright and rather +quick-tempered. She came to the United States from Ireland at +the age of 20, worked as a servant, was well liked, and retained +her position well.</p> + +<p>She was married at 24. After a second confinement, at the age +of 26, the patient had her first attack of manic excitement, from +which she recovered in four months. She had, subsequently, at +the ages of 28, 30, 32, 35, 43, and 45, other attacks of the same +nature, each one lasting about four months. No precipitating +cause was known for any of them. Only one of the attacks, the +fifth, (none were well observed) seems to have shown features +different from an elated excitement with irritability. At the end +of this attack she was said to have been "dull" for a month.</p> + +<p>Her husband died four years before the present admission, evidently +soon after her sixth attack.</p> + +<p>The present attack:</p> + +<p>About two months before admission the patient began, without +appreciable cause, to be sleepless, complained of headaches and +appeared downhearted and sad. She sat about.</p> + +<p>After a week she would not get out of bed and remained in +bed until she was sent to the Observation Pavilion, getting up +only to go to the closet. She said very little and would not eat +much. About a month before admission she began to say that +she did not want to live, begged her daughter to throw her out +of the window. About two weeks before admission she began +to insist that she heard the voice of her brother (living in Ireland) +calling her. She got out of bed to look for him.</p> + +<p>At the <i>Observation Pavilion</i> she was described as slow, looking +about in an apprehensive manner, bewildered, dazed, saying "I +am dead—there is poison in it (not clear in what)—I am dead, +you are dead."</p> + +<p><i>Under Observation:</i> 1. On admission the patient had a coated +tongue, foul breath, constipation, lively knee-jerks and a pulse +of 110. She appeared dull, inactive, lay in bed with her eyes +closed. She would open them when urged but appeared drowsy +and her face was strikingly immobile. At times she moaned a +little. She could be made to respond in various ways such as<!-- Page 93 --><span class='pagenum'><a name="Page_93" id="Page_93">[93]</a></span> +shaking her head, or making some motions as though to indicate +that she could not give any explanations. All movements were +slow. She also responded to a few questions by "I don't know."</p> + +<p>Two days after admission the condition was not essentially +different except that she was a little uneasy when urged to speak, +corrugated her forehead, said "Everything is dark," again "I am +very sick," or she turned away her head.</p> + +<p>On the fourth day, i.e., January 26, the picture altered, inasmuch +as she was much more responsive. She was found sitting up +in bed and, at times, a little uneasy. She was slow in her movements +and answers, speaking in a whisper and sometimes a little +fretfully. The answers, though slow, were, however, by no means +given in the shortest possible manner, but with variations, e.g., +from "I don't know," to "I could not tell you," or "I can't tell +that either." She said herself that everything had "been so dark—it +is light now, but it gets so dark sometimes." She denied +knowing where she was, even in what city, also denied knowing +the month, adding to the latter answer "the nurse can tell you." +She could not tell where she had been before coming to the hospital, +or how she came. Finally, she also claimed not to know +her age, her birthday or the date of her marriage; but she gave +the current year correctly, the place where she went to school, +the names of some of her teachers, and the year of her arrival +in the United States. She also stated in answer to questions that +she came to the hospital "to get well." She repeatedly said "I +am so sick," or "I am so stupid," or "My mind is mixed up, +twisted," or "My mind is not so good," or "I am so tired." +What could be obtained of a content was as follows: When she +spoke of being "twisted," she said, "I got all kinds of medicine." +(How does it affect you?) "Through my head and it made me hot +inside." Again, when asked whether anybody had done anything +to her, she said "No, I have done wrong myself, by speaking +bad of my neighbors." She claimed to hear voices "all over," +but could not tell what they said. When, in the evening of that +day, the nurse asked her why she did not talk more, she said, +"God damn it, I am all twisted, my brain is mixed up, my system +is all upset, the doctor made me stupid with questions, and +the medicine I have taken made me all stupid and I am inhaling +gas now." Then she again settled into a dull state and was found<!-- Page 94 --><span class='pagenum'><a name="Page_94" id="Page_94">[94]</a></span> +by the physician with immobile expression, slow motions and +mute.</p> + +<p>2. For about ten days, i.e., from January 27 to February 8, +her condition was of a more pronounced character. For the +most part she lay in bed with often quite immobile face and with +eyes closed, or she looked about in a bewildered manner. She +was very inactive, presented a marked resistance in her arms and +jaw when passive motions were attempted, or, again, exhibited +decided catalepsy. She had to be tube-fed. Once on the 27th of +January, when the nurse tried to feed her, she pushed her away +and said, "I am dead—I am not home." Sometimes she turned +her hands about with slow tremulous movements, looking at them +in a bewildered manner.</p> + +<p>She usually was mute, except on the few occasions to be mentioned +later, as well as on February 3, when she was generally +a little more responsive. At that time she could be made to open +her eyes, and then replied to a few questions slowly and in a +low tone; others were left unanswered. (To the questions where +she was and how long she had been here, she replied with "I +don't know," but to questions about who the physician and the +nurse were, by saying "You are a doctor," and "she is a nurse.")</p> + +<p>In the general setting just described there occurred at various +times changes in behavior which were as follows: On the evening +of the 27th of January she got out of bed and walked about +with slow restlessness, saying: "They say I am going to be cut +up." On February 1, she was seen for a time making peculiar +slow swimming motions with her hands. Again on the 3d of +February she got out of bed, walked about slowly, with peculiar +steps, as though avoiding stepping on something. Next day (the +4th) she sat up in bed—again made at times her peculiar slow +swimming motions. She presented at the same time a peculiar +dazed bewildered uneasiness and, when questioned what was the +matter, said: "I am—I am—at the bottom of the deep—deep +water—oh—oh—the deep—deep—dark water." And when further +urged she added with the same manner, "I can't swim—I +don't know—but the place"—She did not finish but later again +muttered "the deep—deep—dark water." (Do you really think +you are in the water?) "I don't know—my head is so bad."</p> + +<p>For the following five days this behavior was repeated from<!-- Page 95 --><span class='pagenum'><a name="Page_95" id="Page_95">[95]</a></span> +time to time, when she would sit up and with bewildered uneasiness +make slow swimming motions and mutter when questioned, +"I am in the deep, dark water."</p> + +<p>Some other emotional responses in reaction to external events +must still be mentioned. They were rare. On February 1 the +patient's daughter came while she was lying motionless in bed. +She slowly extended her hands, tried to speak, and then her eyes +filled with tears. Again, at the end of the interview of February +3, after she had made a few replies, she settled down to her +usual inactivity and, when further urged to answer, her eyes +filled with tears.</p> + +<p>3. From about February 9 to February 24 the condition again +presented a different aspect, inasmuch as while there was still +a marked reduction of activity, she showed this to a decidedly +lesser degree. Moreover, there was no bewilderment at any time. +No resistance, but cataleptic tendencies were still seen occasionally. +There was at no time the peculiar dazed uneasiness and +slow restlessness associated with the idea of being in the deep, +dark water.</p> + +<p>She now dressed herself very slowly, ate slowly but of her own +accord, and spoke, though her voice was consistently slow, in a +low tone and her words were few.</p> + +<p>At the beginning of this period on February 9, when asked +how she was, she said "I—I am sick." To the questions as to +where she was, how long she had been here and how she had been +taken sick, she replied by saying "I don't know." But she knew +she was in a hospital, had been here before "many times." (Correct.) +She was then again asked for the name of the hospital, +but replied "I don't know." So the physician pointed out of +the window and asked her what it was that she could see there +(the East River). She replied, "It is the dark water. Sometimes +I go there and don't come back again—and—something +throws me up and I come back." (What has been the matter +with you?) "I have been sick all this time." Again, "I can't +tell—I am not a good woman—I am very sick." (Why do you +say you are not a good woman?) "Oh, I did not do things +right."</p> + +<p>At a later interview, during the same period, she knew the +doctor's name, knew she had seen him at Ward's Island, knew<!-- Page 96 --><span class='pagenum'><a name="Page_96" id="Page_96">[96]</a></span> +she was in a hospital, but somehow could not connect the present +place with Ward's Island. She said she didn't know, when asked +where she was, and when questioned about the season, said, after +a pause "Summer" (February 15).</p> + +<p>We have seen above that she once spoke of not having been a +good woman. She repeated this on February 10, said "I have +done lots of harm, I have been a bad woman all my life." Again: +"I had bad thoughts." (What kind?) "I have forgotten all +about them." It should be added that at this interview she also +said, "My mind is better now."</p> + +<p>On February 25 there was a sudden change. She laughed +when a funny remark was made on the ward. Later, when the +physician came to her, she still lay in bed inactive and had to be +urged considerably at first, but presently began to laugh good-naturedly +and quite freely commented on the funny remark she +had heard earlier in the morning, and on peculiarities of some +patients. She spoke quite freely and without constraint. But it +was striking how little account of the condition she had gone +through could be obtained from her. She either turned the +questions off by flippant remarks, or said she did not know. The +only information obtained was that she had been sick since +Christmas, felt like a dummy, that she had lost track of time, +and did not know how she had felt during that period. When +asked why she had not spoken, she said, "I couldn't, I had a +jumping toothache," or she said, "Ask the nurse, she put it down +in the book." Or again she said, "Did you ever get drunk? +That is the way I felt. I felt like dead."</p> + +<p>She soon developed a lobar pneumonia and died.</p></div> + +<p>The following typical case of partial stupor is +quoted as an example of delusions appearing only +during the onset.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 14.</span>—<i>Maggie H.</i> Age: 26. Admitted to the Psychiatric +Institute February 8, 1905.</p> + +<p><i>F. H.</i> The father died when 33. The mother was living. +Psychopathic tendencies were denied.</p> + +<p><i>P. H.</i> The husband and brother stated that the patient was<!-- Page 97 --><span class='pagenum'><a name="Page_97" id="Page_97">[97]</a></span> +natural, capable, rather jolly. She married about a year before +admission and shortly became pregnant. During the pregnancy +she was rather nervous and had various forebodings, among +which were that the child might be born deformed, or that she +would die in childbirth.</p> + +<p>The baby was born three weeks before admission. The patient +seemed much worried immediately after the childbirth, fretted +about not having enough milk, was quite concerned about her +husband and did not want him to leave her side. The brother +stated that about this time the patient heard that the husband +was out of work. She worried about this and told her sister so. +She also began to say that her head was getting queer. On the +fifth day after childbirth, a change came over the patient. She +cried and said she was going to die. She also spoke of poison +in the food and accused the husband of unfaithfulness. The +next day she became silent, "did not seem to want to have anything +to do with anybody," lay in bed, had a tendency to pull +the covers over her head and scarcely ever spoke. But during +this period she continued to look after the baby faithfully. +Sometimes she clung to her husband, saying she was afraid he +was going to die.</p> + +<p>After recovery the patient said that while she was at home she +thought she saw bodies lying about.</p> + +<p>At the <i>Observation Pavilion</i> she was quiet and apathetic, indifferent +to environment and could not be induced to speak. +She soiled, refused food, and was resistive when anything was +done to her.</p> + +<p><i>Under Observation:</i> 1. On admission the patient was fairly +well nourished but looked rather anemic and weak. The temperature +was normal, the pulse a little irregular but of normal frequency, +the tongue coated. She lay inactive but looked about, +and the facial expression sometimes changed as she did this. Any +interference met with intense resistance. There was no catalepsy. +In contradistinction to this inactivity and resistance, natural, +free motions were observed at times, as, for example, when she +arranged her pillows. She did not speak and could not be made +to answer.</p> + +<p>For the rest of the first week she made no attempt to speak, +except once when she seemed to attempt to return a "good morn<!-- Page 98 --><span class='pagenum'><a name="Page_98" id="Page_98">[98]</a></span>ing," +or on another occasion, when the nurse tried to feed her, she +said, in quite a natural tone, "I can feed myself." The resistance +to interference remained in a variable degree, and was +at times quite strong. It was largely passive, though not infrequently +associated with a scowl, or she moved away when approached. +She sometimes looked dull and stared, again she +looked determined, "disdainful," or scowled; or she looked about +watching others, sometimes only out of the corners of her eyes. +She had to be spoon-fed at times, again she ate naturally when +the food was brought. Repeatedly, when taken out of bed, +though she resisted at first, she dressed with natural free motions. +She always retracted promptly from pin pricks.</p> + +<p>Towards the end of the week she even complied at times with +a request to do some work, but on the same day she would remain +passive, with a look of disdain, or resist intensely when interfered +with, e.g., when an attempt was made to make her sit +down. She never soiled and never showed any catalepsy.</p> + +<p>2. Then the condition changed, inasmuch as the marked resistance +ceased entirely, and the mutism gave way first to slow and +low answers, and later to much freer speech, though the inactivity +improved only gradually. Thus at the examination on +February 19, though she was quite inactive, she answered some +questions, albeit in whispers and briefly. This was the case +when questioned about the year, month and date, which she gave +correctly, but she merely shook her head when asked how long +she had been here, why she was here, what was the matter with +her. Once she smiled appropriately. Later she became freer in +speech, with a more natural tone, although her answers continued +to be short. Not infrequently, when asked to calculate or to +write, she would not coperate, saying "This has nothing to do +with my getting well," or (later) "What has that got to do with +my going home?" or she would simply say she did not want to. +Improvement in her listlessness and inactivity was more gradual.</p> + +<p>The prevailing affective state was indefinite. She denied repeatedly +that she was depressed, though later she admitted once +being downhearted, yet it seems that even then her mood was not +so much one of sadness as of a slight resentment. On one occasion, +however, she showed some tears when asked about the baby. +She repeatedly expressed the wish to go home, but not in a plead<!-- Page 99 --><span class='pagenum'><a name="Page_99" id="Page_99">[99]</a></span>ing, +rather in a resentful, way, saying she would never be better +here, that the questions which were asked had nothing to do with +her going home, that she would be all right if she went home. +She never admitted that she had ever been sick enough to be +taken to a hospital, though she quite appreciated that there had +been something the matter with her head at home and in the hospital. +She stated, in answer to questions, that she had a peculiar +feeling in the head which she could not explain, that she could +not remember so well as formerly. Once she said, "I hear so +much around here that my head gets so full."</p> + +<p>When towards the end she was questioned about her condition, +i.e., the reason for her resistance, her mutism, and her refusal +of food, she said that then she "wanted to be left alone"; that +she did not eat "because she did not want food," and she also +spoke of not having had any interest.</p> + +<p>She was discharged on April 29, i.e., about ten weeks after +admission before she had become entirely free.</p></div> + +<p>The last case is interesting in that a depressive +onset to a deep stupor was observed in the Institute. +It was characterized by constant repetitions of a request +to be killed.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 15.</span>—<i>Meta S.</i> Age: 16. Admitted to the Psychiatric +Institute June 26, 1902.</p> + +<p><i>F. H.</i> The father was dead, and the mother living abroad. +Not much could be learned about them and the immediate family.</p> + +<p><i>P. H.</i> An aunt who gave the anamnesis had known the patient +only since she came to the United States, a year before admission. +After her arrival the patient at once went to work as a +servant. It was claimed that her employer liked her, but that she +was rather slow about the work. The only trouble known was +that she sometimes complained of indigestion. She went to see +her aunt about once every two weeks.</p> + +<p>Three weeks before admission, when the patient visited her +aunt, she seemed quieter than usual. Further, she spoke about +sending money home on the <i lang="de">Kaiser Wilhelm der Grosse</i>, which +was thought peculiar because she had no money, and on a walk<!-- Page 100 --><span class='pagenum'><a name="Page_100" id="Page_100">[100]</a></span> +through a cemetery said "I would like to be here too." At the +time this did not impress the aunt as very peculiar. The patient +continued to work until nine days before admission. The employer +then sent for the aunt and said the patient had been very +quiet for about two weeks, and that she now had become more +abnormal. She suddenly had begun to cry, said the police had +come, claimed, without foundation, that she had "stolen," and +kept repeating "I have done it, I will not do it again." The +aunt took her home with her. There she was quite dejected, +cried, spoke of killing herself (wanted to jump out of the window, +wanted to get a knife). On the whole, she said very little, but +when the aunt pressed her to say why she was so worried, she +said she had allowed men to kiss her and had taken money from +them. It is claimed that she never menstruated.</p> + +<p>After recovery the patient herself described the onset as follows: +Ever since she came to this country she had been homesick, +and felt especially lonesome for some months before admission. +She knew, however, of no precipitating cause, in spite of what +she had said to the aunt and what she said at first under observation. +She consistently denied that anything had happened with +young men. A short time before she left her place (she left +it nine days before admission) she could not work, began to accuse +herself of being a bad girl and of having stolen. Then +she was taken to the aunt's house. There she wanted to die.</p> + +<p><i>Under Observation:</i> 1. On admission the patient appeared depressed, +sat with downcast expression, looking up rarely. She +spoke in a low tone and slowly. But, in spite of delay, she answered +all questions, knew where she was and gave an account of +the place where she had worked. When questioned about trouble +with men, she claimed that a man who lived in the same house +where she worked had tried to make her "lie on the bed," but that +she refused; that later a man had assaulted her and had after +that repeatedly come to her room when she was alone. Yet when +asked whether she worried about this, she denied it.</p> + +<p>2. For eight days her condition was sometimes one of marked +reduction of activity, with preoccupation. She sat in a dejected +attitude, and had to be urged to do anything. Sometimes she +was very slow in greeting and slow in answering, and said very +little. But whenever spoken to she was apt to cry and this might<!-- Page 101 --><span class='pagenum'><a name="Page_101" id="Page_101">[101]</a></span> +lead to such distress that the reduction of activity was no longer +to be seen. Thus on June 28, when greeted, she began to cry +and say, "Oh, what have I done!—Oh, just cut my head off—Oh, +please what have I done—I have given my hand." (Tell me the +whole story.) Imploringly and with hands clasped: "No, I can't +do it—just cut my head off, please, please." (Why can you +not tell me?) "Oh, what have I done!" The imploring to cut +her head off was then several times repeated, and she could not +be made to answer orientation questions. On June 29 she became +agitated spontaneously and cried loudly, saying, "Oh, let me +go home and die with my father." She was then put to bed, and +when seen she could not be made to answer orientation questions. +But when asked whether she had seen the physician before, she +said, "I saw you yesterday." She could not be made, however, +to say how long she had been here, "I think a"—not finishing +the sentence. Although she would not answer further, she presently +began to say "Oh, cut my head off—oh, where is my papa +and mamma?" When told that her people were in Germany +and that she could go back to them, she said "I haven't any +money to pay it." Then she wanted to know if she was to pay +for her board and bed and said she could not do it.</p> + +<p>Again, on July 1, although she had been quite preoccupied, +inactive and silent, she began to say when greeted, "Oh, please +cut my head off." But she then answered some questions, said +she had not worked enough. On questioning, she explained it +was not that the work had been too much, but that she had been +nervous, had tried to work as much as the servant next door, +but could do only half as much, "Oh, I ought to have worked."</p> + +<p>Repeatedly on other occasions she begged, with distress, to +have her head cut off or to be killed. Frequently there were +statements of self-blame: she ought to have worked more, was +lazy or "I am not worthy"; or she said she had lied and stolen; +or again, "I have not paid for these beds and I cannot," or "I +am a bad girl."</p> + +<p>3. For a month she presented a more marked reduction of activity. +She sat about with a dejected look, often gazed in a preoccupied +manner, or she stood or walked around slowly. Sometimes +she had to be spoon-fed. At other times she ate slowly. +Toward the latter part of this period, a distinct tendency to<!-- Page 102 --><span class='pagenum'><a name="Page_102" id="Page_102">[102]</a></span> +catalepsy appeared. During this period, too, as a rule (though +not always), she would cry when spoken to. A few times she +would make some ineffectual motions when questioned, but she +scarcely ever spoke.</p> + +<p>4. Then followed a period again lasting about one month in +which the picture was at times one of still greater inactivity. She +would retain uncomfortable positions, allow flies to crawl over +her face. She presented resistance in the jaws, did not react +to pin pricks. She sometimes sat with eyes closed or, with an +immobile face, the eyes stared with little blinking. The catalepsy +was more decided. She often would not swallow solid food but +swallowed fluid. Again she held her saliva, sometimes drooled. +Once she held her urine and had to be catheterized. When +spoken to she once smiled at a joke, sometimes there was no +response, but as a rule there were tears or flushing of the face. +On the physical side, there were marked dermatographia and, +for a time, towards the end of the period, profuse sweating. +Throughout the stupor proper her temperature was between 99 +and 100 as a rule.</p> + +<p>5. The period which followed and which lasted about two +months was characterized, like the one just described, by marked +stupor symptoms, associated, however, with more resistance, +while the crying practically disappeared. On the other hand, a +number of plainly angry reactions were seen and, towards the +end, smiling and laughing. She lay in bed, on her back, staring, +allowing the flies to crawl over her face; retained uncomfortable +positions without correcting them, and her arms often showed a +decided tendency to catalepsy. Sometimes she soiled. She constantly +held saliva in her mouth, though she did not often drool. +She was totally mute, did not respond in any way except in the +manner to be presently indicated. She had to be tube-fed a +good part of the time, was quite resistive when an attempt was +made to open her mouth. When attended to by the nurse, she +was apt to make herself stiff. But as a rule, she was not resistive +to passive motions when tested. On a few occasions she had, as +was stated, marked angry outbursts. Thus on one occasion when +her temperature was taken she angrily pushed the nurse away +and then struggled vigorously. On another occasion, when the +bed-pan was put under her, she threw it away angrily and struck<!-- Page 103 --><span class='pagenum'><a name="Page_103" id="Page_103">[103]</a></span> +the nurse; once she did the same with the feeding tube. She +struck a patient, on another occasion, when the latter came to +her bed. On two occasions she suddenly threw herself headlong +on the floor. Towards the end of the period, when the blood-pressure +was taken, she smiled and then laughed out loud. She +could be made to smile again later.</p> + +<p>6. The last period, before the more definite improvement, lasted +about a month. She was inactive and slow, ate slowly (feeding +no longer necessary), and was mute. But she did not stare, was no +longer resistive, no longer held saliva. She appeared indifferent, +but could be made to smile quite readily when spoken to. +On one occasion she laughed out loud when a comical toy was +shown her, again was amused at a party. In the beginning of +the period she was once seen to cry a little when sitting by herself, +and at the same time wept a little when spoken to, but this +was now isolated. Towards the end of the period she spoke a +little, asked for paper and pencil and wrote: "Dear Mother.—I +only take up the pencil in order to write you a few lines. We +are all cheerful and in good health and hope that you are the +same and we congratulate you on your birthday 19th of December +that I have not written to you for a long time were in the same +..." (Translated.) This was written very slowly.</p> + +<p>On the day after this letter she was distinctly freer, talked a +little to the nurse and then improved rapidly. A week after +this, January 16, she is described as quite free in her talk and +activity, but when asked about the psychosis she merely shrugged +her shoulders. However, mere extensive retrospective accounts +were taken later.</p> + +<p>The retrospective accounts were obtained on January 24 and +March 13. As these two accounts do not seem to be fundamentally +different for the period of the psychosis, they may here +for the sake of brevity be combined.</p> + +<p>She remembered clearly going to the Observation Pavilion, +and feeling frightened, as she did not know where she was going +and what they were going to do with her. She knew when she +was in the Observation Pavilion and had a good recollection of +the place, also of the transfer to the hospital, the ward she came +to, who spoke to her, etc. She did not know what the place was +until the doctor told her a day or two after admission. Unfor<!-- Page 104 --><span class='pagenum'><a name="Page_104" id="Page_104">[104]</a></span>tunately +definite incidents were inquired into only for the first +part (July). But she remembered those clearly. She also +claimed to remember all visits which were made to her by her +friends, but it was not specifically determined whether there was +a period of less clear recollection or not. However, she remembered +the tube-feeding, which occurred only during the more +marked stupor. Her desire to be killed, to have her head cut +off, she recalled but claimed not to know why she wanted to be +killed. However, she remembered worrying about being bad, +about the fact that she could not "pay for the beds," etc.</p> + +<p>Her mutism and refusal of food she was unable to account +for. She could not talk, her "tongue would not move." As regards +ideas during the more stuporous period, she claimed that +(when quite inactive) she heard voices but did not recall what +they said. But she remembered having dreams at that time "of +fire," "of her dead father and of home."</p></div> + +<p>In a survey of thirty-six consecutive cases of +definite stupor, literal death ideas were found in all +but one case. They seem to be commonest during the +period immediately preceding the stupor, as all but +five of these cases spoke of death while the psychosis +was incubating. From this we may deduce that the +stupor reaction is consequent on ideas of death, or, +to put it more guardedly, that death ideas and +stupor are consecutive phenomena in the same fundamental +process. Two-thirds of these patients +interrupted the stupor symptoms to speak of death +or attempt suicide, which would lead us to suppose +that this intimate relationship still continued. One-quarter +gave a retrospective account of delusions of +being dead, being in Heaven, and so on. From this +we may suspect that in many cases there may be a +thought content, although the patient's mind may<!-- Page 105 --><span class='pagenum'><a name="Page_105" id="Page_105">[105]</a></span> +seem to be a complete blank. It is important to note +that when a retrospective account is gained, the +delusions are practically always of death or something +akin to it, such as being in prison, feeling +paralyzed, stiff, and so on.</p> + +<p>In the one case of the thirty-six who presented no +literal death ideas, the psychosis was characterized +essentially by apathy and mild confusion, a larval +stupor reaction. It began with a fear of fire, smelling +smoke and a conviction that her house would +burn down. It is surely not straining interpretation +to suggest that this phobia was analogous to a death +fear. When one considers the incompleteness of +anamneses not taken <i lang="la">ad hoc</i> (for these are largely +old cases) and that the rule in stupor is silence, the +consistence with which this content appears is +striking.</p> + +<p>To exemplify the form in which these delusional +thoughts occur we may cite the following: Henrietta +H. (Case 8) said, retrospectively, that she +thought she was dead, that she saw shadows of dead +friends laid out for burial, that she saw scenes from +Heaven and earth. Annie K. (Case 5) claimed to +have had the belief that she was going to die, and to +have had visions of her dead father and dead aunt, +who were calling her. She also thought that all the +family were dead and that she was in a cemetery. +Rosie K. (Case 11) said she had the idea that she +wanted to die and that she refused food for that +purpose, and during the stupor she sometimes held +her breath until she was cyanotic. Mary F. (Case<!-- Page 106 --><span class='pagenum'><a name="Page_106" id="Page_106">[106]</a></span> +3), before her stupor became profound, spoke of the +hereafter, of being in Calvary and in Heaven. In +this case, as well as in the above-mentioned Henrietta +H., we find, therefore, associated with "death" the +closely related idea of Heaven. Whether Calvary +merely referred to the cemetery (Mt. Calvary Cemetery) +or leads over to the motif of crucifixion, cannot +be decided. It is, however, clear that this latter +motif may be associated with that of death, as is +shown in Charlotte W. (Case 12), who, during intervals +when the inactivity lifted, spoke of having been +dead, of spirits having told her that she must die, of +having gone to Heaven, of God having told her that +she must die on the cross like Christ. But this patient +also showed in a second subperiod of her +stupor another content. She said: "It was like +water. I was going down." Or again, she spoke +of having gone "under the ground"; "I went down, +down in a coffin." She spoke of having gone down +"into a dark hole," "down, down, up, up"; again, of +having been "on a ship." We shall see in the further +course of our study that this type of content +occurs not at all infrequently.</p> + +<p><i>The internal relationship among the different +ideas associated with stupor:</i> Before we go any +further it may be advisable to examine the meaning +of such ideas when they arise in other settings than +those of the psychoses. If we consider these ideas +of death, Heaven, of going under ground, being in +water, in a boat, etc., we are impressed with the +similarity which they bear to certain mythological<!-- Page 107 --><span class='pagenum'><a name="Page_107" id="Page_107">[107]</a></span> +motifs. This is, of course, not the place to enter +into this topic more than briefly. We are here concerned +with a clinical study, and therefore, among +other tasks, with the interrelationship of symptoms, +but for that purpose it is necessary to point out how +these ideas seen in stupor can be shown to have, not +only a connection amongst each other, when viewed +as deep-seated human strivings, but also are closely +related to, or identical with, ideas found in mythology.</p> + +<p>To one's conscious mind death may be not only +the dreaded enemy who ends life, but also the friend +who brings relief from all conflict, strife and effort. +Death may, therefore, well express a shrinking from +adaptation and reality, and as such may symbolize +one of the most deep-seated yearnings of the human +soul. But from time immemorial man has associated +with this yearning another one, one which, +without the adaptation to reality being made, yet +includes a certain attempt at objectivation, the desire +for rebirth. We need not enter further into +possible symbols for death <i lang="la">per se</i>, but it is quite +necessary to speak briefly of the symbolic forms in +which the striving for rebirth has ever found expression. +The reader will find a large material collected +in various writings on mythology, for the psychological +interpretation of which reference may be +made to Jung's "Wandlungen und Symbole der +Libido" and Rank's "Mythos von der Geburt des +Helden." From them it appears how old are the +symbols for rebirth, and how they deal chiefly with<!-- Page 108 --><span class='pagenum'><a name="Page_108" id="Page_108">[108]</a></span> +water and earth, and the idea of being surrounded +by and enclosed in a small space. Thus we find a +sinking into the water of the sea, enclosure in something +which swims on or in the water, such as a casket, +or a basket, or a fish, or a boat; again, we find +descent into the earth. The striving for rebirth +might be assumed to have adopted these expressions +or symbols on account of the concrete way in which +the human mind knows birth to take place. The +tendency for concrete expression of abstract notions +causes the desire for another existence to appear, +first as a rebirth fantasy and then as a return to the +mother's body. One thinks of Job's cry, "Naked +came I from my mother's womb and naked shall I +return thither," as an example of the literal comparison +of death with birth. We need only refer to +the myths of Moses and the older one of Osiris, and +the many myths of the birth of the hero, to call to the +mind of the reader the examples which mythology +furnishes. There is probably not one of the ideas +expressed by these patients which cannot be duplicated +in myths. We have, therefore, a right to speak +of these ideas as "primitive," and to see in them, +not only deep-seated strivings of the human soul, but +to recognize in them an essential inner relationship. +It is especially this last fact to which at this point we +wish to call attention: that without any obvious connection +the fantasies of our forefathers recur in the +delusions of our stupor cases. We presume that in +each case they represent a fulfillment of a primitive +human demand. In one of our cases a vision of<!-- Page 109 --><span class='pagenum'><a name="Page_109" id="Page_109">[109]</a></span> +Heaven and a conscious longing to be there was followed +by a stupor. On recovery the patient compared +her condition to that of a butterfly just +hatched from a cocoon. No clearer simile of mental +rebirth could be given.</p> + +<p><i>Brief survey of the ideas associated with the +states preceding the stupor:</i> If we now return to +the study of the further occurrence of such ideas in +the cases described, we find motifs, similar to those +seen in the stupor, in the period which immediately +precedes the more definite stupor reaction. Indeed +we find the ideas there with greater regularity. In +Meta S. (Case 15) the stupor followed upon six days +with reduced activity and crying, with self-accusation, +but also with entreaties to be allowed to go +home and die with her father. At the very onset of +her breakdown, the desire for death had also occurred. +Anna G. (Case 1) expressed a wish to be +with her dead father, and, at the visit of a cousin, +she had a vision of the latter's dead mother. A second +attack of this same patient began with the idea +that the dead father was calling her. Maggie H. +(Case 14) saw dead bodies, and during outbursts of +greater anxiousness, she thought her husband was +going to die. In Caroline De S. (Case 2) the psychosis +began with a coarse excitement, with statements +about being killed, with entreaties to be shot, with +the idea of going to Heaven, again with frequent +calling out that she loved her father (who was dead +since her ninth year), while immediately before the +stupor the condition passed into a muttering state<!-- Page 110 --><span class='pagenum'><a name="Page_110" id="Page_110">[110]</a></span> +in which she spoke of being killed. Mary D. (Case +4) began by worrying over the father's death (dead +four years before), had visions of the latter beckoning, +and she heard voices saying, "You will be +dead." Mary F. (Case 3) had a vision of "a person +in white," and thought she was going to die. In +Henrietta H. (Case 8) the stupor was preceded by +nine days of elation, with ideas of shooting and of +war, but this had commenced with hearing voices +of dead friends, and with ideas that somebody +wanted to kill her family. In the case of Annie K. +(Case 5) we find before the stupor a state of worry, +with reduction of activity, and then a vision of the +dead father coming for her. In Charlotte W. (Case +12) the stupor was preceded by a state of preoccupation, +with distress and entreaties to be saved, +partly from being put into a big hole, partly from +the electric chair.</p> + +<p>We see, therefore, in the introductory phase of the +stupor in almost every case ideas of death, and in +one case an idea belonging to the rebirth motif, +namely, of being put into a dark hole. In well-observed +cases apparently we do not find the stupor +reaction without either coincident or preceding ideas +of death.</p> + +<p><i>Relation of death and rebirth ideas with affect:</i> +In order to investigate the relation of these ideas to +the affective condition associated with them, it will +be necessary to study not only the abstract ideational +content but the special formulation in which +the content appears. In looking over the enumera<!-- Page 111 --><span class='pagenum'><a name="Page_111" id="Page_111">[111]</a></span>tion +of the ideas given above, it is very clear that +these formulations differed considerably from each +other. A priori we would say that it is, psychologically, +a very different matter whether a person expresses +a desire to die, or has the idea that he will +die or is dead, or says he will be killed. We associate +the first with sadness, the last with fear, while +our daily experience does not give us so much information +about the delusion of being dead. A vivid expectation +of death is usually accompanied by either +fear or resignation.</p> + +<p>In studying the ideas which we obtained from the +patients by retrospective account after the psychosis +or from a retrospective account during freer intervals, +it is, of course, difficult, especially in the former +case, to say whether they have persisted for any +length of time. Probably in most instances this was +not the case, and we must remember in this connection +that in a considerable number of cases the patients +recalled no ideas whatever.</p> + +<p>Of the five cases which we may consider as types, +Henrietta H. (Case 8) and Mary F. (Case 3) formulated +their ideas simply as <em>accepted facts</em> during the +stupor. The former thought she was dead, saw dead +friends laid out for burial, and scenes from Heaven +and earth. The latter spoke, during the stupor, of +being in "Calvary," "the hereafter," or "Heaven." +We have seen that these stupors were essentially +affectless reactions and we can therefore say that, +so far as these two cases are concerned, the ideas +thus formulated were not associated with any affect.</p> + +<p><!-- Page 112 --><span class='pagenum'><a name="Page_112" id="Page_112">[112]</a></span> +Annie K. (Case 5) was a little different. During +the stupor she made a few utterances about priests +and "all being dead," and retrospectively she said +that she had thought she was in the cemetery, was +going to die, that she had repeated visions of her +dead father and once of a dead aunt calling her; that +she had thought her family were dead, again that +the baby (who was born just before the psychosis) +was dead. The formulation is therefore less one of +fact than of something prospective, something which +is coming—the <em>going</em> to die. Correlated, perhaps, +with this anticipation were slight modifications of +the usual apathy. The patient often had an expression +of bewilderment. She was also more in contact +with her environment than many stuporous patients +are, for, not infrequently, she would look at what was +going on about her. Her apathy was also broken +into in a marked degree by her active resistiveness, +which was sometimes accompanied by plain anger. +It seems that a prospect of death may occur in other +instances in a totally affectless state. We have recently +seen it in a partial stupor during which the +patient spoke and had this persistent idea in a setting +of complete apathy. We see here also, as in +one of the former cases, the idea of other members +of the family being dead.</p> + +<p>More difficult and deserving more discussion are +the two remaining cases, Rosie K. (Case 11) and +Charlotte W. (Case 12). Rosie K. showed a peculiar +condition. She said, retrospectively, that during +the stupor she had the desire to die and that for this<!-- Page 113 --><span class='pagenum'><a name="Page_113" id="Page_113">[113]</a></span> +purpose she refused food. Moreover, she was repeatedly +seen to hold her breath with great insistence, +though without affect. This is worth noting. +We are in the habit in psychiatry to say in a case +like this that "there is no affect," and yet there is +evidently a considerable "push" behind the action. +We shall later have to mention in detail a patient +whom we regard as belonging in the group of stupor +reactions, and who for a time made insistent, impulsive +and most determined suicidal attempts, yet +with a peculiar blank affectless facial expression and +with shouting which was more like that of a huckster +than one in despair. Here also, then, there was a +great deal of "push," yet not associated with that +which we call in psychiatry an affect. In both instances +we see acts which we are in the habit of +calling for this very reason "impulsive." Evidently +this is an important psychological problem which +leads directly into the psychology of affects and +deserves further study. For the present it is +enough to say that with a different formulation—that +of wishing to die—there is here not, as in other +psychoses, a definite affect, such as sadness or despair, +but no affect, though there may be a good +deal of "push" or impulsiveness.</p> + +<p>The case of Charlotte W. (Case 12) is a complicated +one, for she had short stupor periods with +inactivity, catalepsy, resistiveness, etc., which were +interrupted with freer spells. A careful analysis of +her history has been instructive and justifies a detailed +and lengthy discussion. For the purpose in<!-- Page 114 --><span class='pagenum'><a name="Page_114" id="Page_114">[114]</a></span> +hand it is necessary to separate the ideas which she +expressed only in the freer periods (during which +some affect was at times seen) into those which referred +retrospectively to the stupor phase and those +which referred to the freer periods themselves.</p> + +<p>We find that the time during which more marked +stupor symptoms appeared may be divided into two +subperiods. This is not possible in regard to the +manifestations belonging to the general reaction, +which seem to have undergone no decided change, +but only in regard to the form of the delusions. In +this we find there was a first phase in which ideas of +death and Heaven (and crucifixion) occurred, and a +second phase in which ideas were present which belonged +essentially to the motif of rebirth but which +were also associated with ideas of Heaven.</p> + +<p>About the first subperiod she said: "I was mesmerized," +or "I thought I was dead," or "God told +me I must die on the cross as He did," or "I went +to Heaven in spirit." About the second subperiod +she said retrospectively: "We were on a ship and +we were 'most drowned." "It was like water, I was +going down, down." She said she saw the people +of the hospital and "it was all full of water"; or +again, "I went under the ground and it was full of +water and every one got drowned and a sharp thing +struck me"; or "I was out on a ship and I went +down in a coffin." She claimed she put up her arms +to save the ship. Again she spoke of having gone +into a dark hole. She also said: "One day I was +in a coffin—that was the day I went to Heaven."<!-- Page 115 --><span class='pagenum'><a name="Page_115" id="Page_115">[115]</a></span> +"They used to be coming up and down, that was the +day I was coming up in a ship or going down." And +when shown her picture in a cataleptic attitude, she +said: "That must have been when I went to Heaven—everything +seemed strange, things seemed to go +up and down—I guess that was the day I thought I +was on the ship." Finally she also said: "Once I +heard beautiful music—I was waiting for the last +trumpet—I was afraid to move."</p> + +<p>We see, therefore, that most of the ideas which she +thus spoke of retrospectively as having been in her +mind during this stupor, and which belonged both +to the death and the rebirth motifs were formulated +as facts (as in the cases of Henrietta H. and Mary +F. above mentioned). It was, moreover, a condition +which was accepted without protest. Here again an +affect was not associated with these ideas, and when +the patient was asked whether she had not been +frightened, she said herself, "No, I just lay there." +The idea that God told her she would have to die on +the cross like Christ, is, in the religious form, like +the beckoning of the father with Henrietta H. The +only exception to the claim that the ideas were +formulated as facts and accepted as inevitable seems +to be the statement that she held up her arms to save +the ship. This would seem to be, in contradistinction +to the rest, a formulation as a more dangerous situation. +However, this was isolated and we can do no +more than to determine main tendencies. We must +expect, especially in such variable conditions as we +see in this patient, to find occasional inconsistencies.</p> + +<p><!-- Page 116 --><span class='pagenum'><a name="Page_116" id="Page_116">[116]</a></span> +In summing up we may say, therefore, that so far +as the stupor itself is concerned, the ideas are +formulated as a rule:—</p> + +<ol> +<li>As accepted facts (being dead, being in a ship, +etc.).</li> +<li>As accepted prospects (going to die).</li> +<li>As the wish to die.</li> +</ol> + +<p>In the first two types the ideas are not associated +with affect; in the third, though not associated with +affect, they are combined with "impulsive" suicidal +attempts.</p> + +<p>In order not to tear apart the analysis of Charlotte +W. (Case 12) too much, we may begin our study +of the intervals and the conditions preceding the +stupors with the ideas which this patient produced +when the stupor lifted somewhat. We shall see that +the ideas are closely related to those mentioned +above but formulated differently.</p> + +<p>It will be remembered that Charlotte W. had freer +intervals when she responded and was less constrained +generally, and that it was in these that the +ideas above mentioned were gathered. Since they +were spoken of in the past tense, we regarded them +as not belonging to the actual situation but to the +more stuporous period. It seems tempting now to see +whether the ideas which are expressed in the present +tense are different in character, the general aim being +to discover whether any tendencies can be found +in regard to the types and formulations of delusions +associated with different clinical pictures. We see<!-- Page 117 --><span class='pagenum'><a name="Page_117" id="Page_117">[117]</a></span> +that on November 2 the patient, when speaking much +more freely than before, said she had felt that she +was mesmerized, was dead, and that she had gone +to Heaven, ideas which we have taken up above as +belonging to the stupor period. In addition to +speaking much more freely in these intervals, she +showed at times some affect. Thus to the physician +whom she called Christ, she said, with tears, "You +came to tell me what was right," or again with +tears, "I will have to be crucified," or she spoke in +a depressed manner about her children, "I can't see +them any more," "I must stay here till I die," and +she spoke of having to stay here till she picked her +eyes and her brains out; or she claimed her husband +or her children had to pick them out. Once she exclaimed +crossly and with tears, "You are trying to +keep me from Jim" (husband). Another idea was +not plainly associated with affect. She said she +had come back from Heaven, "The wedding ring +kept me on Earth." What strikes one about these +formulations is that they are, on the one hand, sometimes +associated with an affect, and that, on the +other hand, they refer much more to her actual life, +her marriage, her husband, her children. At least +this seems to be a definite tendency. A similar tendency +may be seen later: On November 4, while generally +stuporous, this suddenly lifted for a short +time, and with feeble voice she uttered some depressive +ideas. She said she wanted to go to a convent, +that it would be better if she were dead, that she<!-- Page 118 --><span class='pagenum'><a name="Page_118" id="Page_118">[118]</a></span> +could not do anything right. On November 5 and +6 she said she wanted to go to Jim in Heaven (in +contradistinction to the retrospective statements +that she had gone to Heaven), and on the 8th, when +she had the idea of being in a boat, she said with +some anger that she had wanted to get her husband +into the boat, but that the doctor kept him out and +took his place.</p> + +<p>Later there were at times ideas expressed which +referred to the actual situation or essentially depressive +ideas in a depressive setting. Thus on December +3 she appeared sad, retarded, and spoke of not +being able to see her children and that she had done +wrong in buying carbolic acid (her suicidal attempt). +So far as this case is concerned, therefore, we do +find a distinct tendency for the ideas which refer +to the more stuporous condition to differ from those +which refer to the actual situation in the freer intervals, +a difference which we may formulate by +saying that, though primitive ideas are expressed, +the tendency seems to be to connect them more with +actual life, or that the primitive character is lost +and the ideas take on a more depressive character +with a depressive affect. A few words should be +added in regard to the peculiar ideas that she or her +husband or her child had to pick out her eyes (or +her brain). It is probable that this idea belongs +to the motif of sacrifice (the <i lang="de">Opfer motiv</i> of Jung) +into which we need not enter further, except to say +that in this instance it was plainly connected, like<!-- Page 119 --><span class='pagenum'><a name="Page_119" id="Page_119">[119]</a></span> +some of the other ideas just spoken of, with the real +situation of her life (husband, children).</p> + +<p>It will now be necessary to examine the earlier +state of Charlotte W. The condition preceding the +stupor set in with pre-occupation, slow talk and +slight distress. During the time she asked to be +given one more chance, she said to the husband she +would not see him again. Then followed a day +when she was very slow and with moaning said she +was going to be put into a dark hole. Again on the +next, when speaking more freely, she begged to be +saved from the electric chair, and also said, "Don't +kill me, make me true to my husband," etc. [Again +the connection with real life!] We see here the +idea of death and especially an idea pertaining to +the rebirth motif in a setting of distress and slowness, +as an introduction to the stupor which had in it +both of these motifs. We must leave it undecided +whether it is accidental or not that the distress was +associated with more slowness (i.e., more marked +stupor traits) when she spoke of the dark hole than +when she spoke of the electric chair or death. But +what interests us is that distress and reduction of +activity (not sadness and reduction of activity, +which seems as a rule to have a different content) +are here associated with ideas seen in stupor but +formulated as prospective dangers. We know from +experience that we often find associated with the +fear of dying considerable freedom of action, and +we see at times in involution states conditions with +freedom of motion and marked anxiety, whereas the<!-- Page 120 --><span class='pagenum'><a name="Page_120" id="Page_120">[120]</a></span> +ideas seem to belong to the motif of rebirth; e.g., +the fear of being boiled in a tank.<a name="FNanchor_A_7" id="FNanchor_A_7"></a><a href="#Footnote_A_7" class="fnanchor">[A]</a></p> + +<p>In this connection, however, two other cases +should be taken up which show a condition which reminds +one somewhat of that we have just discussed, +but in which the rebirth motif appeared, not as prospective, +but, as in the stupor, as an actual situation. +At the same time this situation was not passively +accepted but conceived as a dangerous situation. +The significant phenomenon in both these conditions +was that there was not anxiety with freedom of action +but a bewildered uneasiness with marked reduction +of activity.</p> + +<p>The first case is that of Johanna S., whose history +has been given in this chapter. It will be observed +that in the fourth period the patient presented +two days of typical stupor with the idea that +she was dead. We are familiar with this. But this +was followed by several days of bewildered uneasiness +and slow restlessness, with ideas that she was +at the bottom of the deep, dark water and for a time +she made attempts at stepping out of the water or +swimming motions. All of this was in a general +setting of reduction of activity with bewildered uneasiness. +In the ideas about being at the bottom +of the deep, dark water, we recognize again the re<!-- Page 121 --><span class='pagenum'><a name="Page_121" id="Page_121">[121]</a></span>birth +motif, yet the situation is not accepted but +attempts are made by the patient to save herself, +i.e., the attitude is one in which the situation is taken +to be one of danger. It is interesting in this connection +that immediately following this state there +was one day of ordinary retardation with sadness +and ideas of being bad and sick. That is, when the +element of anxiety, the uneasiness, disappeared and +sadness supervened, the rebirth ideas were no +longer present.</p> + +<p>In Mary C. (See <a href="#ChapII_Case7">Chapter II, Case 7</a>) we have, unfortunately, +not a direct observation, but we have, +at any rate, a description from the Observation Pavilion +which seems so plain that we should be justified +in using it here. The condition we refer to is +described as a dazed uneasiness, with ideas of being +shut up in a ship, of the ship being closed up so that +no one could get out, of the boat having gone down, +of the people turning up. We should add here that +the condition was not followed by a typical stupor. +Essentially it was a retardation, in which only on +one occasion was a definite akinesis observed. During +this phase she soiled her bed. Perhaps the persistent +complaint of inability to take in the environment +belonged also more to the retardation of stupor +than to that of depression. We have again, therefore, +in this initial phase, a similar situation, +namely, ideas belonging essentially to the rebirth +motif, formulated as of a threatening character if +not as actually dangerous.</p> + +<p>We can say, therefore, that what characterizes<!-- Page 122 --><span class='pagenum'><a name="Page_122" id="Page_122">[122]</a></span> +these three cases, and brings them together, is the +fact that all three had ideas belonging to the rebirth +motif, but formulated as dangerous situations. Associated +with this there was not a typical anxiety +with the relative freedom of activity belonging to +this state, but an anxiety or distress or uneasiness +with traits of stupor reaction, namely, slow movements, +lack of contact with the environment, and a +dazed facial expression. It would seem that these +facts could scarcely be accidental but that they +must have a deeper significance. As a discussion +of this belongs, however, more into the psychological +part of this study, we shall defer it for the present, +and be satisfied with pointing out here the clinical +facts of observation.</p> + +<p>In brief, then, our findings as to the ideational +content of the benign stupor are as follows: From +the utterances during the incubation period of the +psychosis, from the ideas expressed in interruptions +of the deep stupor, as well as from the memories +of recovered patients, we find an extraordinary paucity +and uniformity of autistic thoughts. They are +concerned with death, often as a plain delusion of +being no longer alive, or with the closely related +fancy of rebirth. The rule is a setting of apathy +for these ideas, but when they are formulated so as +to connect them with the real life and problems of +the patient, or when rebirth is represented as a +dangerous situation, some affect, usually one of distress, +may appear.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> Kirby, <i lang="la">loc. cit.</i>, pointed out that stupor showed resemblance to +feigned death in animals, that the reaction suggested a shrinking +from life and that ideas of death were common.</p></div> + +<div class="footnote"><p><a name="Footnote_A_7" id="Footnote_A_7"></a><a href="#FNanchor_A_7"><span class="label">[A]</span></a> We may mention that since this study was made we risked a +prediction of stupor, which events justified, in the case of a patient +who showed expectation of death without affect. Such opportunities +are rare, however, since we usually do not see these cases till +the stupor symptoms are manifest. It would be unsafe to dogmatize +on the basis of such meager material.</p></div> +</div> + +<p><!-- Page 123 --><span class='pagenum'><a name="Page_123" id="Page_123">[123]</a></span></p> + +<h2>CHAPTER VI<br /> + +<span class="sm">AFFECT</span></h2> + +<p>The most constant and significant symptom in the +stupor reaction is the change in affect. This extends +from mere quietness in the mildest phases of +the disease through the stage of indifference where +apathy replaces the normal reactions of the personality, +to the final condition of complete inactivity +in the vegetative stupor where all mental life seems +to have ceased. It seems as though there were, as +a pathognomonic sign of the morbid process, a lack +of energy and loss of the normal <i lang="fr">lan vital</i>.</p> + +<p>We may say, in fact, that the establishment of a +specific type of emotional change is justification for +classifying all milder stupor reactions with the deep +stupors. In other words, our reason for the enlargement +of the stupor group to include all apathetic +reactions (except those of dementia prcox) +is the belief that this dulling of the emotional response +is as specific a type of emotional change as +is anxiety, depression or elation. Perhaps it would +be more accurate to say that this clinical group is +founded on the symptom complex which is built +around apathy. There is never any resemblance +between apathy and the mood of elation or anxiety.<!-- Page 124 --><span class='pagenum'><a name="Page_124" id="Page_124">[124]</a></span> +A discrimination from depression is the only differentiation +worth discussion.</p> + +<p>The first point that should be made is that there +is a difference between marked depression and the +mood of stupor. In the former we get a retardation +with a feeling of blocking, rather than of an absence +of energy. The expression of the patient is one +of dejection, not of vacancy, which bespeaks a mood +of sadness, even when the patient is so retarded as +to be mute and therefore incapable of describing his +emotions. Running through all the stages of stupor, +however, there is an emptiness, an indifference that +is in striking contrast to the positive pain that is felt +or expressed by the depressed patient. It may be +objected, of course, that this apathy really represents +the final stage in the emotional blocking of +the depressed individual, but the development of +stupor and recovery from it shows an entirely different +type of process. A deep depression recovers +by changing the point of view from a feeling of unworthiness +and self-blame to one of normality. The +stuporous case, on the other hand, evidences merely +less and less indifference, and more and more interest +in his environment and in himself as he gets +well.</p> + +<p>The associated symptoms are no less dissimilar. +The difficulty in thinking which troubles the depressed +patient is slight in proportion to his emotional +gloom, and he feels himself to be much more +incompetent intellectually than examination proves +him to be. On the other hand, in the stupor reac<!-- Page 125 --><span class='pagenum'><a name="Page_125" id="Page_125">[125]</a></span>tion +we find that the thinking disorder runs hand +in hand with the apathy and that the intellectual +capacity of the patient is really markedly interfered +with, as can be shown by more or less objective tests. +A mere slowing of thought processes accompanied +by subjective feeling of effort is the limit reached +in true depression, while it is merely the beginning +of the intellectual disorder in stupor, for one meets +with retardation symptoms only in the partial stupors. +The slowing in these cases seems to represent +an early stage of the intellectual disturbance which +reaches its acme in the mental vacuity and complete +incompetence of the deep stupor, just as slow +movements in the partial stupors seem to represent +a diluted inactivity reaction. This actual thinking +disorder is not present in those forms of manic-depressive +insanity which are characterized by elation, +anxiety or depression but is seen only in stupors, +occasionally in absorbed manic states (manic +stupor) and sometimes in perplexity states. The +psychological mechanisms of this last group are +probably analogous to those of stupor, but this is +not the place for a discussion of this topic.</p> + +<p>Another associated symptom whose manifestations +differ in depression and stupor is that of unreality. +In the former there is frequently a feeling +of unreality that is purely subjective, whereas the +stupor case does not usually complain of this but +does exhibit a difficulty in grasping the nature of +his environment, which the typical depressive case +never has.</p> + +<p><!-- Page 126 --><span class='pagenum'><a name="Page_126" id="Page_126">[126]</a></span></p><p>The occurrence of other mood reactions than +apathy in the same patient is also characteristic. +Manic states (usually hypomanic) frequently occur +during the phase of recovery from the stupor. This +is an unusual, although not unknown, phenomenon +in recovery from severe retarded depressions. The +circular cases who swing from depression to elation +usually show the milder types of depressive reaction +which would never be confused with stupor. On +the other hand, deep stupors very frequently are +terminated by manic reactions, and if not by such +means, recovery seems to occur merely in virtue of +a gradual attenuation of the stupor symptoms. +Rarely do we see a change to depression or anxiety +heralding improvement. This tendency of the stupor +reaction to remain pure or change to hypomania +is a peculiarity which seems to put stupor in a class +by itself among the manic-depressive reactions, as +all the other mood reactions frequently change from +one to the other.</p> + +<p>Although apathy is the central pathognomonic +symptom of stupor conditions, there are other mood +anomalies to be noted. One of these is the tendency +for inconsistency in, as well as reduction of, the expression +of emotion. For instance, in the states +where one would expect anxiety during the onset +of stupor or in its interruptions, manifestation of +this anxiety is often reduced to an expression of +dazed bewilderment. In the anxiety states associated +with stupor one does not meet with the restlessness +and expressions of fear which would be ex<!-- Page 127 --><span class='pagenum'><a name="Page_127" id="Page_127">[127]</a></span>pected. +Quite similarly, when a manic tendency is +present, it occurs either in little bursts of isolated +symptoms of elation (such as smiling or episodic +pranks), or some of the evidences of elation which +we would expect are missing. For instance, Johanna +S. (Case 13) terminated her stupor with a +hypomanic state which was natural except for her +always wearing an expressionless face. Sometimes +laughter occurs alone and gives the impression of a +shallow affect, raising a suspicion of dementia prcox. +In fact, such evidences of affect as do appear +in the course of the stupor are apt to be isolated, +queer and "dissociated." It does not seem as if the +whole personality reacted in the emotion as it does +in the other forms of manic-depressive insanity. +For example, we may think of the resistiveness +which is so frequently present when the patient +seems in other respects to be psychically dead. One +may recall the case of Meta S. (Case 15), who, otherwise +inert, was occasionally seen with tears or smiles. +Anna G. (Case 1), too, was often seen smiling or +weeping. It was noted once of Charlotte W. (Case +12) that she ceased answering questions and remained +immobile with fixed gaze, but when some +mention was made of her going home she flushed +and tears ran down her cheeks, although no change +in the fixedness of her attitude or facial expression +was seen. When Johanna S. was visited by her +daughter and was lying motionless in bed, she +slowly extended her hands, apparently tried to +speak, and then her eyes filled with tears. Two days<!-- Page 128 --><span class='pagenum'><a name="Page_128" id="Page_128">[128]</a></span> +later, at the end of an interview when she had made +a few replies, she settled down into her usual inactivity +and, when further urged to answer, her eyes +filled with tears. Similarly, too, in fairly deep stupor +pin pricking may result in flushing, in tears or +an increased pulse rate without the patient giving +any other evidence of the stimulus being felt. These +examples seem to show a larval effort at normal human +response which, failing of complete expression, +appeared as single isolated features of emotion suggesting +true dissociation. We should also in this +connection bear in mind the impulsive suicidal acts +which occur either as unexpectedly as the impulsiveness +in a true dementia prcox patient, or in a setting +of coarse animal-like excitement that seems +quite unrelated to the personality. One is reminded +of the patient who made suicidal attempts during +the period when she shouted like a huckster, giving +no evidence whatever by her expression or the tone +of her voice of feeling anxiety, sorrow or any other +normal emotion.</p> + +<p>All these queer and larval affective reactions remind +one strongly of dementia prcox. The resemblance +of the benign stupor to certain dementia prcox +types is not merely a matter of identity with +catatonic features (catalepsy, negativism). In +these anomalous mood reactions it seems as if there +were a definite dissociation of affect, and so there is. +How then can we differentiate these emotional symptoms +from the "dissociation of affect" which is regarded +as a cardinal symptom of dementia prcox?<!-- Page 129 --><span class='pagenum'><a name="Page_129" id="Page_129">[129]</a></span> +The answer is that this term is used too loosely as +applied to the latter psychosis. It is a particular +type of dissociation which is significant of the schizophrenic +reaction, for in it there is an acceptance +of what should be painful ideas evidenced either by +incomplete manifestations of anxiety or depression +or actually by smiling. We never see in dementia +prcox the reverse—a painful interpretation of +what would normally be pleasant. It is the pleasurable +interpretation of what is really unpleasant +that gives the impression of queerness in the mood +of these deteriorating or chronic cases. In stupor, +on the other hand, although this dissociation takes +place, the mood is never inappropriate, merely incomplete +in that all the components or the full expression +of the normal reaction are not seen.</p> + +<p>Our description of the mood reactions in stupor +would be incomplete if we omitted to mention the +occasional appearance of an emotional attitude not +unlike that seen in many cases of involution melancholia, +which reminds one in turn of the reactions +of a spoiled child. The commonest of these manifestations +is resistiveness that may occur when an +examination is attempted, feeding is suggested, or a +sanitary routine insisted upon. One also meets +with resentfulness. One patient, who frequently +showed this reaction, explained it retrospectively by +saying that she wanted to be left alone. Quite analogous +to this is sulkiness that occasionally appears. +Then we have, particularly as recovery begins, other +childish tricks, such as flippancy in answering ques<!-- Page 130 --><span class='pagenum'><a name="Page_130" id="Page_130">[130]</a></span>tions +or the playing of pranks. Such tendencies +naturally lead over to frank hypomanic behavior.</p> + +<p>Finally, a peculiar characteristic of the stupor +apathy must be mentioned. This is its tendency to +interruptions, when the patient may return to life, +as it were, for a few moments and then relapse. +Such episodes occur mainly in milder cases or towards +the end of long, deep stupors. It is interesting +that the occasion for such reappearance of affect is +frequently obvious. We usually observe them in response +to some special stimulus, particularly something +that seems to revive a normal interest. Visits +of relatives are particularly common as such stimuli, +in fact recovery can often be traced to the appearance +of a husband, mother or daughter. It is also +important to recognize that with this revived interest, +other clinical changes may be manifest, that the +thinking disorder may, for instance, be temporarily +lifted. Helen M., for example, when visited by her +mother was so far awakened as to take note of her +environment, and remembered these visits after recovery +like oases in the blank emptiness of her stupor. +She further remembered that definite ideas +were at such a time in her mind that ordinarily was +vacant. She then had delusions of being electrocuted.</p> + +<p>In summary, then, we may say that the <i lang="la">sine qua +non</i> of the stupor reaction is apathy in all gradations, +and that this apathy is as distinct a mood +change as is elation, sorrow or anxiety. Incidental +to this loss of affect there is a dissociation of emo<!-- Page 131 --><span class='pagenum'><a name="Page_131" id="Page_131">[131]</a></span>tional +response whereby isolated expressions of +mood appear without the harmonious coperation of +the whole personality which seems to be dead. +Thirdly, there tends to be associated with the stupor +reaction a tendency to childish behavior. Finally, +the apathy and accompanying stupor symptoms may +be suddenly and momentarily interrupted. An explanation +of these apparently anomalous phenomena +will be attempted in the chapter on Psychology of +the Stupor Reaction.</p> + +<p><!-- Page 132 --><span class='pagenum'><a name="Page_132" id="Page_132">[132]</a></span></p> + +<h2>CHAPTER VII<br /> + +<span class="sm">INACTIVITY, NEGATIVISM AND CATALEPSY</span></h2> + +<p><b>1. Inactivity.</b> We must now turn our attention to +the other cardinal symptoms of the stupor reaction, +and quite the most important one of these is the +inactivity. It is convenient to include under this +heading both the reduction of bodily movement and +the diminution or absence of speech. This inactivity +is, of course, related to the apathy which we have +just been discussing, in fact it is one of the evidences +of the loss of emotion. We presume that a patient +is apathetic when there is no expression in the face +and when he does not respond to external stimuli, +whether these be physical or verbal, by movement +or by word.</p> + +<p>Bodily inactivity is present in all degrees, and in +some forty consecutive cases was recognizable in +every one. In its most extreme form there is complete +flaccidity of all the voluntary muscles, and +relaxation of some sphincters. As a result of +the latter we see wetting, soiling and drooling. +Even those reflexes which are only partially under +voluntary control, like those of blinking and swallowing, +may be in abeyance; for instance, saliva may +collect in the mouth because it is not swallowed, and<!-- Page 133 --><span class='pagenum'><a name="Page_133" id="Page_133">[133]</a></span> +tube-feeding is frequently necessary on account of +the failure of the patient to swallow anything that is +put into his mouth. The eyes may remain open for +such long periods of time that the conjunctiva and +sclera may become quite dry and ulcerate. In these +extreme cases there is, of course, no response to +verbal commands. What is more striking, no reaction +appears to pin pricks, so that it seems as if consciousness +of pain were lost.</p> + +<p>This deep torpor does not usually persist indefinitely. +The commonest evidence of some form of +consciousness persisting is probably to be seen in +blinking when the eye is threatened or the sclera or +cornea actually touched. A very large number of +patients, when otherwise quite inactive, showed considerable +response in their muscular resistiveness, +the phenomena of which will be discussed shortly. +The relaxation of the sphincters is apt to persist +even after control of the rest of the body is exercised +to the point of permitting the patient to stand or +walk about.</p> + +<p>The first phase of obvious conscious control is +seen in those patients who will retain a sitting posture +in bed or in a chair. The next stage is reached +where the stuporous case can be stood upon his feet +but cannot be induced to walk. The next degree is +that of walking only when pushed or commanded. +Finally spontaneous movement is observed in which +the inactivity is evidenced merely by a great slowness.</p> + +<p>No correlation can be established between restric<!-- Page 134 --><span class='pagenum'><a name="Page_134" id="Page_134">[134]</a></span>tions +of speech and motion other than that present +in the extremes. With complete inactivity there is almost +always consistent mutism, and perfect freedom +of speech does not, as a rule, appear until the movements +are free. In between these extremes all variations +are possible, even the deepest stupors are +occasionally interrupted by one or two words; for +instance, a patient may remain comatose, as it were, +and absolutely mute for six months, then to every +one's surprise say one or two words and relapse into +a year of silence. Again one sees cases where movements +have become fairly free and yet the patient +says nothing. This is another example of that inconsistency +in reaction which we have already noted +in connection with the mood or affect.</p> + +<p>In so far as inactivity is merely an expression of +apathy, its causation will be considered in connection +with the psychology of the stupor reaction as a +whole. In so far as there may be specific factors, +however, it may be of interest to consider what information +the patients themselves give us from time +to time as to what determined their inactivity. It +is really surprising how frequently something can +be gained either from careful notes taken during the +stupor or from the retrospective accounts of the +psychotic experiences. Of course when one considers +the degree of amnesia which is usually present +and the extent of the intellectual defect in general, +it becomes obvious that one cannot think of getting +anything like a complete explanation of the behavior +of any given case. Nevertheless this material is<!-- Page 135 --><span class='pagenum'><a name="Page_135" id="Page_135">[135]</a></span> +quite suggestive in the mass; it gives one some idea +of the mental state as a whole.</p> + +<p>Among 40 cases, 27 offered some explanation +either during or following the psychosis. Of these, +20 spoke of feeling dead, numb or drugged, or feeling +as if paralyzed or having lockjaw. This group, +just half of all the cases, apparently ascribed their +disability to something which seemed physical. +One might call them somatopsychic cases. The +other 7 gave more allopsychic explanations: 3 attributed +their inactivity to outside influence; 3 more +said they were afraid (one of these because she imagined +herself to be in prison), which is analogous to +the outside influence; the 7th case thought she would +injure people if she moved.</p> + +<p>The following are some examples of the statements +of the somatopsychic group: Laura A.: "I +can't move," and retrospectively, "My arms were +stiff." Bridget B. claimed retrospectively that she +felt dead or drugged, that her limbs were lifeless, +she felt as if she had lockjaw. Johanna B. remembered +being pricked with a pin on several occasions +but claimed that she did not feel the pain at any +time. This suggests a definitely hysterical mechanism. +Anna L. (Case 16) said retrospectively that +she felt as if she were dead, although walking +around, and also that she thought she was a ghost +and not supposed to speak. Anna M. said she had +tried to speak but everything stuck in her throat. +Alice R. said that she had no energy, did not want to +talk. Meta S. (Case 15) claimed that while stupor<!-- Page 136 --><span class='pagenum'><a name="Page_136" id="Page_136">[136]</a></span>ous +her tongue would not move. Isabella M. in intervals +claimed that during the stuporous periods +she felt as if dead and said retrospectively when +the whole psychosis was over that it was "an effort +to speak." Johanna S. (Case 13), while stuporous +when pressed with questions would say: "I can't +think," "I don't know," "I am twisted." When +food was offered her she protested, "I am dead." +Charlotte W. (Case 12), in reviewing her case, said: +"I was mesmerized," "I thought I was dead." +Anna G. (Case 1), in retrospect said: "I don't think +I could speak," again "I made no effort," or "I did +not care to speak." Henrietta H. (Case 8) said, "I +lost speech." She claimed that she did not move +because she was tired and had a numb feeling. +Mary C. (Case 7) said that her tongue had been thick +and that she felt dull. Rose Sch. (Case 6) said during +the psychosis that her head was upside down +and retrospectively that she had been mixed up, +could not remember well, did not feel like talking. +Mary D. (Case 4) said that she had been dazed, that +she had not felt like talking, and that her limbs +"were stiff like." We should probably also include +here as a delusion of death the statement of Annie +K. (Case 5) who wanted to die and thought she would +do so if she kept still enough.</p> + +<p>It is rather striking that among all the forty cases +only one spoke of being sick—"I am so sick." Only +one evaded questions with "that was my illness." +One would expect a priori that these patients would +offer some vague explanations or make complaints<!-- Page 137 --><span class='pagenum'><a name="Page_137" id="Page_137">[137]</a></span> +of weakness. If these stupors were purely physical +in origin, one would expect such explanations as +weakness or illness to be offered in accounting for +the inactivity. That there is a rather definite type +of explanation offered is, we think, distinctly suggestive. +If one tries to correlate and group the +death ideas, one sees that they are all delusions of +death or of loss of energy or complaints of hysterical +symptoms that look like sham death. If the +lack of energy complained of be looked upon as lifelessness, +one can conceive of these explanations being +variations of one theme, namely, that of death. +In the last chapter it has been shown that a delusion +of dying, being dead, or having been dead is +extremely frequent in the stupor group. It would +seem only natural then to regard the inactivity, in +so far as it may be specifically determined, as an expression +of some such delusion.</p> + +<p>Psychiatrists are more or less aware of there being +typical ideational contents in the different +manic-depressive psychoses. For instance, every +one is familiar with ideas of wickedness and inadequacy +in depression, ideas of violence in anxiety, or +expansive and erotic fancies in manic states. Quite +similarly we have seen that death is a dominant +topic in a stupor. Now in addition to these typical +ideas we often hear expressed what we might term +non-specific delusions, ideas that seem to have nothing +to do with a peculiar type of reaction which the +patient presents. It is therefore not surprising to<!-- Page 138 --><span class='pagenum'><a name="Page_138" id="Page_138">[138]</a></span> +find that inactivity is not consistently ascribed to +death or a related delusion.</p> + +<p>For instance, Henrietta B. had much talk of higher +powers that were controlling her, also said that +it was fear which kept her quiet. Josephine G. said +retrospectively that she had thought she would injure +people if she moved and that if she opened her +eyes she would murder the people around her. Johanna +B. was afraid to talk because she fancied she +was in prison. Laura A.: During her stupor was +more vague, saying, "I can't move, they won't let +me be," without betraying any suggestion of whom +"they" might be. Finally Mary C. (Case 7) was +still more indefinite, ascribing her immobility merely +to fear. When one considers, however, that these +five were the only ones who gave any atypical explanation +of their inactivity among the thirty-seven +cases, the preponderance of the death idea becomes +striking.</p> + +<p><b>2. Negativism.</b> The next of the cardinal symptoms +to be considered is negativism. This term, which is +often loosely used, we would define as perversity of +behavior which seems to express antagonism to the +environment or to the wishes of those about the +patient. Naturally it is only in the minor stupors +that we see it in well-developed form as active opposition +and cantankerousness. For example, Harriett +C., who stood about until her feet became +edematous, would spit out food when it was placed +in her mouth but would eat if she were left alone +with the food. Josephine G., in a milder state,<!-- Page 139 --><span class='pagenum'><a name="Page_139" id="Page_139">[139]</a></span> +would turn her back on people. When more inactive +once rolled out of bed and lay on the floor. At this +time also she tried to keep people out of her room. +Rarely, patients may have angry outbursts, as did +Annie K. (Case 5) who would strike at the nurses.</p> + +<p>Very often the failure to swallow and anomalous +habits of excretion seem to be negativistic in their +nature. One thinks at once of the necessity for tube-feeding, +which is so common even when patients +seem otherwise fairly active. Naturally this form +of treatment is necessary only when the patient refuses +to swallow. Quite frequently a refusal to +urinate is met with so that catheterization is necessary, +or a patient may never use the toilet when +led to it, but will defecate or urinate so soon as he +leaves it. These latter, like some other perversities, +suggest reactions of a petulant, spoiled child.</p> + +<p>By far the commonest manifestation is muscular +resistiveness, often spoken of as "resistiveness." +It was present in thirty-two out of thirty-seven of +our cases. Usually it takes the form of a contraction +of the whole system of voluntary muscles when +the patient is touched or the bed approached. Often +it appears only when any passive movement of the +limb is attempted. All muscles of the limb then +stiffen, making the member rigid. Sometimes the +negativism is expressed by quite isolated symptoms, +such as stiffness in the jaw muscles alone. One patient +showed no opposition except by holding her +urine for two days. Another kept her eyes constantly +directed to the floor. The reaction of an<!-- Page 140 --><span class='pagenum'><a name="Page_140" id="Page_140">[140]</a></span>other +showed no irregularity except for stiffness in +the neck and arms and wetting herself once after +she had been taken to the toilet. One displayed +merely a slight stiffness in her arms. An interesting +case was that of Annie G. (Case 1) who kept +one leg sticking out of bed. If this were pushed +in, she would protrude the other. Mary F. (Case +3) sometimes expressed her antagonism to the environment +by slapping other patients. She spoke +only twice in a year and a half, and each time it was +when interfered with. By far the commonest cause +of muscular movement in these inactive cases is resistiveness, +and as a rule the inactivity is interrupted +only by negativistic symptoms.</p> + +<p>If we look for some explanation or correlation of +these symptoms, we find that chance references to +conduct seem to point in the same direction, namely, +to the desire to be left alone. This resentment +against interference again reminds us of the reactions +of a spoiled child. For instance, Laura A., in +manic spells during which she was still constrained +and drooled, said, "I don't want to have my face +washed." In the intervals she showed an intense +muscular resistiveness. Mary G. used to say, "Leave +me alone," and covered her head or buried it in +the pillows. Maggie H. (Case 14) said in retrospect +that she had wanted to be left alone. Similarly Alice +R. thought she did not want to talk. Emma K. +thought that she was in prison and apparently resented +this. Henrietta B. combined in her behavior +tendencies both to compliance and opposition.<!-- Page 141 --><span class='pagenum'><a name="Page_141" id="Page_141">[141]</a></span> +When her arms were raised they retained the new +position for a minute. Then she dropped them and +said, "Stop mesmerizing me." But then she put +them up again of her own accord, and when she had +done this presented intense resistiveness to any +movement. Later she extended her arms in front +of her and said, "I am all right," in a theatrical +manner, and then added, "Why don't you go +away?"</p> + +<p>There seems to be some correlation between inaccessibility +and muscular resistiveness. For example, +Charlotte W. (Case 12), whose condition varied +a great deal, always lost the resistiveness when she +became accessible, during which periods she also +showed some facial expression. The resistiveness +would invariably return when the inaccessibility +reappeared. Caroline DeS. (Case 2) lost her resistiveness +as she became more accessible, although the +inactivity and apathy persisted. This tendency, +which is quite common, suggests that muscular resistiveness +represents a lower level of expression of +opposition which patients put into words or purposeful +actions when there is other evidence of some +contact with the environment. Sometimes one observes +both general resistiveness and specific acts. +For instance, Mary G., who said, "Leave me alone," +and covered her head or buried it in the pillows, +accompanied her muscular resistiveness with laughter. +This shows the affective nature of the apparently +purposeless muscular tension. The case of +Annie K. (Case 5) is more instructive. In the stage<!-- Page 142 --><span class='pagenum'><a name="Page_142" id="Page_142">[142]</a></span> +of deeper stupor she had the automatic type of resistiveness +but also outbursts of anger, particularly +toward the nurses, striking one of them she said, +"You are the cause of it all." When food was offered +her, she said, "I wonder people would not leave +me alone sometimes." Again, when her bed was approached, +she would clutch and hold the bed clothes +in an apparently aimless way as if the impulse to +resist never reached its goal. Retrospectively she +could not account for her muscular rigidity on the +basis of definite ideas, and could recall only that +she felt stubborn. In a later period when more accessible, +she felt cross and did not want to be bothered. +This emotional attitude was quite conscious +with her, whereas the acts and speech of the earlier +period, when her stupor was more profound, seemed +more automatic and impulsive. In other words, the +resistiveness looks like a larval attempt to express +an idea which is probably not fully conscious and +therefore gives the appearance of being aimless. +As another example of this we may cite the case of +Pearl F. (Case 9), who said when she recovered, "I +was stubborn." In addition to the muscular resistiveness +she had shown, she would often bite the bed +clothes or scratch herself when she was approached. +Mary F. (Case 3), while in a stupor, slapped at +nearby patients quite aimlessly. When somewhat +better, this conduct appeared in a more conscious +form, as sullenness, indifference and smearing of +feces (again the behavior of a naughty child). Here +one might quote Laura A. once more, whose resis<!-- Page 143 --><span class='pagenum'><a name="Page_143" id="Page_143">[143]</a></span>tiveness +when stuporous was intense but who in her +manic spells expressed her negativism in a definite +idea, "I don't want my face washed."</p> + +<p>To summarize, then, we may say that negativism +is apparently the result of a desire to be left alone, +and that muscular resistiveness is a larval exhibition +of the same tendency. But the appearance of +this attitude in such aimless, impulsive acts or +habits reminds us strongly of the dissociation of +affect, which was commented on in the previous +chapter. It would seem to be another example of +this rather fundamental tendency of the stupor reaction, +not merely to diminish conative reactions in +general, but to reduce their appearance to that of +isolated, partial and therefore rather meaningless +expression.</p> + +<p><b>3. Catalepsy.</b> The last of the cardinal symptoms +to be considered is catalepsy. It occurred in thirteen +of thirty-seven cases, although it was present only +as a tendency in three of these. If we define it as +the maintenance of position in which a part of the +body is placed regardless of comfort, we can see that +sometimes it is difficult to differentiate from the +phenomenon of resistiveness with its rigidity. It is +most frequently observed in the hands and arms, +perhaps because it is, as a rule, most convenient +to demonstrate the retention of awkward positions +in the upward extremities. But any part or even +the whole body may be involved; for example, +Charles O. retained standing positions even where +balance was difficult. This phenomenon is often<!-- Page 144 --><span class='pagenum'><a name="Page_144" id="Page_144">[144]</a></span> +accompanied by "waxy flexibility," where the joints +move stiffly but retain whatever bend is given them, +like a doll with stiff joints.</p> + +<p>The significance of catalepsy is best studied by +considering its relationship to other symptoms and +by noting remarks made by the patients in reference +to it. The most important observations which we +have made seem to indicate that it never occurs with +that degree of deep inactivity which suggests a complete +lack of mentation on the part of the patient. +One is therefore forced to conclude that back of this +phenomenon there must be some purpose, some kind +of an ideational content, although this may be of a +primitive order. This is demonstrably true in some +cases, at least such as that of Isabella M., who left +her arm sticking up in the air but took it down to +scratch herself and then put it back. Somewhat +similarly, Charlotte W. (Case 12), when she was +shown during convalescence a photograph of herself +in a cataleptic state, said that that was when she was +waiting to go to Heaven and was afraid to move. +Again she remarked, "I was mesmerized." Josephine +G., who showed only a tendency to catalepsy, +said that she feared the devil would get control of +those about her if she moved. Sometimes there is +a development of this symptom from others which +seem to be ideational in their origin. For instance, +Charles O. began making flail-like movements. +These passed over into slow circular motions which +finally subsided into the maintenance of fixed position.</p> + +<p><!-- Page 145 --><span class='pagenum'><a name="Page_145" id="Page_145">[145]</a></span></p><p>References to hypnotism are not infrequent, and +in many cases there is evidence of a delusion that +the posture is desired by those in charge of the +patient. Annie G. (Case 1) said so directly. In +retrospect she explained the holding of her arms in +the air by saying, "I thought you wanted me to have +them up." Henrietta B. at one examination kept +her arms raised in the position in which they had +been put for a minute and then dropped them, saying, +"Stop mesmerizing me." But she then put +them up again of her own accord and now presented +intense resistance to any motion. Later she extended +her arms in front of her and said, "I am all +right," in a theatrical manner. Some patients give +evidence in other symptoms of larval efforts at coperation +with the actual or supposed wishes of the +physician and in such cases it is not impossible that +passive movements are interpreted as orders. One +must remember in this connection that the more +primitive are the mental operations of any individual, +the more important do signs, rather than +speech, come to be a medium of communication with +other people. As an example of this type we might +mention Rose Sch. (Case 6), who flinched from pin +pricks (showing that she felt them) but made no +effort to get away. When somewhat clearer she said +that she was "here to be cured." Similarly Mary +D. (Case 4), who showed no catalepsy from ordinary +tests, kept her head off the pillow for a long time +after it was raised to have her hair dressed. She +showed such perseveration in many constrained po<!-- Page 146 --><span class='pagenum'><a name="Page_146" id="Page_146">[146]</a></span>sitions. +She too flinched from pin pricks but not +only made no effort to prevent them but would even +stick out her tongue to have a pin stuck in it.</p> + +<p>The relationship of catalepsy to resistiveness is +interesting but unfortunately complicated and unclear. +In only one of our cases was catalepsy definitely +present without resistiveness, and in one +other a "tendency to catalepsy" was noted without +muscular rigidity being observed. In this latter +case, when the catalepsy became unquestionable, +resistiveness also appeared. It is one thing to note +this coexistence and another to explain it adequately. +All that we can offer are mere speculations +as to the real meaning of the association of these +phenomena. It may be that the tension of muscles +that occurs when resistiveness is present gives the +idea to the patient of holding the position. There +would be two possible explanations for this. We +might think there is a dissociation of consciousness, +like that of hysteria, where the feeling of tenseness +in the muscles that comes from the resistance to +gravity is not discriminated from the resistance to +the movements made by the examiner. On the other +hand, there might be a similar dissociation where +the perception of contraction in the antagonistic +muscles is interpreted as the action of the examiner +in placing the limb in a given position. This latter +view would seem, on the face of it, ridiculous, inasmuch +as its presumes the existence of two directly +opposed tendencies, namely, those of opposition to +the will of the physician and compliance with it. But<!-- Page 147 --><span class='pagenum'><a name="Page_147" id="Page_147">[147]</a></span> +ambivalent tendencies are frequently present in +psychopathic states, and moreover we find occasionally +some evidence in the behavior of the patient +to substantiate this view. For example, at one stage +of the stupor of Annie G. (Case 1), her arm could be +moved without resistance. Then the elbow would +catch and at this moment the position would be +maintained. Such observation is highly suggestive +of the resistance being signal for the catalepsy. In +Isabella M. the catalepsy appeared when resistance +to passive movements also developed. On the other +hand, when the resistance became extreme, the catalepsy +was reduced, and vice versa. This makes one +think of two tendencies: suggestibility on the one +hand, and opposition on the other. We might presume +that when both are present and equally strong, +stiffness with passive movements results as a kind +of compromise, but when there is a greater development +of one, the other is inhibited.</p> + +<p>Such speculations remind one strongly of the +psychology of conversion hysteria and of hypnotism. +In some cases of stupor hysterical symptoms are +quite definitely present. For instance, Celia G. +began her psychosis with hysterical convulsions +which would terminate with short periods of stupor. +Later the stupor became persistent and during this +stage she had catalepsy (and restiveness as well) +in her left arm only. On recovery from her stupor +she complained of stiffness in her hands, which +examination proved to be a purely hysterical difficulty.</p> + +<p><!-- Page 148 --><span class='pagenum'><a name="Page_148" id="Page_148">[148]</a></span></p><p>This whole subject is without question obscure +and many more and very careful observations are +needed before really satisfactory explanations can +be given for these phenomena. That it is a reaction +which is related to the primitiveness of the mental +content and the intellectual deficit in stupor would +seem to be a reasonable view, inasmuch as quite +similar phenomena have been observed in a large +number of animals, even among crustaceans. As a +result of our own observations the only thing we +feel at liberty to state with real confidence is that +catalepsy is presumably a phenomenon mental in +origin rather than somatic, because it always occurs +in conditions which show other evidence of mentation.</p> + +<p>Whatever may be the origin of the idea of the +posture assumed, there can be little doubt that its +indefinite maintenance is a phenomenon of perseveration. +The conception of the position being in +the patient's mind, it is easier to hold it than elaborate +another idea. This, of course, is part of the +intellectual disorder in stupor. In fact, it is difficult +to imagine any one whose critical faculty was functioning +coperating in a test for catalepsy.</p> + +<p><!-- Page 149 --><span class='pagenum'><a name="Page_149" id="Page_149">[149]</a></span></p> + +<h2>CHAPTER VIII<br /> + +<span class="sm">SPECIAL CASES: RELATIONSHIP OF STUPOR TO +OTHER REACTIONS</span></h2> + +<p>We have described typical cases of benign stupor +and isolated certain interrelated symptoms which, +when they dominate the clinical picture, we believe +establish the diagnosis of stupor, regardless of the +severity of the reaction. These symptoms are +apathy, inactivity, a thinking disorder and, quite as +important as these, an absorbing interest in death. +It is typical that the patient contemplates his dissolution +with indifference or, at most, with mild or +sporadic anxiety. There seems little reason to doubt +that when these four symptoms occur alone, we are +justified in making a diagnosis of stupor. The next +problem is to consider the meaning and classification +of cases where these symptoms occur in conjunction +with others. This naturally introduces the subject +of relationship of stupor to other manic-depressive +reactions.</p> + +<p>It is probably best to begin with presentation of +three such cases.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 16.</span>—<i>Anna L.</i> Age: 24. Admitted to the Psychiatric +Institute August 21, 1916.</p> + +<p><i>F. H.</i> Maternal grandmother temporarily insane during illegitimate +pregnancy, thereafter a little odd. Mother high strung<!-- Page 150 --><span class='pagenum'><a name="Page_150" id="Page_150">[150]</a></span> +and emotional. Father high strung, impulsive and irritable.</p> + +<p><i>P. H.</i> As a child she was quick tempered, quite a spitfire and +given to tantrums. At the age of 14 she became a vaudeville +actress in Cleveland, which was the home of her childhood. +When 17 she married a Jew, although she was herself a Catholic. +Her husband noted that she was fretful, sensitive, resentful and +quick tempered, although apt to recover quickly from her rages. +Previously healthy, neurotic symptoms began with marriage, taking +the form of stomach trouble and a tendency to fatigue. +Shortly after marriage an abortion was induced. After being +married for two years she had a quarrel and separated from her +husband. They were reconciled later, but in the meantime she +had been having relations with another man. When 20 an abdominal +operation was performed in the hope of relieving her +gastric symptoms, but no improvement occurred. The patient +after recovery stated that she continued to be nervous, shaky and +dizzy, at times trembling when going to bed at night. Two years +later, however, she took up Christian Science and showed objectively +some improvement in her health, although according to her +later accounts she continued to feel somewhat nervous and fatigable. +Her husband stated that at this time she also began to +ponder much about such questions as the difference between life +and death, what "matter" was, and also studied "grammar" and +"etiquette." According to the patient some five or six months +before admission she began to have peculiar sensations following +intercourse—a feeling of bulging in the arms, legs and back of the +neck. One evening after an automobile ride there were peculiar +sensations on her right side like "electricity" or as if she were +inhaling an anesthetic. She gasped and thought she was dying. +Two months before her admission she went with her husband and +his family to a summer resort where she felt increasingly what +had always been a trouble to her, namely, the nagging of this +family.</p> + +<p>Just before her breakdown, because she went daily to the +Christian Science rooms in order to avoid the family, they suspected +her of immorality and accused her of going to meet other +men. Even her husband began to question her motive. Retrospectively +the patient herself said that she now felt she was losing +her mind and did not wish to talk to any one. At the time she<!-- Page 151 --><span class='pagenum'><a name="Page_151" id="Page_151">[151]</a></span> +told her husband that she felt confused and as if she were guilty +of something and being condemned. Repeatedly she said she +knew she was going to get the family into a lot of trouble. Once +she spoke of suicide, and for a while felt as if she were dying. +Finally she became excited and shouted so much that she was +taken to the <i>Observation Pavilion</i>, where she was described as +being restless and noisy, thinking that she was to be burned up +and that she had been in a fire and was afraid to go back.</p> + +<p><i>On admission</i> she looked weary and seemed drowsy. Questions +had to be repeated impressively before replies could be obtained, +when she would rouse herself out of this drowsy state. She +seemed placid and apathetic. She said that nothing was the +matter, but soon admitted that she had not been well, first saying +that her trouble was physical and then agreeing that it had been +mental. When asked whether she was happy or sad, she said +"happy," but gave objectively no evidence of elation. Her +orientation was defective. She spoke of being in New York and +on Blackwell's Island, but could not describe what sort of place +she was in, saying merely that it was "a good place," or "a nice +country place," again "a good city." Once when immediately +after her name L. had been spoken and she was asked what the +place was, she said "The L." She knew that she had arrived in +the hospital that day but said that she had come from Cleveland, +and to further questions, that she had come by train, but she +could not tell how she reached the Island. She claimed not to +know what the month was and guessed that the season was either +spring or autumn (August). She gave the year as 1917, called +the doctor "a mentalist," and the stenographer "a tapper," or +"a mental tapper." She twice said she was single. When asked +directly who took care of her, said "Mr. Marconi," who she +claimed at another time had brought her to the hospital. To the +question, who is he? she replied, "Wireless," and could not be +made to explain further. That night she urinated in her bed, +and later lay quite limp, again held her legs very tense.</p> + +<p>For five days she remained lying quietly in bed for the most +part, although once she called out "Come in, I am here," "Jimmie, +Jimmie" (husband's name). Several times she threw her bed +clothes off. Otherwise she made no attempt to speak and took +insufficient food unless spoon-fed. At one examination she looked +up rather dreamily but did not answer. When shaken she<!-- Page 152 --><span class='pagenum'><a name="Page_152" id="Page_152">[152]</a></span> +breathed more quickly and seemed about to cry but made no +effort to speak. When left to herself she closed her eyes and +did not stir when told she could go back to the ward. She was +then lifted out of her chair and took a step or two and stopped. +Such urging had to be repeated, as she would continue to remain +standing, looking about dreamily, although finally when taken +hold of she whimpered. When she got to the dining-table she +put her hand in the soup and then looked at it. So far there is +nothing in this case atypical of what we would call a partial +stupor. The cardinal symptoms of apathy, inactivity, with a +thinking disorder, are all present and dominate the clinical picture. +There is, further, the history of a delusion of death during +the onset of the psychosis. Had her condition remained like this, +there would be no difficulty in classifying the case, but other +symptoms appeared.</p> + +<p>Five days after admission she was restless, somewhat distressed, +and announced that she wanted to talk to the physician. When +examined, the distress, with some whimpering, continued. She +asked the doctor not to be harsh to her, frequently said there was +something wrong and began to cry. A normal interest appeared +only once, when she spontaneously said she wanted to see her +relatives. A most interesting feature, however, was a certain +perplexity that now appeared. She spoke of this directly: "I do +not know what it is all about. I know you are a doctor, that is all. +I don't know whether I passed out and came back again or +what—I don't know what to make of it." She also felt confused +about her marriage—"There is where all the mixup is. I was +married when I was 16." She was reminded that she had said +she was single, and replied "I am single." Then where is your +husband? she was asked. "He must be dead." She recalled the +examination on admission and remembered some of the questions +that she was asked then, also knew that she had been at the +Observation Pavilion and that she had reached this hospital by +boat. On the other hand she still claimed that the year was 1917, +and in connection with the delusion of having died was quite +unclear as to the time. She said that it seemed as if she had +died many years ago and that she had come to the hospital years +ago. She also spoke of having died at a summer resort the year +before. When asked for her age, she said that she must be very<!-- Page 153 --><span class='pagenum'><a name="Page_153" id="Page_153">[153]</a></span> +old, but on the other hand claimed that she was supposed to die +and to come to the hospital when she was 26 (two years more +than her actual age).</p> + +<p>Her psychosis continued from then on for about ten weeks. +She soon began to feed herself, but otherwise for most of this +period remained quietly in bed, looking about a good deal, +although showing no particular mood reaction until questioned, +when she was apt to make repeated statements about her perplexity—that +she did not know what it was all about, every one +had mixed her up, everything was so strange, "my head is mixed +up, I am trying to straighten things up." She frequently when +interviewed became lachrymose and often with her subjective +confusion there was considerable anxiety. Another unusual +phenomenon for a stupor patient was that she was frightened +at a thunder storm. On the whole, however, her apathy and +indifference were quite marked. For instance, during the latest +phase of her psychosis, when the nurses would sometimes make +her dance with them, she did so but without showing any interest +and not until immediately before her recovery did she begin to +speak spontaneously to any extent whatever. A marked difference +from the ordinary stupor was that this apathy was invariably +broken into when she was questioned and ideas came to her mind, +the nature of which seemed to be essentially connected with her +perplexity.</p> + +<p>Not only did ideas appear more frequently than one meets +them in stupor cases, but they were present in greater variety. +The dominant stupor death idea was, it is true, almost constantly +present, but it did not come to the direct and unequivocal expression +which we are accustomed to see in typical stupor. She +did not say "I am dead," or "I was dead," but it was always +"It seems as if I were dead," or "I think I must have died," or +some such dubious statement. Other ideas were that her mother +was dead and had been put into a box. She frequently gave her +maiden name and said that she lived in Cleveland with her mother +and that this was Cleveland. At times she thought she was engaged +and was going to be married to her husband shortly. +Again there were notions that her husband had married somebody +else or that some harm was going to come to him. Sometimes<!-- Page 154 --><span class='pagenum'><a name="Page_154" id="Page_154">[154]</a></span> +she thought that her mother's name was her own, that is, Mrs. L. +The hospital once seemed like a convent to her.</p> + +<p>Her subjective and objective confusion seemed quite definitely +to be connected with the insecurity and changeability of these +ideas. It appeared as if insight and delusion were struggling +for mastery in her mind, so that reality and fancy were alternately, +even simultaneously, possessing her, and that this gave her +the feeling of perplexity from which she suffered. Once when +she remarked "It seems as if I had been dead all the time," she +was questioned more about this and replied, "Well, sometimes I +thought I was dead, at other times it seemed as if I wasn't." +In answer to a direct question about her feeling of confusion she +said "I don't know. I know I have lots of good friends, they +all want to help me and it seems as if everything got mixed up +between the L.'s (her married name) and the G.'s (her maiden +name)." This was apparently an elaboration of the wavering +ideas she had about her singleness or her married state. Once +after referring to her husband as her sweetheart whom she was +to marry, and immediately thinking that perhaps he had married +somebody else, she added, with a sigh, "The more this goes on, +the more mixup." In short, any question, even on some apparently +neutral topic, seemed to start up conflicting ideas in her +mind, the inconsistency of which she recognized without being +able to control their appearance. Hence, whenever she was +spoken to, she became perplexed and distressed.</p> + +<p>Her orientation gradually improved so that, although it remained +vague, it was no longer glaringly inaccurate. Then quite +suddenly she one day came to a nurse and asked how long she had +been in the hospital. When told, she remarked that it seemed +as if she had spent the whole winter there. She was examined at +once and found to be quite clear and at first in good control of +her faculties. She remembered a good many of her ideas, in fact +was able to elaborate a little from memory on what had already +been reported from her utterances during the psychosis. The +recovery was not immediately complete, however, for at this +examination, when told that she had constantly given her maiden +name, she became distressed and said the physician was trying +to mix her up and was reluctant for this reason to discuss her +ideas. This soon passed, however, and within a few days she<!-- Page 155 --><span class='pagenum'><a name="Page_155" id="Page_155">[155]</a></span> +was quite normal and had remained so for some months after her +discharge from the hospital, when last seen. In fact, according +to the husband, she was in better mental and physical health +following the psychosis than she had been for years.</p></div> + +<p>Essentially, then, this case shows what was at +first a typical partial stupor, but soon became complicated +by a tendency for questioning to provoke +rather a free flow of ideas and a distressed perplexity. +This symptom of perplexity soon grew to +dominate the clinical picture, so that the psychosis +was really a perplexity ushered in by a brief stupor +reaction with a background of stupor symptoms +running through it. The second case shows similar +tendencies but different from the one whose history +has just been cited in that the perplexity was never +complained of by the patient herself and that her +emotional reactions were more marked and varied.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 17.</span>—<i>Celia C.</i> Age: 18. Admitted to the Psychiatric +Institute May 2, 1914.</p> + +<p><i>F. H.</i> Four years after this attack her mother was a patient +in the hospital with an atypical manic-depressive psychosis from +which she apparently recovered.</p> + +<p><i>P. H.</i> The patient herself was described by superficial observers +as being bright, sociable, well-informed and very ambitious.</p> + +<p>When 18 years of age she was working very hard preparing +for some examinations, and worried lest she should fail in them. +Some years later the patient accounted for her psychosis by +saying she had a quarrel with her sister, immediately after which +she began to feel depressed. The anamnesis states that she was +slow, complained of not being able to think and feeling as if she +had no brain. She was sent to a general hospital, where she was +apprehensive, wanted her mother to stay with her and one night +called out "Mother."</p> + +<p><!-- Page 156 --><span class='pagenum'><a name="Page_156" id="Page_156">[156]</a></span> +The case being recognized after a few days as a psychosis, +she was sent to the <i>Observation Pavilion</i>, where she was described +as jumping about in bed in a jerky, purposeless manner, resistive +when anything was done for her, and mute. Her sister reported +that when she visited her the patient said "Go away, I am dead."</p> + +<p><i>On admission</i> she looked dazed, stared vacantly and had a +tendency to draw the sheet over her. When put on her feet she +let herself fall limply. At times she became agitated, sobbed and +cried loudly, especially when attempts were made to examine +her physically, or, when she was asked questions, she scarcely +spoke.</p> + +<p>Her psychosis lasted but a little more than three months under +observation and was characterized by the following symptoms: +She was usually in bed, staring blankly or appearing otherwise +quite indifferent and apathetic, but not infrequently, especially +during the first few weeks, she was quite restless, resistive, +whined and suddenly appeared startled or distressed with no +occasion for this reaction in the environment. Rarely she was +suddenly assaultive. When attempts were made to examine her, +she was frequently mute or would repeat the question with a +rising inflection, not getting anywhere, or would say, "What shall +I say," or "I, I——" never finishing her sentence. After orientation +questions she might say "This is—this is—this is——" all +this, together with a rather perplexed appearance, gave the +impression of considerable bewilderment, but at no time did she +complain of autopsychic perplexity. It was difficult to judge of +her orientation on account of her failure to answer questions, +but it soon appeared that she knew the names of the nurses, for +she sometimes called them spontaneously by name. She always +ate reluctantly.</p> + +<p>During these examinations, however, other symptoms often appeared. +When she was talked to, she was apt to indulge in +depressive statements and show considerable distress. Such +remarks were: "I must confess my guilt," "I am a bad girl and +I have to face my guilt," or "I have sinned," or, standing up with +a dramatic air, "I must stand up and tell the truth." Once she +said, "It is too late to live now." She spoke of having lied and +usually would not say what about, but once on questioning replied +"I said I would not tell what happened here." She was asked,<!-- Page 157 --><span class='pagenum'><a name="Page_157" id="Page_157">[157]</a></span> +What do you mean? and answered "I took my oath not to tell +anything." Pressed further she said that the nurses poisoned +her. Another time she said she was in prison. To her aunt who +visited her she said, "I am a prostitute," and once she remarked +to the doctor, "I have killed my honor," and on another occasion +in the middle of the night she called out, "Chinatown Charlie, +come here." She thought the doctor was her brother.</p> + +<p>Most of these statements were associated with painful emotion, +but there were a few occasions when an element of elation +cropped out. Thus on one occasion she laughed, another time +gripped the doctor's pad and tried to read it. When the nurse +laughed, she made a funny grimace at her and said "Why do you +laugh?" Again she once sang two songs, but after the first verse +got stuck and kept repeating one word.</p> + +<p>At the end of three months she improved rather rapidly and +was in a condition for discharge as "recovered" a month later. +Retrospectively she said that she recalled feeling guilty, thinking +that her mother was dead, having been killed by the patient as a +result of worrying over the latter's failure in her examinations +and refusal to eat. She remembered, too, that at times she +thought the building was burning. Some things like "Chinatown +Charlie" she denied remembering, although she had a good recollection +for the external facts throughout the psychosis. Her +insight was superficially good, but she was reluctant to discuss her +psychosis, in fact claimed that she had been made more of a +lunatic by coming to the hospital than she was on admission.</p> + +<p>Some five years later she had another somewhat similar attack, +again following a quarrel, this time with a fellow employee. In +this second psychosis, however, manic elements were much more +prominent.</p></div> + +<p>Here again, then, we have the symptoms of apparent +apathy, inactivity, and similar ideas of death, +but the thinking disorder was possibly not very +profound, inasmuch as she had a good memory for +external events. Her ideas, too, are much more +florid than those which we customarily meet with in +stupor cases, but the most marked peculiarity was<!-- Page 158 --><span class='pagenum'><a name="Page_158" id="Page_158">[158]</a></span> +that this "stupor" was liable to constant interruption, +either spontaneously or as a result of questioning, +which always produced a mood reaction. She +was apathetic only so long as she was left alone. In +other words, whenever an effort was made to test +what seemed to be apathy, the evidences of it disappeared.</p> + +<p>The third case to be considered is somewhat like +that of the first, Anna L. (Case 16), in that with +the inactivity and apathy there was a coincident +subjective perplexity. The apathy, however, was +less marked than in the case of Annie L.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 18.</span>—<i>Catherine M.</i> Age: 24. Admitted to the Psychiatric +Institute November 10, 1913.</p> + +<p><i>F. H.</i> Information as to the family is confined to the two +parents. The mother, who was frequently seen, seemed to be a +natural, sensible woman. The father, on the other hand, had +been alcoholic all his life, had had two convulsions while drinking, +and had little respect from any member of the family, including +the patient.</p> + +<p><i>P. H.</i> The patient was said always to have been healthy, from +a physical standpoint, although never robust. She got on well +at school, and then worked first as a stock girl and later as clerk +in a department store, where her work was efficient and she +advanced steadily. As a child she played freely with other +girls but little with boys. As she grew older she moved about +socially a little more, made the acquaintance of men as well as +of girls, but never cared much for the former and had no love +affairs until she met her husband. She was never demonstrative +but always rather quiet and modest. Occasionally she spoke of +thinking that people talked about her, but the informant doubted +if she brooded over this, because she was not of a worrying +disposition. Considering the ideas which appeared in her +psychosis, it is striking that in her normal life she was rather<!-- Page 159 --><span class='pagenum'><a name="Page_159" id="Page_159">[159]</a></span> +antagonistic towards her father on account of his alcoholism and +the crudity of his speech and manners.</p> + +<p>When she met her husband she liked him from the first, +although she at no time became really demonstrative. They were +engaged for a year, during which time she agreed to a postponement +of three months for the marriage, which was suggested by +her mother. For some time before this event she was working +harder than usual and seemed a bit worn out. She ceased working +a month before marriage and improved physically, although she +became rather nervous, that is, she was more easily startled, an +accentuation of what had been a characteristic for some years. +Her husband stated that at this time she became fearful of the +approaching marriage relations and asked him to be kind to her +in this respect. She was married a year before admission. For +two and a half months she refused intercourse and visited her +mother's home a great deal. She finally submitted. She was +quite frigid but became pregnant at once. Her abnormality then +became apparent. She kept the fact of her pregnancy to herself +for several months and then when she told her mother wanted +to have an abortion performed. Neurotic symptoms appeared. +She became sensitive with her husband, correcting his grammar, +and cried easily. She also began to be anxious about the approaching +childbirth, and with this became more religious.</p> + +<p>For the first few days after the delivery, she was fussy with +the nurse so that two in succession had to be discharged. On +the fifth day she woke up and seeing a nurse lying on the couch +beside her bed thought the latter was colored. On the seventh +day she had a dream in which she thought she "nearly died in +childbirth." Then she began to talk of dying for her baby or +of having two babies, of dying herself and rising again after +Easter Sunday. She became antagonistic to her husband and +with this excited and confused so that she was taken to the +Observation Pavilion.</p> + +<p>On <i>admission</i> she looked pale and exhausted, had a slight temporary +fever and a coated tongue. Her orientation was usually +vague but sometimes she gave fair answers. Her verbal productions +were rather fragmentary and with the exception of some +repetitions there did not seem to be any special topics which +dominated her train of thought.</p> + +<p><!-- Page 160 --><span class='pagenum'><a name="Page_160" id="Page_160">[160]</a></span> +For some days the great weakness and the slight fever continued, +and then, as it gradually cleared up, there came a change +in her mental condition that settled into the state which characterized +the rest of her psychosis. She talked less and was often +quite inactive, frequently lying with her eyes closed for long +periods, or sat or stood about. Such movements as she made +were slow and languid. Her expression was either blank, absorbed, +or gave the appearance of peculiar appealing perplexity. +This last was not infrequently associated with a rather sheepish +smile. She was never resistive and always ate and slept well. +With the exception of a few times she did not soil herself. The +most interesting feature of her mood reaction was that in a +general setting of a slight perplexity there appeared at times +and evidently associated with definite ideas, changes in her emotional +state. Sometimes this was a matter of distress or of mild +ecstasy, sometimes she became markedly blocked. There was at +no time any frank elation, but often an appropriate smile, that +is, appropriate to the situation and to the thought to which she +was giving expression at the time. Then, rarely, there were +sudden bursts of peculiar conduct, such as throwing herself on +the floor or running down the hall. When questioned as to her +motive for these acts, she would flush, look perplexed and apparently +be unable to explain them.</p> + +<p>Her verbal productions dealt with a rather limited range of +topics which can be briefly summarized. As in the other cases, +the reader will notice that the bulk of these ideas are of a kind +not usually prominent in the typical stupor cases. Many of her +thoughts seemed centered around her husband. She always knew +him when he visited her, but in her thoughts there was a constant +change as to his personality. She persistently confused him +with the physicians, with her father, and with God, and one +remark is typical, "I thought he was God, priest, doctor, lawyer—well, +I wanted to go to Heaven; I thought he would still be my +husband; I always hoped that I would be home in Heaven." Not +unnaturally with this confusion there were doubts about her +marriage. People said her marriage was wrong and her husband +bad. Frequently she thought he was dead, or voices informed +her that she was not married to him, or that he was the devil in +Hell. In this connection she also said that people called her a<!-- Page 161 --><span class='pagenum'><a name="Page_161" id="Page_161">[161]</a></span> +whore, or it seemed as if she were accused of not being married.</p> + +<p>As prominently as appeared the ideas of the invalidity or impossibility +of her marriage, to the same extent did her father +assume an important rle for her. As a rule he appeared in +religious guise as God, but often he was the doctor—"I knew my +father at home and my father in Heaven; which God do you +mean? did you say God or father?" At times she spoke of +being in Heaven and that God seemed to be God, doctor or priest. +In this connection there were ideas of being under the power of +some one, God, devil or father.</p> + +<p>As is usually the case where strong interest is expressed in +the father, ideas of the mother being dead occurred, although +in the frankest form she reported them as dreams; for instance, +one night she woke up screaming, said that she had dreamed that +her mother was dead and her sister dying. That, in the +psychoanalytic sense, this represented a removal of a rival, +making union with her father easy, appeared in the statement +that her father was dead but that she had dreamed he had +come to life again for some one else. When asked what she +meant, the question had to be repeated several times, then she +said "My mother died, my father and mother had a quarrel." +There is more than a suggestion here of a difference in the +significance of death, in so far as it concerned the two parents. +The mother dies and remains dead, that is, she is gotten rid of. +The father dies but takes on a spiritual existence and comes to +life again, a frequent method in psychoses for legitimizing the +idea of union with the parent by elimination of the grossly +physical.</p> + +<p>There were strikingly few allusions to the plainly sexual. She +spoke of being married to the doctor, and even went so far as +to say that they belonged together in bed. On another occasion +she called him "darling." Once she reported that it was said +that she was going to have babies and babies and babies. These +references were, however, quite isolated, so that the erotic formed +a very small part of her productions.</p> + +<p>Delusions of death, we have seen, are the most constant content +of true stupors. In this case they were present but distinctly +in the background. She spoke quite frequently of being in +Heaven. She also talked of being crucified. Once she said "I<!-- Page 162 --><span class='pagenum'><a name="Page_162" id="Page_162">[162]</a></span> +died but I came back again." This last utterance was rather +significant in that frankly accepted ideas of death were unusual; +for instance, she would say sometimes, "I think I am in Heaven, +again not. It confuses me, but I know I am in Heaven."</p> + +<p>In general, then, her ideas were, on the whole, not at all typical +of stupor but much more like those met with in other manic-depressive +conditions. Correlated with this was an unusual mood +picture. Quietness and apparent apathy of the patient were +interrupted by little bursts of emotion, and throughout the +psychosis there was a coloring of perplexity. Not only was this +last objectively noticeable, but she spoke very frequently of it +and always in connection with the inconsistency of the ideas in +her mind which puzzled her. For instance, in speaking to the +doctor she said "I think of you as Bill (her husband's name) +sometimes—I get confused thinking of Bill as God, doctor, lawyer, +priest." Again, referring to her husband, she made these curious +statements: "They seemed to speak of him as being in the +wrong—the right—it seems that the right devil is the wrong one +for me—they say he is not the right one for me; they say he +went wrong from the time we were married." Again, she said +that she did not know who her father was, and went on: "It +puzzles me, this father business, I knew my father at home and +my father in Heaven." Again, "Which God do you mean? Did +you say God or father?" A hint as to how this subjective +confusion made the environment seem uncertain comes from the +statement, "You looked like the devil and yet you were God."</p> + +<p>Distress and anxiety appeared not infrequently and always +appropriately. The distress was usually occasioned by an idea +of injury to others, as when she cried over the fancied accusation +of drowning her husband and mother; or in connection with +accusations of herself, such as when she reported "They called +me a whore." As has been stated, there was never any frank +elation, but an element of pleasurable expansive emotion was +frequently present in connection with her religious utterances. +This came particularly when she spoke of union with her father +as God. She seemed to swell with ecstatic emotion. It was +especially well marked once when she threw herself on the floor +and when asked what she was trying to do replied, "I want to +do what God wants me to do, drop dead or anything at all."<!-- Page 163 --><span class='pagenum'><a name="Page_163" id="Page_163">[163]</a></span> +Perhaps the most unusual affective reaction was a blocking which +occurred when certain topics appeared. This is a phenomenon +quite unusual for stupor, where speech seems to stimulate and +arouse the patient as a rule. One got the impression that ideas +tended to come into this patient's mind which were painful +enough to disturb her capacity for connected thought. A good +example of this reaction was when she was speaking of her +father having died and coming to life again. On being asked +what she meant, she became quite blocked and the question had +to be repeated several times, when finally the apparently unrelated +statements appeared: "I dreamed my mother died—they +had a quarrel." Who had a quarrel? she was asked, and replied +"My mother and father." Apparently her thinking about her +father coming to life for some one not her mother stimulated +deeply unconscious ideas concerning the separation of her mother +and father, and her taking the mother's place, and these ideas +were sufficiently revolutionary to upset her capacity of speech +for the time being.</p> + +<p>She recovered completely about six and a half months after +her admission.</p></div> + +<p>If we consider together the common features of +these three cases, we see that they resemble stupors +only in the presence of inactivity and apparent +apathy. It is true that death appears in the ideational +content but not with that prominence, bordering +on exclusiveness, which characterizes such delusions +in the true stupors. These three patients give +one the impression of being absorbed in thoughts +that have many variations. It seems as if they had +difficulty in grasping the facts of the environment, +while feeling at the same time the vividness of the +changing internal thoughts, hence a confusion develops +which is either subjective, objective, or both.<!-- Page 164 --><span class='pagenum'><a name="Page_164" id="Page_164">[164]</a></span> +It is probably the introversion of attention which +gives rise to the apparent apathy, because normal +emotions emerge as part of our contact with reality +around us. This lack of contact with the environment +leads also to inactivity. If one's attention and +interest is turned inwards, there can be no evidence +of mental energy exhibited until the patient is +roused to contact with the people or things about +him. It is noteworthy that in these cases emotional +expression emerged when the patients were stimulated +to some productiveness in speech.</p> + +<p>These conditions really constitute a different +psychosis in the manic-depressive group, essentially +they are perplexity states such as have recently been +described by Hoch and Kirby.<a name="FNanchor_7_8" id="FNanchor_7_8"></a><a href="#Footnote_7_8" class="fnanchor">[7]</a> Not infrequently +we see exhibitions of this tendency in what are +otherwise typical stupors. For example, Mary F. +(Case 3) (the third case to be described in the first +chapter), showed for a few days after admission a +condition when she was essentially somewhat restless +in a deliberate aimless way. At the same time +she looked dazed or dreamy. With this restlessness +she appeared at times "a little apprehensive." Although +she spoke slowly, with initial difficulty she +answered quite a number of questions. Her larval +perplexity was evidenced by the doubt expressed in +a good many of her utterances, such as, "Have I<!-- Page 165 --><span class='pagenum'><a name="Page_165" id="Page_165">[165]</a></span> +done something?" "Do people want something?" +"I have done damage to the city, didn't I?" When +asked what she had done, she said, "I don't know." +She asked the physician, "Are you my brother?" +and when questioned for her orientation said, "Is +not this a hospital?" The atmosphere of perplexity +also colored the information which she did recall +correctly; for instance, when asked her address, she +said, "Didn't I live at ——?" then giving the +address correctly.</p> + +<p>As stated in Chapter V dealing with the ideational +content of stupor, one has to look on the delusions +of patients as symptoms subject to analysis and +classification just as truly as the variations in mood +or intellectual processes, in fact they should be +subject to the same correlation as are the mental +anomalies which are usually studied, particularly if +we are to understand these psychoses as a whole. +Let us, therefore, consider the death ideas in the +three cases studied in this chapter. We find that, as +in the ordinary stupors, there are delusions of +death, also of mutual death (with the father), but +there is a tendency to elaboration so that the death +is only part of a larger Œdipus drama, the rest of +which is usually lacking in stupors. Here it is present. +So we have thoughts of the death of the mother +or husband, another rival, considerable preoccupation +with Heaven, and also erotic fancies.</p> + +<p>We find in manic-depressive insanity a tendency +for more or less specific ideational contents with dif<!-- Page 166 --><span class='pagenum'><a name="Page_166" id="Page_166">[166]</a></span>ferent +types of the psychoses.<a name="FNanchor_8_9" id="FNanchor_8_9"></a><a href="#Footnote_8_9" class="fnanchor">[8]</a> For example, there +are religious and erotic fancies or ambitious schemes +dominating the thoughts of manic patients, fears of +aggression and injury met with in anxiety cases, and +so on. In stupors, death seems to be a state of +non-existence with other meanings lacking or only +hinted at occasionally. When it tends to be elaborated, +it leads over to formulations suggesting personal +attachments and emotional outlet, and then +we are apt to find interruptions of the pure stupor +picture. For example, Charlotte W. (Case 12), +whose case has been described, thought much about +being in Heaven and ended with a hypomanic state. +Atypical symptoms appear just as constantly in +these cases, as do the atypical ideas. In other +words, the thought content is definitely correlated +with the clinical picture.</p> + +<p>As the clinical pictures show the relationship of +stupor to other psychoses, so there is also a correlation +with varying formulations of the death fancy. +We are now in a position to define more narrowly +what death means in stupor. It is an accepted fact, +a Nirvana state. When death means union with God +or appears in other religious guise, manic symptoms +tend to develop. When it is unwelcome and appears +as "being killed," we find anxiety symptoms. A +patient can conceive of death variously and have<!-- Page 167 --><span class='pagenum'><a name="Page_167" id="Page_167">[167]</a></span> +various clinical pictures. A knowledge of the metamorphoses +of ideas and their relationship to other +symptoms enables us to understand such cases, that, +without this key, seem confused and lawless jumbles +of symptoms. Such theories tend to justify the view +of essential unity of the manic-depressive group.</p> + +<p>It would be instructive at this point to consider +another case which illustrates beautifully how a +stupor reaction may crystallize out of other manic-depressive +states when attention has become focused +on personal death. This patient went +through four phases while under observation. First, +while showing a perplexed expression but with fair +orientation, she gave utterance to erotic and expansive +fancies. She was restless, somewhat intractable +and gave the impression of brooding over her imaginations +rather than luxuriating in them. In other +words, her condition seemed to be more that of absorbed +than active mania. Second, these same ideas, +somewhat reduced, continued in an apathetic state +while impulsive symptoms developed: She began +to shout like a huckster to be taken to Heaven and +made numerous affectless, suicidal attempts. Third, +came a true stupor and, fourth, a period of recovery +when the stupor symptoms all disappeared but insight +into the falsity of her ideas was lacking.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 19.</span>—<i>Celia H.</i> Age: 19. Admitted to the Psychiatric +Institute October 22, 1913.</p> + +<p><i>F. H.</i> The father was living; he always drank, and especially +in later years contributed little to the support of the family.<!-- Page 168 --><span class='pagenum'><a name="Page_168" id="Page_168">[168]</a></span> +The mother was living and said to be normal, while a brother +was coincidentally insane, with a recoverable psychosis.</p> + +<p><i>P. H.</i> The mother stated that the patient was bright at school, +enjoyed company and going out, had a droll wit, was not at all +seclusive, no dreamer, helped to support the family and was +efficient. She was very much attached to her brother and once +said that if anything should ever happen to him she thought she +would die. She also cared much for her older sister, with whom +she worked, and for her mother.</p> + +<p>Three months before the patient's admission her brother became +depressed, mute, seemed worried, cried at times. He was sent +to the country. Two months before admission, when the mother +and the patient went to bring the brother to town, and while +they were at the station, he suddenly tried to throw himself under +a train but was restrained just in time. The patient appeared +intensely frightened, but did not talk. In fact, she seemed somewhat +bewildered and at once became dull. "Her movement and +manner were much as at present."</p> + +<p>When the patient was able later to give a retrospective account +of the onset, she claimed that for some months before this +incident she saw that her brother was losing his mind. She +worried about this as well as about her work, and felt worn out. +She said that when the brother tried to throw himself under the +train she was terrified and could not speak or move, and that her +mind got upset at once, "I lost my memory." The others forgot +her and left her alone on the platform. Strangers put her on +another train and she knew nothing until she arrived at home.</p> + +<p>The mother added that at the time when the incident with the +brother happened, the patient was menstruating and that this +ceased at once.</p> + +<p>At home she sat about inactive and did not seem even to worry. +Whenever any one asked her about her brother she replied that +he was dead. For two weeks before admission she said she was +rich, that she owned all the property around. She also said she +was married to Mattie S. In this connection the mother says +that a foolish neighborwoman, the mother of Mattie S., told the +patient since her sickness, by way of encouragement, that she +should marry her son (the man mentioned). Finally, the patient<!-- Page 169 --><span class='pagenum'><a name="Page_169" id="Page_169">[169]</a></span> +also expressed the idea that her mother was a stranger, that her +real mother was dead.</p> + +<p>At the <i>Observation Pavilion</i> she was described as wandering +about in a perplexed manner, restless, resistive, answering few +questions and in a low tone. She said things were "changed," +also that she was married to S.</p> + +<p><i>Under Observation:</i> 1. For about ten days the patient's condition +may be described as follows: The most striking feature +was a certain restlessness with insistence on going out, with +complaints that this and that had been done to her and with +senseless struggling when interfered with. But all the motions +were slow, the whole restlessness aimless and impulsive. Although +the facial expression was somewhat perplexed, it changed remarkably +little, and whenever asked whether she felt worried or +anxious she denied it, and, indeed, there was only a suggestion +of perplexity in her face.</p> + +<p>The ideas which she expressed during this time referred to +a few topics only, namely, marriage, wealth, and State prison. +The remarkable fact was that all the ideas about marriage and +wealth were spoken of, often immediately, again after some +interval, now in the positive and again in the negative sense. +Thus she said she was "Mrs. S.," again "You kept me from +marrying Mattie S.," or "I am not supposed to be here—I am +a married person," but also "You kept me from getting married." +Or, "Take off that black dress, I am a bride," again "You have +taken my bridal crown off my head," "The steamboats (seen +from the window) are mine—I own the ships, the oceans, the land +and everything," or again, she said she owned a kingdom, was +Sh.'s wife, a wealthy woman, had millions. Sometimes she +connected the millions with Sh. "Sh. has millions." On the +other hand, she said: "I owned all this before I came. I have +nothing now," or "You have taken the regal crown from me," +"You have made a pauper of me," "They did it again, they took +my millions away," or "Let me out, they are taking my millions."</p> + +<p>Other ideas throughout this period were that this was a State +prison, that "bums" were around. On one occasion she said +"You can't put down all these things and make me out a lunatic." +At another time she pulled a patient's hair and then said without +fun: "I fixed the leading lady of the dump—she knows a lot,<!-- Page 170 --><span class='pagenum'><a name="Page_170" id="Page_170">[170]</a></span> +but she does not know enough to keep her soup cool." When +questioned about this woman (who at the time while cleaning had +moved the furniture), she said: "I don't know where I am at."</p> + +<p>The orientation during these days was not markedly disordered, +when one got down to it. Although she spoke of State prison, it +was always found she knew the name and the location of the +hospital, the names of people around her, even the date approximately, +though she was apt to say it was February 19, 1492, or +October 19, 1492, or when the year was not given as 1492 she +said it was "1900 or 1901, or 1911 or 1912." Frequently, however, +it was hard to hold her attention.</p> + +<p>Finally, it should be mentioned that she very often wet herself +in bed or when standing, even when standing in the examining +room.</p> + +<p>2. The period following and lasting for two months may be +given in the form of abstracts of each note.</p> + +<p><i>November 7:</i> Yesterday quiet, though struggling. Says without +change of expression, "I saw four people killed—my mother, +my brother, a priest, and my dear sister—we were all killed." +Again, "I don't know where I am," "I am an orphan, my people +died" (without affect).</p> + +<p><i>November 20:</i> More quiet recently, says little, but tries to get +out when brought to the examining room, but when not prevented +walks slowly about as before, says she wants to go home. Looks +peculiarly blank.</p> + +<p><i>November 23:</i> Has remained quiet, says she is Dr. M.'s wife. +But when told she is not married, she agrees. Her attitude towards +the doctor is not changed, but when the nurses talk to him, +she has tried to prevent it.</p> + +<p><i>December 6:</i> Has remained quietly in bed, gazing about. +Slow in motion. She has spoken of being Dr. M.'s wife, again +President Wilson's wife, again "Vincent (brother) is the ruler +of the world."</p> + +<p>At interview says little, seems abstracted, answers briefly in +low tone. (Does anything bother you?) "No." (Are you natural?) +"Yes." (Who are you?) "C. H." (correct). (You +said you were the President's wife?) "No." (Are you married?) +"No." (You talked about the kingdom?) "I own the kingdom" +(affectlessly). (Where is Vincent?) "Here." (Have you heard<!-- Page 171 --><span class='pagenum'><a name="Page_171" id="Page_171">[171]</a></span> +him?) "Yes." (What did he say?) "Nothing." (Is he all +right?) "Yes." (Where is your mother?) "Home." (Why +don't you go home?) "I can't." (Why not?) "I can't." (Why +not?) "The family tree is broken, the Cardinal." (What about +him?) "Nothing." (Retrospectively she said later she thought +her brother was a cardinal.)</p> + +<p><i>December 8:</i> When her mother visited her she said "It is +about time you come—I thought you were dead." Has walked +down the hall "looking" for her dead cousin. When asked if she +wanted to see her brother, said, "Ain't he dead?"</p> + +<p><i>December 12:</i> Cries out in an affectless tone like a huckster, +"Father MacN., take me to Heaven," repeating this over and over.</p> + +<p><i>December 15:</i> Quiet as a rule, then for a time at the door, +pulling at it and with whining voice but affectlessly saying "Give +me the key—I want to go to the river—you can't keep me from +Heaven—it is either Heaven or the river, give me the keys, give +me the keys, open the door," "The niggers are taking possession." +To the physician to whom she had claimed to be married, often +repeats "You don't belong to me, I don't belong to you." (What +about the niggers?) "A band of niggers, that is all they are." +(Are the nurses niggers?) "That is all they are." Asked about +her people, she says "They are in Heaven." (Where are you?) +"I am in Heaven" (without change of expression). Again, when +asked where her people are, says "At home." Then she went +willingly back to bed and was quiet. In the afternoon she again +went to the door and tried to get out. When questioned, she +said "I don't want to be an animal," "Everybody is making an +animal of me" (pointing to an animal picture). Then again, +while trying the door, repeats in the same affectless manner that +she wants to go "to the river," "to the bottom of the river," "to +Heaven to see my mother." This last was said in a whining +tone, with some tears. She kept turning the knob, tried to get +the keys, and struggled impulsively when prevented.</p> + +<p><i>December 23:</i> Though quiet on the whole, when a visitor came +yesterday, she ran after this woman saying "I want my generations," +and clung to her, and to-day at intervals keeps talking +about wanting to see her generations but is often quiet. (Retrospectively +she said she wanted to see all her ancestors from the +beginning of time.)</p> + +<p><!-- Page 172 --><span class='pagenum'><a name="Page_172" id="Page_172">[172]</a></span> +<i>December 27:</i> Of late often talks affectlessly about wanting +to die or wanting to go to Heaven, struggling impulsively to get +medicine away from the nurses, asking for poison, trying to drink +her own urine, or even the fluid in the bed pan after she had been +given an enema, all evidently with suicidal intent.</p> + +<p><i>December 28:</i> Still constant, impulsive and apparently affectless +attempts at suicide, tries to get medicine away from nurses, +to get the fire extinguisher bottles, a bottle of ink, etc., struggling +when prevented.</p> + +<p>But when examined quiet, even smiles at a joke. When questioned, +denies feeling either worried or depressed. She said she +wanted to go home. She gave poor attention to the questions. +Later she threw a wet sheet over a patient and laughed (this is +rare). Later she slapped another patient. Again she began to +talk about wishing to go to the grave. Calls Dr. M. "Uncle John."</p> + +<p><i>December 30:</i> Talks either about wanting to die, or wanting +to go to Heaven, or wanting to go to Ireland, all this as usual +in an affectless way. Calls Dr. M. "Uncle John." Keeps shouting +"Take me to Ireland."</p> + +<p><i>January 9, 1914:</i> Often quiet in bed, again goes to door, +talks about wanting to go "to Heaven" or "to Ireland." On the +whole, says little.</p> + +<p>It seems, then, that the transition was not abrupt, that many +traits of the first period remained, but that she was on the whole +much quieter, with the exception of some spells when she insisted +on going out or killing herself. At such times she showed an +affectless, impulsive excitement. Whether there was an element +of perplexity then is not clear from the notes. The topics of +which she spoke also changed. The idea of wealth was rarely +expressed, also the idea of marriage was much in the background, +but prominent ideas were those of death, Heaven, killing herself, +going to Ireland—all of which she produced in an affectless way. +It should be added that she persistently wet and soiled during +this, as well as in the first period.</p> + +<p>3. Then followed three months of greater inactivity. She lay +in bed gazing, moving very little, not even when her meals were +brought. She answered but little and consistently wet and soiled. +This state lasted from about the middle of February until the +beginning of April.</p> + +<p><!-- Page 173 --><span class='pagenum'><a name="Page_173" id="Page_173">[173]</a></span> +4. From this stuporous state she emerged during the next +four weeks, the awakening being associated with persistent efforts +to arouse her. She then was, for six or seven weeks, nearly +normal, so far as her mood went, but had a tendency to cling to +some of her ideas and was overtalkative. Her memory for the +earlier phases of the psychosis was good, as she recalled not only +many external events but most of her false ideas. She said, +however, that her mind had been a blank for the third stage and +she remembered nothing of it. At the end of this time she cleared +up entirely and was discharged as "recovered." She continued +well for some months, during which she was occasionally examined.</p></div> + +<p>This case gives an excellent example of the relationship +of stupor to other manic-depressive reactions. +She begins with an absorbed state, showing +elements of perplexity and mania. With this there +are expansive ideas but, also, statements about +losing everything and being in prison, which suggest +abandonment of life. Next, with increasing +apathy, she begins to speak of death and soon makes +impulsive suicidal attempts. Evidently her mind +was becoming more and more focused on death and +with this there was an appropriate emotional +change. She was either apathetic or the affect exhibited +itself in pure impulsiveness. Then comes +the stupor, when all ideas disappear and mentation +is reduced or absent. When the stupor lifts, the +original ideas appear not only in memory but occasion +a wavering insight. It is appropriate that +she recalled all of her psychosis fairly well with the +exception of the pure stupor, which she remembered +only as a time when her mind was a blank.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_7_8" id="Footnote_7_8"></a><a href="#FNanchor_7_8"><span class="label">[7]</span></a> Hoch, August, and Kirby, George H.: "A Clinical Study of +Psychoses Characterized by Distressed Perplexity." <cite>Archives of +Neurology and Psychiatry</cite>, April, 1919, Vol. I, pp. 415-458.</p></div> + +<div class="footnote"><p><a name="Footnote_8_9" id="Footnote_8_9"></a><a href="#FNanchor_8_9"><span class="label">[8]</span></a> Hoch, August: "A Study of the Benign Psychoses." <cite>Johns +Hopkins Hospital Bulletin</cite>, May, 1915, XXVI, 165.</p> + +<p>A book on "the psychology of manic-depressive insanity" will +shortly appear by the editor.</p></div> +</div> + +<p><!-- Page 174 --><span class='pagenum'><a name="Page_174" id="Page_174">[174]</a></span></p> + +<h2>CHAPTER IX<br /> +<span class="sm">THE PHYSICAL MANIFESTATIONS OF STUPOR</span></h2> + +<p>We must now discuss the most difficult of all the +aspects of the stupor problem. The subject is so +involved and the evidence so inconclusive that observers +will probably interpret the phenomena here +reported according to their individual preconceptions. +What we have to say is therefore published +not so much to convince as to stimulate further +work. The problem is wider than that of the mere +etiology of the stupors we are considering. Their +relationship to manic-depressive insanity is so intimate +that we must tentatively consider this affectless +reaction as belonging to that larger group. A +discussion of the basic pathology of manic-depressive +insanity is outside the sphere of this book. The +author, therefore, thinks it advisable to state somewhat +dogmatically his view, as to the etiology of +these affective reactions, merely as a starting point +for the argument concerning stupors specifically.</p> + +<p>It is our view that the manic-depressive psychoses +may be, and probably are, determined remotely but +fundamentally by an inherent neuropsychic defect, +but this physical and constitutional blemish is non-specific. +The actual psychosis is determined by<!-- Page 175 --><span class='pagenum'><a name="Page_175" id="Page_175">[175]</a></span> +functional, that is, psychological factors. A predisposed +individual exposed to a certain psychic stress +develops a manic-depressive psychosis. Naturally +any physical disease reduces the capacity for normal +response to mental difficulties; hence physical +illness may facilitate the production of a psychosis. +But this intercurrent factor is also non-specific.</p> + +<p>Such is our view of the etiology of manic-depressive +insanity as a whole. When we approach the +study of benign stupors, however, difficult problems +appear. As will be discussed in a later chapter on +the literature, reactions resembling benign stupors +occur as a result of toxins, particularly following +acute rheumatism. Recently the medical profession +has been called on to treat many cases of encephalitis +lethargica where similar symptoms are observed. +If the resemblance amounted to identity, we would +have to admit that a specific toxin may produce a +specific mental reaction which we have concluded on +other grounds to be psychogenic. As a matter of fact, +in two particulars these reactions show relationship +to organic delirium. Knauer reports that in post-rheumatic +stupors illusions are frequent—an ice +bag thought to be a cannon, or a child, etc.—and +there are bizarre misinterpretations of the physical +condition, such as lying on glass splinters, animals +crawling on the body, and so on. Such illusions are, +in our experience, not found in stupor, and, on the +other hand, are cardinal symptoms of delirium. +Further, Knauer reports that even at the height of +post-rheumatic stupor, external stimuli make some<!-- Page 176 --><span class='pagenum'><a name="Page_176" id="Page_176">[176]</a></span> +impression, in that a thoughtful facial expression +appears. In deep stupors, such as occurred in our +series, this response is not seen. The same phenomenon +of "rousing," larval in Knauer's cases, +is often well marked in encephalitis lethargica and +is, of course, a pathognomonic symptom of delirium. +We might therefore think that these conditions are +mixtures of two organic tendencies, namely, delirium +and coma. It is not impossible that resemblances +to benign stupor are due to functional elements +appearing in the reduced physical state as +additions to the organic symptoms. The prominence +of pain might be taken as a likely cause for +an instinctive reaction of withdrawal, which would +account for the emotional palsy of these conditions +on psychogenic grounds. [This argument can be +better understood when the chapter on Psychological +Explanation of Stupor has been read.] We therefore +feel justified in holding that the resemblance +of the symptoms of certain plainly organic reactions +to those of benign stupor do not necessitate a splitting +of these stupors from the manic-depressive +group.</p> + +<p>When we consider certain bodily manifestations +of these typical stupors, however, fresh difficulties +are encountered. Unlike depressions, elations and +anxieties, certain physical symptoms appear with +frequency, even regularity. This would seem to indicate +the presence of physical disease. Inasmuch +as the most constant of them is fever, the natural +conclusion would be that we are dealing with an<!-- Page 177 --><span class='pagenum'><a name="Page_177" id="Page_177">[177]</a></span> +infection which produces a mental state called stupor. +If we were not faced with an obvious relationship +to manic-depressive insanity, where such symptoms +are usually accidental and intercurrent, we +would accept this explanation, but this quandary necessitates +further analysis.</p> + +<p>Let us first consider the fever. In 35 cases, on +whom data of temperature could be found from the +records extant, 28 showed fever usually running +between 99 and 100, often up to 101 or slightly +over this point. When these cases were analyzed, +however, it was found that 27 were typical and 8 +atypical, showing pictures resembling those described +in the last chapter. Of the latter only one +had a rise of temperature, while of the typical group +only one was afebrile. Therefore, since out of 27 +typical cases 26 had the typical slight fever, we must +conclude it to be a highly specific symptom. Of +these 28 cases the incidence of the fever was as follows: +8 showed it only on admission; in 7 it was +highest on admission but continued at a low rate +throughout the rest of the psychosis; in 5 it extended +without much variation throughout the psychosis; +in 4 it appeared intermittently, while in 2 it was +accentuated during periods when the mental symptoms +were most pronounced. We see, then, that +there is a distinct tendency for the fever to be associated +with the onset of the disease.</p> + +<p>When we look for other data from which we might +discover causes for the fever, we find less than we +would like. The records are of observations made,<!-- Page 178 --><span class='pagenum'><a name="Page_178" id="Page_178">[178]</a></span> +some of them, twenty years ago. Although the +mental examinations were careful, the records of the +physical symptoms either were not made or were +lost in many cases. Consequently our description +must be tentative and is published merely to stimulate +further research as cases come to the attention +of psychiatrists.</p> + +<p>One looks, first, for other evidence of infection. +Some of the cases were thoroughly examined with +modern methods and nothing whatever found. +Blood examinations were made in five cases; three +of these had rather high temperature with the following +blood pictures: Charles O., 103, leucocytosis +of 23,000, with 91.5% polymorphonuclears; Annie G. +(Case 1), 103, leucocytosis of 12,000 to 15,000, and +89% polymorphonuclears; Caroline DeS. (Case 2), +104, 15,000 leucocytes, no differential made, Widal +and diazo reaction negative. These three cases, +then, had marked febrile reactions and leucocytosis. +It is quite possible that they had infections which +were not discovered. Of the other two Rosie K. +(Case 11) had a temperature of 100 and 17,500 +leucocytes associated with a fetid diarrhea, an unquestioned +infection, while Mary C. (Case 7), with +a temperature of only 100, had no rise in number +of total white cells but 41% of lymphocytes. This +last might be due to an internal secretion or an involuntary +nervous system anomaly. The possibility +of the three high temperatures with leucocytosis +being due to intercurrent infections must be +considered. Charles O. had high fever only for ten<!-- Page 179 --><span class='pagenum'><a name="Page_179" id="Page_179">[179]</a></span> +days during a psychosis of several months. Annie +G.'s high fever was of about the same duration. +Caroline DeS. had short periods of marked pyrexia +in the first and seventh months of her long psychosis. +Except for these episodes, these three patients +had the typical slight elevation of temperature. +Three cases out of thirty-five, in which high fever and +leucocytosis appeared episodically, are hardly +enough to justify the view that stupors are the result +of a specific infection. We must remember, too, that +no focal neurological symptoms are ever observed, +which makes the possibility of a central nervous +system infection highly unlikely.</p> + +<p>An alternative view might be that the slight rise +of fever is somehow the result of stupor, not the +cause of it. The editor consulted Professor Charles +R. Stockard, of Cornell Medical College, as to this +possibility. The following argument is the result +of his suggestions:</p> + +<p>What we call a normal temperature is, of course, +the result of a balance maintained between heat production +and heat loss. Either an increase in the +former or a decrease in the latter must produce +fever. It is possible that heat production may be +increased in many stupors as a result of the muscular +rigidity. Some cases showed higher temperature +when this was more marked, but this was not +sufficiently constant to justify any conclusions being +drawn.</p> + +<p>Heat loss occurs preponderantly as a result of radiation +from the skin and by sweating with conse<!-- Page 180 --><span class='pagenum'><a name="Page_180" id="Page_180">[180]</a></span>quent +evaporation of the secretion. These processes +are functions of the skin and surface circulation. +Are they disturbed in our stupors? We find considerable +evidence that they are. Flushing or dermatographia +occurred in six cases, cold or blue +extremities in four cases, greasy skin in four, +marked sweating in three, the hair fell out in two +cases, while the skin was pathologically dry in one +case, in fact there were few patients who showed +normal skin function. Circulatory anomalies were +also observed. The pulse was very rapid in eleven +cases, weak or irregular in two, and slow in one +case. All these symptoms are expressions of imbalance +in the involuntary nervous system, further +evidence of which is found in the rapid respiration +of six cases and the shallow breathing of one patient. +These pulse and respiration findings are the more +striking in that individuals in stupor are, by the +very nature of their disease, free from emotional +excitement.</p> + +<p>This imbalance could result from a poverty of circulating +adrenalin which is necessary for the activation +of the sympathetic nerves. A cause for low +suprarenal function is to be found in the apathy of +the stupor case. As Cannon and his associates have +so conclusively demonstrated, any emotion which +was open to investigation resulted in an increase of +adrenalin output. As our emotions are constantly +operating during the day—and often enough during +sleep as well in connection with dreams—we must +presume that emotional stimulus is a normal excitant<!-- Page 181 --><span class='pagenum'><a name="Page_181" id="Page_181">[181]</a></span> +for the production of adrenalin. It is therefore inconceivable +that the blood could receive its normal +supply of adrenalin with an apathy of the degree +seen in stupor unless some purely hypothetically +substitutive excitant were found.</p> + +<p>We may therefore tentatively assume that the +fever which marks the onset and frequently the +course of these benign stupors is the result of a +failure of the heat loss function, this being due to +an imbalance in the involuntary nervous system that +is occasioned, in turn, by insufficient circulating adrenalin, +and the final cause for the poor suprarenal +function is to be traced to the most consistent symptom +of the stupor, namely, apathy. This hypothesis +is welcome, not only because it would account adequately +for the fever, but it also tends to accentuate +the relationship with other forms of manic-depressive +insanity, all of which are marked fundamentally +by a pathological emotion. Naturally +enough, one turns to the records again to see if the +blood-pressure of these patients was low, as would +be expected with a poor adrenalin supply. Unfortunately +record was made of the blood-pressure +in only two cases, in both of which the reading was +110 m.m. Two such isolated observations mean, of +course, nothing whatever. It is possible that the +drooling which so many stupor cases show is not +merely the result of the failure of the swallowing +reflex, but represents as well a compensation for +anhydrosis by excessive salivary secretion.</p> + +<p>Another symptom suggestive of involuntary ner<!-- Page 182 --><span class='pagenum'><a name="Page_182" id="Page_182">[182]</a></span>vous +system or endocrine disorder is the highly frequent +suppression of the menstrual function. At +times this may occur as a sequel to mental shock, +as it did in the case of Celia H. (Case 19), who was +menstruating when, frightened by the suicidal attempt +of her brother, the flow ceased abruptly. +That purely psychic factors can produce marked +changes in such functions has been demonstrated by +Forel and other hypnotists time and again; presumably +the effect is produced by way of alteration in +the endocrine or involuntary nervous system influence. +In such cases, however, we can trace the menstrual +suppression directly to an emotional cause. +On the other hand, most women in stupor fail to +menstruate during the bulk of the psychosis at a time +when we believe emotions to be absent or greatly reduced +in their intensity. The recent work of Papanicolaou +and Stockard<a name="FNanchor_9_10" id="FNanchor_9_10"></a><a href="#Footnote_9_10" class="fnanchor">[9]</a> offers a simple explanation +for this phenomenon. They have shown that +in the guinea pig the œstrous cycle can be delayed +by starvation, while in weaker animals a period may +be suppressed completely. When one considers that +even with the greatest care the nutrition of tube-fed +patients is bound to be poor, it would be only +natural to suppose that this malnutrition would +cause such a disturbance in the œstrous cycle and +was evidenced objectively by a failure to menstru<!-- Page 183 --><span class='pagenum'><a name="Page_183" id="Page_183">[183]</a></span>ate. +Even in patients who are not tube-fed, under-nutrition +is to be expected and, as a matter of fact, is +usually observed. The work of Pawlow and Cannon +has shown how essential psychic stimulus is for gastric +digestion. Any condition of apathy would +therefore tend to retard digestion and indirectly affect +nutrition.</p> + +<p>Finally, under the heading of Physical Manifestations +of Stupor, we must consider epileptoid attacks, +of which there was a history in two of our cases, +both of which have already been described in the +first chapter of this book. Anna G. (Case 1), in her +second attack, was treated at another hospital, and +from the account which they sent it appears that +the stupor was immediately preceded by a seizure +in which the whole body jerked. This is, of course, +rather thin evidence of the existence of a definite +convulsion, but in the case of Mary F. (Case 3) we +have a fuller description. During the two days +when the stupor was incubating, she had repeated +seizures of the following nature. She sometimes +said that prior to the attacks it became dark before +her eyes and that her face felt funny or that she had +a pain in the stomach which worked toward her right +shoulder. The attack would begin when sitting in +a chair, with the closing of her eyes, clenching her +fists and pounding the side of the chair. She would +then get stiff and slide on to the floor, where she +would thrash her arms and legs about and move her +head to and fro. The warning of the pain working +from the stomach to the right shoulder is highly<!-- Page 184 --><span class='pagenum'><a name="Page_184" id="Page_184">[184]</a></span> +suggestive of an epileptic aura, although the other +symptoms mentioned so far could have been considered +hysterical or poorly described epileptic phenomena. +The rest of the description indicates an +epileptic seizure more strongly. She frothed at the +mouth and once wet herself during an attack. They +lasted only for a few minutes and she would breathe +heavily after them. At the end of one attack she +wiped the froth from her mouth with her handkerchief +and gave it to her aunt, saying, "Burn that, it +is poison." This is perhaps a little less like epilepsy. +It is plainly impossible for us to say with +any positiveness that either these were or were not +genuine convulsions, but it is nevertheless important +to record them, because such phenomena are observed +fairly frequently in dementia prcox cases +but are practically unknown in manic-depressive insanity. +This, then, would be another example of +the resemblance to dementia prcox in these stupors +which are unquestionably benign.<a name="FNanchor_10_11" id="FNanchor_10_11"></a><a href="#Footnote_10_11" class="fnanchor">[10]</a></p> + +<p><!-- Page 185 --><span class='pagenum'><a name="Page_185" id="Page_185">[185]</a></span> +We see, then, in reviewing all the physical manifestations +of the benign stupors, that none occurred +which cannot be explained as secondary to the mental +changes, and therefore, until such time as physical +symptoms are reported which cannot be so explained, +we see no reason for changing our view +that the benign stupor is to be regarded as one of +the manic-depressive reactions.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_9_10" id="Footnote_9_10"></a><a href="#FNanchor_9_10"><span class="label">[9]</span></a> Papanicolaou, G. N., and Stockard, C. R., "Effect of Under-feeding +on Ovulation and the Œstrous Rhythm in Guinea-pigs." +<cite>Proceedings of the Society of Experimental Biology and Medicine</cite>, +Vol. XVII, No. 7, Apr. 21, 1920.</p></div> + +<div class="footnote"><p><a name="Footnote_10_11" id="Footnote_10_11"></a><a href="#FNanchor_10_11"><span class="label">[10]</span></a> As a matter of fact, if the views of Clark and MacCurdy<a name="FNanchor_B_12" id="FNanchor_B_12"></a><a href="#Footnote_B_12" class="fnanchor">[B]</a> be +accepted, some reason for these epileptic-like attacks may be imagined. +According to them, epilepsy is a disease characterized by a +lack of the natural instinctive interest in the environment which +is expressed chronically in the deterioration, and episodically in +the attacks, the most consistent feature of which is loss of consciousness. +Now, in stupor we have an analogous reaction where, +although consciousness is not disturbed in the sense in which it is +in epilepsy, it is nevertheless considerably affected, inasmuch as +contact with the environment is practically non-existent. The coincident +thinking disorder is quite similar, both in epileptic dementia +and the torpor following seizures and in these benign stupors. MacCurdy +has suggested tentatively that the epileptic convulsion may +be secondary to a very sudden loss of consciousness which removes +a normal inhibition on the muscles, liberating the muscular contractions +which constitute the convulsion. If this view were correct, +it would not be hard to imagine that during the onset of these +stupors the tendency to part company with the environment, which +ordinarily comes on slowly, might occur with epileptic suddenness +and hence liberate convulsive movements. This is, however, a pure +speculation but not fruitless if it serves to draw attention to the +analogies existing between the stupor reaction and some of the mental +symptoms of epilepsy. These analogies are strong; aside from +the obvious clinical differences, the stupor and epileptic reactions +are dynamically unlike in that they are the product of different +temperaments and precipitated by different situations.</p></div> + +<div class="footnote"><p><a name="Footnote_B_12" id="Footnote_B_12"></a><a href="#FNanchor_B_12"><span class="label">[B]</span></a> Clark, L. Pierce. "Is Essential Epilepsy a Life Reaction Disorder?" +<cite>Am. Jour. of the Medical Sciences</cite>, November, 1910, Vol. +CLVIII, No. 5, p. 703. This paper gives a summary of Dr. Clark's +theories.</p> + +<p>MacCurdy, John T., "A Clinical Study of Epileptic Deterioration." +<cite>Psychiatric Bulletin</cite>, April, 1916.</p></div> +</div> + +<p><!-- Page 186 --><span class='pagenum'><a name="Page_186" id="Page_186">[186]</a></span></p> + +<h2>CHAPTER X<br /> + +<span class="sm">PSYCHOLOGICAL EXPLANATION OF THE STUPOR +REACTION</span></h2> + +<p>In the previous chapter mention has been made +of our view that manic-depressive insanity is a +disease fundamentally based on some constitutional +defect, presumably physical, but that its +symptoms are determined by psychological mechanisms. +In accordance with this hypothesis we seek, +when studying the different forms of insanity presented +in this group, to differentiate between the +different types of mental mechanisms observed, and +by this analysis to account for the manifestations of +the disease on purely psychological lines. If benign +stupors belong to this group, then we should +be able to find some specific psychology for this type +of reaction.</p> + +<p>All speech and all conduct, except simple reflex behavior, +are presumably determined by ideas. When +an individual is not aware of the purpose governing +his action, we assume, in psychological study, that an +unconscious motive is present, so that in either case +the first step in psychological understanding of any +normal or abnormal condition is to discover, if +possible, what the ideas are that lead to the actions<!-- Page 187 --><span class='pagenum'><a name="Page_187" id="Page_187">[187]</a></span> +or utterances observed. In the case of stupors the +situation is fairly simple, in that the ideational content +is extremely limited. As has been seen, it is +confined to death and rebirth fancies, other ideas being +correlated with secondary symptoms, such as +belong to mechanisms of other manic-depressive +psychoses. It is not necessary to repeat the catalogue +of the typical stupor ideas, as they have been +given in an earlier chapter. Our task is now to +consider the significance of these death and rebirth +delusions and their meaning for the stupor reaction.</p> + +<p>Thoughts concerned with future and new activities +require energy for their completion in action and +are therefore naturally accompanied by a sense of +effort which gives pleasure to an active mind. When +the sum of energy is reduced, one observes a reverse +tendency called "regression." It is easier to +go back over the way we know than to go forward, +so the weakened individual tends to direct his attention +to earlier actions or situations. To meet a +new experience one must think logically and keep +his attention on things as they are, rather than imagine +things as one would like to have them.</p> + +<p>Progressive thinking is therefore adaptive, while +regressive thinking is fantastic in type, as well as +concerned with the past—a past which in fancy takes +on the luster of the Golden Age. Sanity and insanity +are, roughly speaking, states where progressive +or regressive thinking rule. The essence of a +functional psychosis is a flight from reality to a retreat +of easeful unreality.</p> + +<p><!-- Page 188 --><span class='pagenum'><a name="Page_188" id="Page_188">[188]</a></span></p><p>Carried to the extreme, regression leads one in +type of thinking and in ideas back to childhood and +earliest infancy. The final goal is a state of mental +vacuity such as probably characterizes the infant at +the time of birth and during the first days of extra-uterine +life. In this state what interest there is, +is directed entirely to the physical comfort of the +individual himself, and contact with the environment +is so undeveloped that efforts to obtain from it the +primitive wants of warmth and nutrition are confined +to vague instinctive cries. Evolution to true +contact with the world around implies effort, the +exercise of self-control, and also self-sacrifice, since +the child soon learns that some kind of <i lang="la">quid pro quo</i> +must be given. Viewed from the adult standpoint, +the emptiness of this early mental state must seem +like the Nirvana of death. At least death is the +only simple term we can use to represent such a complete +loss of our habitual mental functions. When +life is difficult, we naturally tend to seek death. +Were it not for the powerful instinct of self-preservation, +suicide would probably be the universal mode +of solving our problems. As it is, we reach a compromise, +such as that of sleep, in which contact with +reality is temporarily abandoned. In so far as sleep +is psychologically determined, it is a regressive phenomenon. +It is interesting that the most frequent +euphemism or metaphor for death is sleep. Sleep +is a normal regression. It does not always give the +unstable individual sufficient relaxation from the demands +of adaptation and so pathological regressions<!-- Page 189 --><span class='pagenum'><a name="Page_189" id="Page_189">[189]</a></span> +take place, one of which we believe stupor to be. +It is important to note that objectively the resemblance +between sleep and stupor is striking. So far +as mental activity in either state can be discovered +by the observer, either the sleeper or the patient in +stupor might be dead. Briefly stated, then, our hypothesis +of the psychological determination of stupor +is that the abnormal individual turns to it as a +release from mental anguish, just as the normal +human being seeks relief in his bed from physical +and mental fatigue. When this desire for refuge +takes the shape of a formulated idea, there are delusions +of death.</p> + +<p>The problem of sleep is, of course, bound up with +the physiology of rest, and as recuperation, in a +physical sense, necessitates temporary cessation of +function, so in the mental sphere we see that relaxation +is necessary if our mental operations are to be +carried on with continued success. This is probably +the teleological meaning of sleep in its psychological +aspects, for in it we abandon diurnal adaptive +thinking and retire to a world of fancy, very often +solving our problems by "sleeping over them." +The innate desire for rest and a fresh start is almost +as fundamental a human craving as is the tendency +to seek release in death. In fact the two are +closely associated both in literature and in daily +speech, for in many phases we correlate death with +new life. If one is to visualize or incorporate the +conception of new life in one term, rebirth is the +only one which will do it, just as death is the only<!-- Page 190 --><span class='pagenum'><a name="Page_190" id="Page_190">[190]</a></span> +word which epitomizes the idea of complete cessation +of effort. Not unnaturally, therefore, we find in +the mythology of our race, in our dreams and in the +speech of our insane patients, a frequent correlation +of these two ideas, whether it comes in the crude +imagery of physical rebirth or projected in fantasies +of destruction and rebuilding of the world. +Many of our psychotic patients achieve in fancy that +for which the Persian poet yearned:</p> + +<div class="poem"><div class="stanza"> +<span class="i0">"Ah Love! could you and I with Him conspire<br /></span> +<span class="i1">To grasp this Sorry Scheme of Things entire,<br /></span> +<span class="i1">Would we not shatter it to bits—and then<br /></span> +<span class="i1">Re-mold it nearer to the Heart's Desire!"<br /></span> +</div></div> + +<p>A vision of a new world is a content occurring not +infrequently in manic states, but before the universe +can be remolded it must be destroyed. Before the +individual can enjoy new life, a new birth, he must +die, and stupor often marks this death phase of a +dominant rebirth fantasy. In this connection it +was not without significance to note that stupors +almost universally recover by way of attenuation +of the stupor symptoms, or in a hypomanic phase +where there seems to be an abnormal supply of energy. +Antus-like, they rise with fresh vigor from +the Earth. They do not pass into depressions or +anxieties.</p> + +<p>Rebirth fancies unquestionably, then, contain +constructive and progressive elements, but, as has +been stated above, any thinking which implies a +lapse of contact with the environment is, in so far<!-- Page 191 --><span class='pagenum'><a name="Page_191" id="Page_191">[191]</a></span> +as that lapse is concerned, regressive, and in consequence +rebirth fancies, as dramatized by the stupor +patients, are regressive, just as are the delusions +of death itself.</p> + +<p>It is obvious that an acceptance of death implies +rather thorough mental disintegration. Before that +takes place there may be some mental conflict. The +instinct of self-preservation may prevent the individual +from welcoming the notion of dissolution, so +that this latter idea, though insistent, is not accepted +but reacted to with anxiety; hence we often meet +with onsets of stupor characterized by emotional +distress. It has already been suggested that death +may foreshadow another existence. Often in the +psychoses we meet with the idea of eternal union +in death with some loved one whom the vicissitudes +and restrictions of this life prevent from becoming +an earthly partner. This fancy is frequently the +basis of elation. Similarly, new life in a religious +sense as expressed in the delusion of translation to +Heaven, is a common occasion for ecstasy. These +formulations of the death idea may occur as tentative +solutions of the patient's problems leading to +temporary manic episodes while the psychosis is incubating. +It seems that stupor as such appears +only when death and nullity are accepted.</p> + +<p>The above are more or less a priori reasons for +regarding the stupor as a regressive reaction. We +must now consider the clinical evidence to support +this view. In the first place, we always find that +stupor occurs in an individual who is unhappy and<!-- Page 192 --><span class='pagenum'><a name="Page_192" id="Page_192">[192]</a></span> +who has found no other solution than regression +for the predicament in which he is. There is nothing +specific in the cause of this unhappiness. At +times the factors producing it are mainly environmental; +at others, the problem is essentially of the +patient's own making. Of course almost any type +of functional psychosis may emerge from such a +state of dissatisfaction, but it is important to note +that unlike manic states, for instance, stupors invariably +develop from a situation of unhappiness. +Quite frequently the choice of the stupor regression +is determined by some definitely environmental event +which suggests death. This often comes as the actual +death of the patient's father (in the case +of a woman) or employer, events which inflate the +already existing, although perhaps unconscious, desire +for mutual death. Again, the precipitating +factor may be a situation which adds still another +problem and makes the burden of adaptation intolerable, +forcing on him the desire for death. In these +cases the actual psychosis is sometimes ushered in +dramatically with a vision of some dead person +(often a woman's father) who beckons, or there are +dream-like experiences of burial, drowning, and +so on.</p> + +<p>A few cases taken at random from our material +exemplify these features of the unhappiness in +which the psychosis appears as a solution with its +development of the death fancy.</p> + +<p>Alice R., at the age of 25, was much troubled +by worrying over her financial difficulties and the<!-- Page 193 --><span class='pagenum'><a name="Page_193" id="Page_193">[193]</a></span> +shame of an illegitimate child. Retrospectively she +stated, "I was so disgusted I went to bed—I just +gave up hope." Shortly before admission she said +she was lost and damned, and to the nurse in the +Observation Pavilion she pleaded, "Don't let me +murder myself and the baby."</p> + +<p>Caroline DeS. (Case 2) for some time was worried +over the engagement of her favorite brother to a +Protestant (herself a Catholic) and the threatened +change of his religion. At his engagement dinner +she had a sudden excitement, crying out, "I hate her—I +love you—papa, don't kill me." This excitement +lasted for three weeks, during two of which +she was observed, when she spoke frequently of being +killed and going to Heaven. The conflict was +frankly stated in the words, "I love my father but +don't want to die." Then for two weeks she had +some fever, was tube-fed, muttered about being +killed or showed some elation, there being apparently +interrupted stuporous, manic and, possibly, +anxiety episodes. Finally she settled down to a +year of deep stupor.</p> + +<p>Laura A. had for three months poor sleep with +depression over her failure in study. Another +cause for worry was that her father was home and +out of work. She reached a point where she did +not care what happened but continued working. +Ten days before admission she was not feeling well. +The next morning she woke up confused and frightened, +speedily became dazed, stunned, could not +bring anything to her memory. This rather sudden<!-- Page 194 --><span class='pagenum'><a name="Page_194" id="Page_194">[194]</a></span> +stupor onset was not accompanied by any false ideas, +at least none which the family remembered.</p> + +<p>Mary C. (Case 7) was an immigrant who felt +lonely in the new country. Two weeks before admission +her uncle with whom she was living died. +She thought she had brought bad luck, complained +of weakness and dizziness, then suddenly felt mixed +up, her "memory got bad," and she thought she was +going to die. Next she was frightened, heard voices, +thought there was shooting and a fire. For a short +time she was inactive and later began shouting +"Fire!" When taken to the Observation Pavilion, +she was dazed, uneasy, thought she was on a boat or +shut up in a boat which had gone down; all were +drowned. Then came a mild stupor.</p> + +<p>Maggie H. (Case 14), while pregnant, fancied +that her baby would be deformed and that she would +die in childbirth. Three weeks before admission +this event took place. For five days she worried +about not having enough milk, about her husband +losing his job (he did lose it) and thought her head +was getting queer. On the fifth day she cried, said +she was going to die, that there was poison in the +food, that her husband was untrue to her. She became +mute but continued to attend to her baby. She +saw dead bodies lying around, and by the time she +was taken to the Observation Pavilion was in a +marked stupor.</p> + +<p>Turning now to the symptoms of the stupor +proper, we note, first, the effects of the loss of energy +which regression implies. The inactivity and<!-- Page 195 --><span class='pagenum'><a name="Page_195" id="Page_195">[195]</a></span> +apathy which these patients show is too obviously +evidence of this to require further comment. Another +proof of the withdrawal of the libido or interest +is found in the thinking disorder. Directed, +accurate thinking requires effort, as we all know +from the experience of our laborious mistakes when +fatigued. So in stupor there is an inability to perform +simple arithmetical problems, poor orientation +is observed, and so on. Similarly what we remember +seems to be that which we associate with the +impressions received by an active consciousness. +Actual events persist in memory better than those +of fancy, in proof of which one thinks at once of +the vanishing of dreams on waking, with its restablishment +of extroverted consciousness. This registration +of impressions requires interest and active +attention. Without interest there is no attention +and no registration. The patient in stupor presents +just the memory defect which we would expect. Indifference +to his environment leads to a poor memory +of external events, while on recovery there may +be such a divorce between consciousness of normal +and abnormal states that the past delusions are +wiped from the record of conscious memory. Withdrawal +of energy then produces not only inactivity +and apathy but grave defects in intellectual capacity.</p> + +<p>The natural flow of interest in regression is to +earlier types of ambition and activity. This is betrayed +not merely by the thought content dealing +with the youth and childhood of the patient, but also +is manifested in behavior. Excluding involution<!-- Page 196 --><span class='pagenum'><a name="Page_196" id="Page_196">[196]</a></span> +melancholia there is probably no psychosis in which +the patients exhibit such infantile reactions as in +stupor. Except for the stature and obvious age of +these patients, one could easily imagine that he was +dealing with a spoiled and fractious infant. One +thinks at once of the negativism which is so like +that of a perverse child and of the unconventional, +personal habits to which these patients cling so stubbornly. +Masturbation, for instance, is quite frequent, +while willful wetting and soiling is still more +common. We sometimes meet with childishness, +both in vocabulary and mode of expression. In one +case there was evidently a delusion of a return to +actual childhood, for she kept insisting that she was +"in papa's house."</p> + +<p>The frequency with which the delusion of mutual +death occurs in stupor is another evidence of its +regressive psychology. The partner in the spiritual +marriage is rarely, if ever, the natural object of +adult affection, but rather a parent or other relative +to whose memory the patient has unconsciously +clung for many years, reawakening in the psychosis +an ambition of childhood for an exclusive possession +that reaches its fulfillment in this delusion. Closely +allied with this is another delusion, that of being +actually dead, which the patients sometimes express +in action, even when not in words. The anesthesia +to pin pricks, the immobility and the refusal to recognize +the existence of the world around, in patients +who give evidence of some intellectual operations +still persisting, are probably all part of a feigned<!-- Page 197 --><span class='pagenum'><a name="Page_197" id="Page_197">[197]</a></span> +death, with the delusion expressing itself in corpse-like +behavior.</p> + +<p>Finally we must consider the meaning of the deep +stupor where no mentation of any kind can be proven +and where none but vegetative functions seem to be +operating. This state is either one of organic coma, +in which case it marks the appearance of a physical +factor not evidenced in the milder stages, or else it +is the acme of this regression by withdrawal of interest. +As has been stated, back of the period of +primitive childish ideas there lies a hypothetical +state of mental nothingness. If we accept the principle +of regression we find historically an analogue +to what is apparently the mental state of deep stupor +in the earliest phases of infancy. This view receives +justification from the study of the phenomenon +of variations in symptoms. Mental faculties at +birth are larval, and if such condition be artificially +produced mental activity must be potentially present +(as it would not be if we were dealing with +coma). In Chapter IV phenomena of interruption +of stupor symptoms were detailed. One case that +was mentioned is now of particular importance as +demonstrating that an appropriate stimulus may +dispel the vacuity of complete stupor by raising +mental functions to a point where delusions are entertained. +This patient retrospectively recalled +only certain periods of her deepest stupor, occasions +when she was visited by her mother. At these times, +as she claimed, she thought she was to be electrocuted +and told her mother so, adding, "Then it<!-- Page 198 --><span class='pagenum'><a name="Page_198" id="Page_198">[198]</a></span> +would drop out of my mind again." Otherwise her +memory for this state was a complete blank. Here +we see a normal stimulus producing not normality +but something on the way towards it, that is, a +condition less profound than the state out of which +the patient was temporarily lifted.</p> + +<p>This case exemplifies the principle of levels in the +stupor reaction which we have found to be of great +value in our study. These levels are correlated +with degrees of regression, as a review of the symptoms +discussed above may show. In the first place, +the dissatisfaction with life, the first phase of regression, +leads to the quietness—the inactivity and +apathy, which are the most fundamental symptoms +of the stupor reaction as a whole. Initiative is lost +and with this comes a tendency for the acceptance +of other people's ideas. That is the probable basis +for the suggestiveness which we concluded was a +prominent factor in catalepsy. Indifference and +stolidity may exist with those milder degrees of regression +which do not conflict with one's critical +sense, and hence may be present without any false +ideas. The next stage in regression is that where +the idea of death appears. Although not accepted +placidly by the subject, its non-acceptance is demonstrated +by the idea being projected—by its appearance +as a belief that the patient will be killed. This +notion of death coming from without has again two +phases, one with anxiety where normality is so far +retained that the patient's instinct of self-preservation +produces fear, and a second phase where this in<!-- Page 199 --><span class='pagenum'><a name="Page_199" id="Page_199">[199]</a></span>stinct +lapses and the patient so far accepts the idea +of being killed as to speak of it with indifference. +The next step in regression is marked by the spoiled-child +conduct, interest being so self-centered as to +lead to autoerotic habits and the perverse reactions +which we call negativism. When death is accepted +but mental function has not ceased, the latter is confined +to a dramatization of death in physical symptoms +or to such speech and movements as indicate +a belief that the patient is dead, under the water, or +in some such unreal situation. Finally, when all +evidence of mentation in any form is lacking, we see +clinically the condition which we know as deep stupor +and which we must regard psychologically as +the profoundest regression known to psychopathology, +a condition almost as close to physiological unconsciousness +as that of the epileptic.</p> + +<p>Naturally we do not see individual cases in which +all these stages appear successively, each sharply +defined from its predecessor. To expect this would +be as reasonable as to look for a man whose behavior +was determined wholly by his most recent experience. +Any psychologist knows that every +human being behaves in accordance with influences +whose history is recent or represents the habit of a +lifetime. At any given minute our behavior is not +simply determined by the immediate situation, but is +the product of many stages in our development. +Quite similarly we should not expect in the psychoses +to find evidences of regression to a given period of +the individual's life appearing exclusively, but<!-- Page 200 --><span class='pagenum'><a name="Page_200" id="Page_200">[200]</a></span> +rather we should look for reactions at any given +time being determined preponderantly by the type +of mentation characteristic for a given stage of his +development. As a matter of fact, we see in psychoses, +particularly in stupor, more sharply defined +regressions to different levels than we ever see in +normal life.</p> + +<p>Our psychological hypothesis would be incomplete +and probably unsound if it could not offer as valid +explanations for the atypical features in our stupor +reactions as for the typical. The unusual features +which one meets in the benign stupors are ideas or +mood reactions occurring apparently as interruptions +to the settled quietude or in more protracted +mild mood reactions, such as vague distress, depression +or incomplete manic symptoms, which have been +described in the chapter on affect. The interruptions +are easily explained by the theory of regression. +If stupor represents a complete return to the +state of nothingness, then the descent to the Nirvana +or the re-ascent from it should be characterized +by the type of thinking with the appropriate mood +which belongs to less primitive stages of development. +A review of our material seems to indicate +that there is a definite relationship between the type +of onset and the character of the succeeding stupor. +For instance, in the cases so far quoted in this book, +the onsets characterized by mere worry and unhappiness +and gradual withdrawal of interest had all +of them typical clinical pictures. On the other +hand, of those who began with reactions of definite<!-- Page 201 --><span class='pagenum'><a name="Page_201" id="Page_201">[201]</a></span> +excitement, anxiety or psychotic depression, there +were interruptions which looked like miniature +manic-depressive psychoses in all but one case. +This would lead one to think that these patients retraced +their steps on recovery or with every lifting +of the stupor process, moved slightly upward on +the same path on which they had traveled in the first +regression. The case of Charlotte W. (Case 12), +which is fully discussed in the chapter on Ideational +Content, offers excellent examples of these principles.</p> + +<p>The next atypical feature is the phenomenon of +reduction or dissociation of affect, the frequency of +which is mentioned in Chapter V. As the law of stupor +is apathy, normal emotions should be reduced +to indifference and no abnormal moods, such as elation, +anxiety or depression, should occur. What +often happens is that these psychotic affects appear +but incompletely, often in dissociated manifestations. +This looks like a combination of two +psychotic tendencies, the stupor reduction process +which inhibits emotional response and the tendency +to develop abnormal affects which characterize +other manic-depressive psychoses. There is no +general psychological law which makes this view unlikely. +One cannot be anxious and happy at the +same instant, although one can alternate in his feelings; +but one can fail to react adequately to a given +stimulus when inhibited by general indifference. In +fact it is because apathy is, properly speaking, not<!-- Page 202 --><span class='pagenum'><a name="Page_202" id="Page_202">[202]</a></span> +a mood but an absence of it, that it can be combined +with a true affect. It is possible, therefore, to have +a combination of stupor and another manic-depressive +reaction, while the others cannot combine but +only alternate.<a name="FNanchor_11_13" id="FNanchor_11_13"></a><a href="#Footnote_11_13" class="fnanchor">[11]</a></p> + +<p>Finally we must discuss the psychological meaning +of cases, such as those described in Chapter +VIII, where we concluded that there were +psychoses resembling stupors superficially. It +seemed likely that these patients were absorbed in +their own thoughts, rather than being in a condition +of mental vacuity. It is not difficult to explain the +objective resemblance. All evidence of emotion +(apart from subjective feeling tone which the subject +may or may not report) is an expression of contact +with the outer world. There must be externalization +of attention to environment before a mood +becomes evident. A moment's reflection will show +this to be true, for no further proof is needed than +the phenomena of dreaming. The attention being +given wholly to fantasies, the subject lies motionless, +mute and placid, although passing through varied +autistic experiences. Only when the dream becomes +too vivid, disturbs sleep and re-directs attention to +the environment—only then is emotion objectively<!-- Page 203 --><span class='pagenum'><a name="Page_203" id="Page_203">[203]</a></span> +betrayed. There is an appearance of apathy and +mental vacuity which the dreamer can soon declare +to be false. He was feeling and thinking intensely. +In any condition, therefore, such as that of perplexity +or of an absorbed manic state, the patient may +be objectively in the same condition as a typical +stupor. The histories of the two psychoses differentiate +the two reactions which may be indistinguishable +at one interview. The keynote of one reaction +is <em>indifference</em>, while that of absorption is +<em>distraction</em>, a perversion of attention to an inner, +unreal world.</p> + +<p>In summary we may recapitulate our hypotheses. +Stupor represents, psychologically speaking, the +simplest and completest regression. Adaptation to +the actual environment being abandoned, attention +reverts to earlier interests, giving symptoms of +other manic-depressive reactions in the onset or +interruptions, and finally dwindles to complete indifference. +The disappearance of affective impulse +leads to objective apathy and inactivity, while the +intellectual functions fail for lack of emotional +power to keep them going. The complicated mental +machine lies idle for lack of steam or electricity. +The typical ideational content and many of the +symptoms of stupor are to be explained as expressions +of death, for a regression to a Nirvana-like +state can be most easily formulated in such a delusion. +Other clinical conditions may temporarily +and superficially resemble stupor on account of the<!-- Page 204 --><span class='pagenum'><a name="Page_204" id="Page_204">[204]</a></span> +attention being misdirected and applied to unproductive +imaginations. To employ our metaphor +again, in these false stupors the current is switched +to another, invisible machine but not cut off as in +true stupor.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_11_13" id="Footnote_11_13"></a><a href="#FNanchor_11_13"><span class="label">[11]</span></a> The reader will note that this view is opposed to that of +Kraepelin, who has written largely on so-called "<em>mixed conditions</em>" +in manic-depressive insanity. We believe that careful clinical studies +confirm our opinion and that his classification is based on less +thorough observation and analysis. This subject will be discussed +at greater length in a forthcoming book on "The Psychology of +Morbid and Normal Emotions," by Dr. MacCurdy.</p></div> +</div> + +<p><!-- Page 205 --><span class='pagenum'><a name="Page_205" id="Page_205">[205]</a></span></p> + +<h2>CHAPTER XI<br /> +<span class="sm">MALIGNANT STUPORS</span></h2> + +<p>As we have seen, the benign stupors are characterized +by apathy, inactivity, mutism, a thinking disorder, +catalepsy and negativism. All these symptoms +are also found in the stupors occurring in dementia +prcox. In fact this symptom complex has usually +been regarded as occurring only in a malignant setting. +There can be no question about the resemblance +of benign to dementia prcox stupors. Even +such symptoms as poverty and dissociation of affect, +usually regarded as pathognomonic of dementia +prcox, have been described in the foregoing chapters. +Either recovery in our cases was accidental +or there is a distinct clinical group with a good prognosis. +If the latter be true, the symptoms must +follow definite laws; if they did not, we would have +to abandon our principles of psychiatric classification. +Naturally, then, we seek to find the differences +between the cases that recover and those that do not. +There is never any difficulty in diagnosis where a +stupor appears as an incident in the course of a recognized +case of catatonic dementia prcox. We +shall therefore consider only such clinical pictures as +resemble those described in this book, in that the<!-- Page 206 --><span class='pagenum'><a name="Page_206" id="Page_206">[206]</a></span> +symptoms on admission to a hospital or shortly +after are those of stupor. It should be our ambition +to make a positive diagnosis before failure to +recover in a reasonable time leads to a conclusion +of chronicity.</p> + +<p>It is probably safe to assume, on the basis of as +large a series as ours, that the symptoms of stupor +<i lang="la">per se</i> imply no bad prognosis. Further, it has been +noted that a relatively pure type of reaction is seen, +the symptoms appearing with tolerable consistency. +In analyzing the histories of dementia prcox patients, +therefore, one looks for inconsistencies +among, or additions to, the stupor symptoms. We +may say at the outset that we have been able to find +no case of malignant stupor that showed what we +regard as a typical benign stupor reaction, and it is +questionable whether partial stupor as we have described +it, ever occurs with a bad prognosis. Usually +the discrepant symptoms in the dementia prcox +cases are sufficiently marked to enable one to +make a positive diagnosis quite soon after the case +comes under observation.</p> + +<p>The law of benign stupor is a limitation of energy, +emotion and ideational content. In dementia prcox +we have a re-direction of attention and interest +to primitive fantastic thoughts and a consequent +perversion of energy and emotion. In many malignant +stupors one can detect evidence of this second +type of reaction in symptoms that are anomalous +for stupor. For instance, one meets with frequent +silly and inexplicable giggling. Then, too, smiling,<!-- Page 207 --><span class='pagenum'><a name="Page_207" id="Page_207">[207]</a></span> +tears or outbursts of rage, the occasions for which +are not manifest, are much more frequent than in +typical stupor. Similarly, delusional ideas (not +concerned with death at all) may appear or the patient +may indulge in speech that is quite scattered, +not merely fragmentary. Two cases may be cited +briefly to illustrate these dementia prcox symptoms +superadded to those of stupor.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 20.</span>—<i>Winifred O'M.</i> Age: 19. Single. Admitted to the +Psychiatric Institute May 6, 1911.</p> + +<p><i>F. H.</i> The occurrence of other nervous or mental disease in +the family was denied.</p> + +<p><i>P. H.</i> The patient seems to have been rather shy and goody-goody +in disposition. According to her mother this seclusiveness +did not begin to be markedly noticeable until the winter before +her psychosis, when there was some trouble about getting work. +She had previously been to a business school. Then she held a +position as stenographer temporarily. When this job was over +she had a number of positions that did not last long and was +once idle for two months. In February (three months before +admission) her father was out of work, which added to her worry.</p> + +<p><i>Onset of Psychosis:</i> Nine days before admission a young man +died in the house where they lived. The next day her mother +insisted on the patient and her sister going to the funeral. On +coming home the patient complained of being afraid and having +a funny feeling. She woke up at 2:30 that night and lit all the +gas, for which she could give no explanation. The day following, +or a week before admission, she was slow, confused, could not get +her clothes together. The next day she was restless and worried, +giving a superficial explanation for the latter. She played the +piano a great deal. The following day she was fidgety and cried. +At 4 p.m. she was put to bed and appeared to fall asleep. At +midnight when a priest called she said to him privately that she +was all over the world, that she went to the 12th floor of the +Metropolitan Building, that she sat down and took the man's +money, $7, and came right away. She recognized the priest.<!-- Page 208 --><span class='pagenum'><a name="Page_208" id="Page_208">[208]</a></span> +Three days before admission she wanted to stay in bed, kept her +eyes closed. When spoken to she would smile but did not open +her eyes. She did not pass her urine all day. Her mother then +gave her some medicine which the doctor had left. The patient +immediately had a peculiar attack in which she heaved her breast, +drew her head back, clenched her fists and worked her feet. Saliva +escaped from the side of her mouth. This attack lasted some +three to five minutes.</p> + +<p>Her mother then called an ambulance and she was taken to the +<i>Observation Pavilion</i>. She thought that the ambulance doctor +was an uncle, a soldier in the Philippines, of whom she was very +fond. There she remained in bed, with all her muscles relaxed, +her mouth constantly open, saying nothing and indeed resisting +efforts which were made to get her to open her eyes.</p> + +<p><i>Under Observation:</i> She sat or lay down with her eyes closed +and usually limp, although occasionally resistive. There was practically +no reaction to pin pricks. Sometimes she opened her +mouth as if to speak but rarely did so except in a very low tone +and after repeated questioning. Her answers were rarely relevant. +To the usual orientation questions she gave no answers +that would indicate that she knew where she was. Sometimes she +said "Jimmy" when asked her name, and replied to another +question, "Jimmy big smile on." Once she said, "I don't know +myself—what I am talking for—what I am doing." In general +her speech seemed to indicate that her thought was directed +entirely inward and that she paid no attention whatever to the +questions. In most benign cases such a condition is accompanied +by perplexity or a dreamy, dazed expression. This the patient +had not. On the other hand, she was sometimes definitely scattered. +For example, when asked, How do you feel? she replied, +"Large all name." Again to the command, Tell me your trouble, +her answer was, "I couldn't tell my mother last night and I can't +tell her this night and I can't tell my <em>proud</em>." She referred in +a fragmentary way to being crazy and to having been dead. She +admitted hearing voices but may not have understood the question.</p> + +<p>A week after admission, when visited by her mother, the latter +asked her to kiss her. The patient opened her mouth widely and +put out her tongue. This is a type of response which we have +never seen in our benign cases.</p> + +<p><!-- Page 209 --><span class='pagenum'><a name="Page_209" id="Page_209">[209]</a></span> +Two days later repeated questioning made it evident that the +patient knew more about her environment than would be expected, +judging from her other symptoms. She gave the month correctly +knew that she was in a hospital and told of having recently been +visited by her father. At the same interview she spoke of masturbation, +of wanting to marry her uncle, and of having been in +bed with her father. The last she referred to as a "fall." Such +frank incest ideas are never found in benign psychosis in our +experience. Other dementia prcox ideas appeared quite soon, +for within three days, when she was talking slightly more freely, +she spoke of having often imagined she was having sexual experiences +as a result of the influence of a man who lived upstairs, +and that even when sitting with her family at the table she felt +sexual sensations.</p> + +<p>Her condition then remained essentially the same for some +time. Then about six weeks after admission she became somewhat +less resistive, was frequently seen sitting up in bed, moving her +lips considerably (without speech) and regarding the surroundings +with a bright interested expression and occasionally smiles. +About this time she began exposing herself and chewing her +finger nails.</p> + +<p>Four months after admission she was noted as being very +resistive and negativistic, allowing saliva to accumulate in her +mouth and making no attempt to keep the flies off her. At the +same time she would keep in her mouth food that had been put +there without chewing it.</p> + +<p>Two months later she seemed to laugh occasionally when other +patients did so, but at the same time she showed a cataleptic +tendency and was quite mute.</p> + +<p>Six months after admission she began to feed herself but rather +sloppily. When one would speak to her, she would occasionally +smile, but if shaken she would weep silently. About this time she +began to do a little work in the ward, pushing a floor polisher.</p> + +<p>For the next couple of months her condition was about the +same. She would stand around the ward, doing a little work if +urged, might even dance if forced to. She was consistently mute. +She was dirty but often decorated herself. Rarely she was +assaultive.</p> + +<p>Then ten months after admission she one day suddenly became<!-- Page 210 --><span class='pagenum'><a name="Page_210" id="Page_210">[210]</a></span> +talkative, distractible and emotional, laughing and crying. There +was with this, however, no open elation. Her talk was obscene, +at times flighty, at times definitely scattered. All her habits were +filthy.</p> + +<p>This pseudomanic episode lasted for a couple of months, and +then she settled down to a fairly consistent deterioration with +indifference, silly laughter, occasional assaultiveness, destructiveness +and untidiness.</p> + +<p>Nearly two years after admission she had another period of +excitement lasting about a couple of months. Shortly after this +she began to fail physically, and in November, 1913, two years +and five months after her admission, she died of pulmonary +tuberculosis.</p></div> + +<p>In summary, then, we see that this patient exhibited +symptoms of dementia prcox from the outset +of her stupor, with scattering, genital sensations +and incest ideas. The stupor symptoms gradually +gave way to the typical indifference, negativism, obscenity, +filthiness and inexplicable conduct of +dementia prcox. At the beginning, however, the +condition was superficially similar to that of a benign +stupor, it being only on careful observation +that other symptoms were noted.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 21.</span>—<i>Rose S.</i> Age: 23. Admitted to the Psychiatric +Institute April 5, 1905.</p> + +<p><i>F. H.</i> The mother was living, the father dead. Otherwise no +pertinent information was secured.</p> + +<p><i>P. H.</i> The patient was said always to have been somewhat +seclusive, mingling little with other people; this tendency was so +strong that she would leave the room when visitors came. She +always slept a great deal. It was stated that she was able to do +heavy housework quite well, but never learned cooking.</p> + +<p>At 16 she hired out as a servant for a year and a half, and then +did laundry work. When 18 she had an illegitimate child by a +co-worker.</p> + +<p><!-- Page 211 --><span class='pagenum'><a name="Page_211" id="Page_211">[211]</a></span> +<i>History of Psychosis:</i> About a year before admission the +patient's sister was burned to death. When the patient heard of +this she said that something had come up in her throat. Henceforth +she often complained of a lump in her throat, and often bit +her nails. Two months before admission she suddenly left the +laundry, again spoke of the lump in her throat, and claimed to +have seen the dead sister. Two weeks later when the family had +an anniversary mass for the sister the patient appeared sad, but +the following day laughed, said she had seen her "sister beckoning +her to come." She also thought she saw her picture "and Heaven +was behind it." She also talked of "dead relatives and friends." +A reaction of levity in connection with a sister's death is highly +suggestive of a malignant psychosis.</p> + +<p>Two weeks before admission her mother found her in a stupor, +immovable, with her eyes closed. In 24 hours she woke up, began +to sing "Rest for the Weary," prayed, then was stuporous again +for six hours. When she came out of this, she said she was +"going to die," God had told her so and talked of her own funeral +arrangements. She again went into a stupor, in which she was +sent to the Observation Pavilion.</p> + +<p>At the <i>Observation Pavilion</i> she was described as happy, laughing, +singing, saying she felt happy, but adding, "I like to be sad +too, I am going to Heaven Easter Sunday." She claimed that +her sister frequently stood in front of her, and that she knew she +wanted her to go with her.</p> + +<p><i>Under Observation:</i> For about three weeks the patient showed +a variable stupor. She would lie with a mask-like face inaccessible, +cataleptic, drooling saliva, often with her mouth open. +When taken up, she was usually perfectly flaccid, but once she +let herself slide on the floor after she had stood immobile at the +window. Sometimes there was marked resistance to passive +motions, especially when attempts were made to open her mouth +or eyes, or on one occasion when the examiner tried to open her +hand in which she held her handkerchief. Yet when one persisted +in urging her to respond there frequently could be elicited more +or less marked reactions. Thus repeatedly she could be made to +obey some commands, as showing the tongue, etc., even when she +would not answer. Once when her eyes were opened, tears rolled +down her cheeks—again, she usually reacted to pin pricks by<!-- Page 212 --><span class='pagenum'><a name="Page_212" id="Page_212">[212]</a></span> +slight flushing, once she said, "Stop! it hurts." Again, she said, +"Leave me alone, I want to sleep."</p> + +<p>So far the description of this reaction is that of a benign +stupor. There were, however, other symptoms. In the first place, +she could sometimes be made to open her eyes and write, although +she would not speak. In spite of the penmanship being careless, +there were no mistakes. This exhibition of an unhabitual and +more difficult intellectual effort when the patient was mute is +suggestive of an inconsistency. So was her habit of sometimes +singing a hymn, "Rest for the Weary," when no other sign of +mental life was given. But, more important than these, she could +not infrequently be induced to answer questions and at such times +she spoke promptly and with natural affective response.</p> + +<p>A number of her replies were of the type to be expected in a +benign stupor. In the first place, she spoke of her condition as +"going off to sleep" and also as "death," "I was dead all day." +"I died three times yesterday," or she merely described it by +saying "I go off into states when I lie with my mouth open and +eyes closed, and cannot speak or open my eyes." When asked +how she got into this condition, she said "My sister died and I +think it was on my mind." Again she said she became sad at +the anniversary mass of the sister and had been sad ever since. +On the other hand, she also stated that when she came home +from the mass she first was silly and danced. Spontaneously she +spoke of having frequently had visions of her dead sister; once +she saw her with wings. In explanation of her singing "Rest for +the Weary," she said it was the hymn sung at her father's +funeral. An anomalous feature had to do with her description +of her feelings. She claimed to have no memory of her stupor +periods and yet said of them: "I feel peaceful-like," or "I feel +awfully happy and sad together," or "I am sad and contented—I +like it that way."</p> + +<p>A striking symptom was that, when a sensory examination was +made during the first few days during one of the periods when +she responded well, she showed glove and stocking anesthesia, +also anesthesia of neck and left breast.</p> + +<p>But in addition to the above statements the patient also began +to make others of a definite dementia prcox type. About ten +days after admission she said, "What any one says goes right<!-- Page 213 --><span class='pagenum'><a name="Page_213" id="Page_213">[213]</a></span> +through my brain," or she talked of being hypnotized. "The +typewriting machine turned my eyes—three or four girls turned +my eyes—they look at me and get their chance, their left eye—turning +me into images. I want to be the way I was born—turn +my body! look how their bodies are turned before they die," or +"Take it if you get it—he got the name out—I was over there to +death—himself to death—of, you know—you played out—she is +played out." ... This while she snickered between the sentences. +As early as four weeks after admission she had begun to giggle +or laugh, often in an empty fashion, and a transition from the +more constrained stuporous state, with interruptions of laughter, +to an indifferent silly, muttering to herself was gradual.</p> + +<p>In 1909 she was described as not talking, standing around, +showing no interest in anything, muttering. The only response +obtained was "I don't know." In December, 1911, she was transferred +to another hospital as a case of deteriorated dementia +prcox.</p></div> + +<p><i>To Recapitulate:</i> We have here a young woman +who for a year had indefinite mental symptoms and +suddenly developed a stupor. This was atypical in +that she sang and wrote when otherwise apparently +deeply stuporous. When persuaded to talk, her utterances, +even as early as ten days after admission, +were of a malignant type and with such statements +she giggled. This last is apparently a highly important +sign. Quite frequently in our cases the first +signal of a dementia prcox reaction has been giggling +in a setting of what was apparently a typical +benign stupor.</p> + +<p>As has frequently been stated, symptoms of benign +stupor are closely interrelated. Consequently +the reaction is, when benign, a consistent one. We +do not find free speech with profound apathy and in<!-- Page 214 --><span class='pagenum'><a name="Page_214" id="Page_214">[214]</a></span>activity, +nor do we expect to meet with unimpaired +intellectual functions when other evidences of deep +stupor are present. The inconsistency of mental +operations which characterize dementia prcox, +however—the "splitting" tendency which Bleuler +has emphasized in his term "schizophrenia"—is +just that added factor which may produce disproportionate +developments of the various stupor +symptoms in the dementia prcox type of that reaction. +Examples of this have been given in the two +cases just quoted. The history of the following patient +shows this tendency more prominently.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 22.</span>—<i>Nellie H.</i> Age: 20. Admitted to the Psychiatric +Institute June 11, 1907.</p> + +<p><i>F. H.</i> The father had repeated depressions; he died of typhus +fever. The mother was living.</p> + +<p><i>P. H.</i> The brother of the patient stated that she was like other +girls, and very good at school. At 16 she became quieter, less +energetic. She came to America at 17. After arriving here she +has seemed low spirited, cranky and faultfinding. She often +complained of indefinite stomach trouble and headaches; when +at home she often had a cloth around her head. The informant +recalled that she said, "I wish I could get sick for a long time +and get either cured or die." However, she worked. For one and +a half years prior to admission her "crankiness" is said to have +become much worse. She complained continually of being tired; +quarreled much with her mother; said she did not have enough +to eat. It is also stated that she was constantly afraid of losing +her job.</p> + +<p><i>History of Psychosis:</i> For six months before admission she +said frequently that her boss was giving her hints that he liked +her. (She did not know him socially at all.) Six days before +admission she came home, saying the boss had told her he had +no more work for her. Nevertheless, she went back next day and +was again sent home. At home she sat gazing. Next day again<!-- Page 215 --><span class='pagenum'><a name="Page_215" id="Page_215">[215]</a></span> +wanted to go and see the boss, but was prevented. At times she +tried to get out of the window; again sat gazing, repeating to +herself "Always be true." She said she was in love with the +boss. When the doctor gave her medicine she thought it was +poison. Finally she began to be talkative and elated. At the +<i>Observation Pavilion</i> she became very quiet.</p> + +<p><i>Under Observation:</i> She lay in bed indifferent, not eating, +unless spoon-fed, when she would swallow. She soiled herself. +She answered no questions as a rule, and only on one occasion, +when urged considerably, said in answer to questions that this +was a hospital, so that she evidently had more grasp on the nature +of her environment than her behavior indicated. To her brother +who called on her during the first ten days she said she could not +find her lover here (an idea inconsistent with the benign stupor +picture).</p> + +<p>Then she became more markedly stuporous, drooling saliva, +very stiff, often lying with head half raised, gazing stolidly, never +answering, soiling. Later, after a month, this was less consistent. +She now and then went to the closet, sometimes she +smiled, ate some fruit brought to her, spoke a little. Repeatedly +when people came she clung to them, wanted to go home, again +was seen to weep silently. On another occasion she suddenly +threw the dishes on the floor with an angry mood, without there +being any obvious provocation. Again she got quite angry when +urged to eat her breakfast, and on that occasion pulled out some +of her own hair. Usually she had to be fed, was stiff, sitting +with closed fists, not reacting as a rule in any other way, wholly +inaccessible and has been that way for years. The stupor merged +into a catatonic state merely by the development of the inconsistency +in her affective reactions.</p></div> + +<p>We see then that inconsistencies among the stupor +symptoms themselves and the intrusion of definitely +dementia prcox symptoms differentiate the malignant +from the benign reactions. As a matter of +fact, we find, as a rule, that careful examination of +the onset reveals further atypical features, sugges<!-- Page 216 --><span class='pagenum'><a name="Page_216" id="Page_216">[216]</a></span>tions +or definite evidences of a dementia prcox reaction +before the stupor itself appears. One common +occurrence is a slow deterioration of character +and energy that proceeds for months or years before +flagrantly psychotic symptoms appear.</p> + +<p>Then when delusions or hallucinations are eventually +spoken of by the patient, an appropriate or +adequate reaction is lacking. In a benign psychosis +false ideas do not appear with an equable mood +unless the stupor reaction has already begun.</p> + +<p>More important than this, although in benign stupors +there may be a reduction or an insufficient affect, +it is never inappropriate. This pathognomonic +symptom of dementia prcox frequently occurs in +the onset to malignant stupors. In fact we often +find in reviewing such cases that a plain dementia +prcox reaction has been in evidence, that a diagnosis +has not been made simply because the stupor +picture blotted out this earlier psychosis before an +opinion was formed. Frequently these early symptoms +are reported in the anamnesis and not actually +observed by the physician.</p> + +<p>Three cases may be cited as examples of dementia +prcox onsets. It will be noted that the ensuing +stupors were, like those already quoted, atypical.</p> + +<div class="blockquot"> +<p><span class="smcap">Case 23.</span>—<i>Catherine H.</i> Age: 21. Admitted to the Psychiatric +Institute October 10, 1904.</p> + +<p><i>F. H.</i> The mother's brother had two attacks of delirium +tremens. The mother died when the patient was eleven years old; +she is said to have been normal. The father was living.</p> + +<p><i>P. H.</i> The patient was always a nervous child, had very bad<!-- Page 217 --><span class='pagenum'><a name="Page_217" id="Page_217">[217]</a></span> +dreams, but she was smart at school up to ten or eleven, and +played with other girls. Then she began to work less well, got +thin, more nervous, complained of headaches. It was about that +time that her mother died. (The reaction to the death was said +not to have been different from that of her sister.) She was +kept at home and was quiet.... "You could see something was +working on her." She began to menstruate at 14, and it was +claimed that she then wakened up a little. It was further stated +that she was always "stuck up" about her clothes.</p> + +<p>At 16 she went to work in a factory, but her sister thought +the work was too much for her, so she was taken home. Thereafter +she lived alone with her father, doing his housework, her +sister having married about that time. At 17 her hair began +to come out excessively, so that she had to cut it, and when it +grew again it was gray. She became very sensitive about this, +even refused to take positions because she thought people would +remark about it.</p> + +<p>For two years before admission she evidently was different. +Although she did her father's housework well enough, she turned +against her sister and refused to speak to her because, she alleged, +the sister had not come to help her in her housework. Another +pronounced manifestation during that time was her frequent talk +about her bowels. She complained of constipation, creepy, +crawling sensations in the stomach which she thought was a +"tapeworm." She got pamphlets and took patent medicines. She +was taken to a physician nine months before admission, who +operated on her for piles. While still in the hospital she asked +her father to take her home to die (although there was no reason +for such a request). Again she said the gauze had been left in +the rectum too long and that the rectum was full of wind. Later +she said the rectum was closing up. After this, the sister stated, +she was extremely nervous if she passed a day without a movement +of the bowels. She was quiet henceforth, went out less and +said little, claiming it was better for her head if she said little. +She often sat, head in hand, in the hall. All through the summer +she frequently remarked, "I am a good girl." Four months before +admission during a period of five weeks she would let her bowels +move when standing up. This was relieved by enemas. The +father states that she was cranky to him, that sometimes when<!-- Page 218 --><span class='pagenum'><a name="Page_218" id="Page_218">[218]</a></span> +he merely asked a question she would say, "You hurt my feelings," +and once, "You break my heart." Occasionally she seemed to +worry about the money spent for her on doctors and medicine.</p> + +<p>About two months before admission she said everybody was +looking at her. Ten days before admission she said, "I have been +sick all this time and thought I was going to die. Now I think +Tom (her brother) is going to die." She became fearful of +being left alone. Finally she went to the priest, who told her to +go home. Then she prayed, leaving the candles burning in the +room. That night she was found kneeling before a church in her +nightgown. Again she threw a lot of articles into the yard, saying +a curse had been put on her by her father, and she did not wish +to give him anything. When she was taken to the Observation +Pavilion she said, "I am a good girl—my mother is dead—it is all +my father's fault."</p> + +<p>At the <i>Observation Pavilion</i> she put her arm under a hot +water faucet "to save the world," prayed and laughed—again +sank back and appeared as if asleep. She said, "I hear angels +telling me how to pray when I lose my thoughts—sisters and nuns +are all around me here, to save and purify the world now and +forever, and at the hour of our death."</p> + +<p><i>Under Observation:</i> On admission the patient kept her eyes +closed, sang hymns in measured tones, or prayed, or showed a +certain ecstasy in her face while her lips quivered and tears ran +down her cheeks. On the whole, she answered few questions. +When asked how she felt, she said she was happy. (Why do +you cry?) "I was crying when I asked God to save souls." (Are +you afraid?) "Not now, I have been afraid of everything on +Earth ever since my mother died." (What do you mean?) "No +one would look at me or talk to me—they said I was a bad girl, +but I was pure." Again she said, "They laughed about me, talked +about me—and they drew up a play about me—Devil's Island." +Or she spoke about having had stomach trouble, bowel trouble, +teeth trouble, eye trouble, compound, complicated trouble. (What +do you mean?) "Father scolding all the time, he sent me to get +bug medicine (true). God gives that medicine to the one that +started all the trouble—Devil's Island."</p> + +<p>She soiled her bed and was asked why she did it. She said +"I have been transformed into a baby, the Lord said I was too<!-- Page 219 --><span class='pagenum'><a name="Page_219" id="Page_219">[219]</a></span> +pure to be a woman—I had to become a baby to save the world." +Or when asked her name she called herself "Baby Chadwick of +the whole world—divine Irish Catholic World—Amen," or again +"I am the Roman Catholic Irish Divine Baby."</p> + +<p>Although she was not essentially disoriented she called the place +"mid-heaven," or "a holy house, sort of a hospital." She also +said, "In two years more there will be a new world and it will +be more happy and holy."</p> + +<p>The day after entrance the patient, though in part as described, +had a spell when she kept her eyes closed and was rigid. +Spells like these returned. (About a month after admission she +became completely stuporous.) She prayed at times, at other +times was constrained, or kept her eyes closed. Her orientation +throughout was good. The content of her psychosis, in addition +to the praying attitude, had a more or less vague religious +coloring. Thus she called the hospital the "House of God." +Again, when on one occasion she had jumped at the window +guard and was asked "why?" she said "holy communion." Again +she said she was "Mary, Virgin Mother." But this religious trend +was intermingled with remarkable elements of another sort. Thus +when in order to study her knowledge of the events after admission, +she was asked what she had done when she was brought +into the ward, she said, "I went into the sanctuary where my +bowels moved and water passed from me." (Why do you call it +sanctuary?) "Because Jesus did the same thing I did."</p> + +<p>Possibly vague sexual allusions are also contained in the following: +She said one day to the doctor, "Everything went wrong +last night, good, pure, true and holy doctor, I led you astray and +you were dying last night, may the Almighty God forgive me, +I ought to have died, but I fought it out, for, if I had died, my +mother's soul would not have been saved in Heaven and from the +flames of Hell." Again, "I will not look at you again, good, +pure, holy doctor of the world." (Why?) "I am afraid I will +lead you astray." And also: "I led James. Peter astray too." +It should be added that she sometimes masturbated rather +shamelessly.</p> + +<p>She said she heard her mother's voice. (What did she say?) +"Something in the sky for me, angels call for me." (What do the +angels say?) "The name of my good mother in Heaven." Again<!-- Page 220 --><span class='pagenum'><a name="Page_220" id="Page_220">[220]</a></span> +she said she had heard her mother the night she came here. +(What did she say?) "It was like a voice—feed the calf—that +means me, I suppose."</p> + +<p>Then after a month the stupor became more continuous. She +lay totally inactive for the most part, had to be fed, soiled +herself, drooled saliva, was at times cataleptic, often rigid. Her +limbs became cyanotic. A few times tears were seen. On other +occasions she whispered "peace," or "peace for hazing," or "pray—peace," +or "I like to be good." Usually no responses could be +obtained.</p> + +<p>After some months she was at times seen laughing. This +gradually passed into a state of total disinterestedness and inaccessibility. +She could finally be made to polish the floor in an +automatic fashion, but never spoke, and five years after admission +she was transferred to another hospital, where she died +(eleven years after admission to the ward of the Institute) without +any change in her mental condition having taken place.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 24.</span>—<i>Adele M.</i> Age: 22. Admitted to the Psychiatric +Institute November 11, 1904.</p> + +<p><i>P. H.</i> The father stated that the patient was always "cranky," +had outbursts of temper, even when a small child and was quarrelsome; +also said that she was "seclusive," had few friends, was +averse to meeting people, never had a beau. She was taken out +of school at 14 because she was not promoted on two successive +occasions from the same class. Then she was put to work, but +she was usually discharged for incompetency.</p> + +<p><i>Onset of Psychosis:</i> Three years before admission it was +noted that she laughed occasionally without cause. She was idle. +This laughing, and also crying, was sometimes more frequent, +again less noticeable.</p> + +<p>Six months before admission she began to say she wanted to +leave home, but made no move to do so. Then she began to speak +of bad odors, made some remarks about the neighbors talking +about her—saying she should kill herself; again she said the +family would be brought to death, or the mother was falling to +pieces, the father looked sick. She also said her head was swelling +and was getting thick. Finally she wanted to hire a furnished +room and kill herself and asked if 75 cents which she had was +enough to do it with.</p> + +<p><!-- Page 221 --><span class='pagenum'><a name="Page_221" id="Page_221">[221]</a></span> +Two weeks before admission she left home, wandered about +all night, was picked up by the Salvation Army, and returned +to her home. She said she wanted to die.</p> + +<p>At the <i>Observation Pavilion</i> she stated that her mother was +falling to pieces and her father sick. She also said she wanted +to die.</p> + +<p><i>Under Observation:</i> The patient was at first petulant, saying +"I don't want to stay here," turning her face away from the +doctor, generally uninterested. Though it could be established +that she was quite oriented, often her answers were "I don't +know," or she did not answer. But she was also seen crying at +times, and she was apt to bite her finger nails. She had to be +tube-fed. Gradually these tendencies increased so that she lay +in her bed with head covered, saying in a peevish tone, when +spoken to, "Oh, let me alone." And for years she was mute, lying +with her head covered, tube-fed. When rexamined in 1914 (ten +years later), she was found lying in bed with an empty smile. +There was paper stuffed in her ears. When approached, she +turned her head away and would not talk.</p></div> + +<div class="blockquot"> +<p><span class="smcap">Case 25.</span>—<i>Catherine W.</i> Age: 42. Admitted to the Psychiatric +Institute November 11, 1904.</p> + +<p><i>F. H.</i> The father died at 75, the mother at 44. Two sisters +died of tuberculosis. A brother wanted to marry but was opposed +by the father; he set fire to the house of the girl and then +drowned himself.</p> + +<p><i>P. H.</i> The patient came to this country when 20, and worked +for some years as a servant. Then she married after a short +acquaintance. The husband, according to his own statement, +drank, and there was friction from the first. She left him a few +weeks after marriage, and a few months later he went to Ireland; +she also went some time later but did not go to see him. Then +they lived together again. They had four children, but had had +no intercourse for nine years.</p> + +<p><i>Development of Psychosis:</i> Eight years before admission the +patient became nervous, slept badly, but got better. It was +claimed that for six years she had been quieter and more sullen +than before. Three years before admission the patient had to +take a place as janitress, since she needed the money. From the +first she had trouble with the tenants and accused everybody of<!-- Page 222 --><span class='pagenum'><a name="Page_222" id="Page_222">[222]</a></span> +being in league against her. Some six or eight weeks after she +had taken the position, she developed what was called typhoid +fever, and some time later the daughter came down with the same +disease. After the typhoid she was more antagonistic towards +her husband, accused him of infidelity, repeatedly locked him out +of the house, but continued to do her housework. About six +months after this illness she left her home, but returned in a +week. She had vague ideas thereafter that the priests were saying +things against the family, and she often quarreled with the +tenants. For a year she had done no work but sat about. Ten +days before admission she stopped eating.</p> + +<p><i>Under Observation:</i> The patient was mute, stolid, gazing +straight ahead, sometimes cataleptic. She had to be tube-fed, +was usually very resistive to any passive motions; quite often she +retained her urine, but she did not hold her saliva. Yet there +was some quick responses at least in the beginning. At such +times it was found that she was oriented, but nothing could ever +be obtained about her feelings, etc., except that she once said, +when asked whether she was worried, that she "felt weak," had +"nothing to worry about." Occasionally she was seen to cry +silently; at times she would breathe faster when questioned, or +flush; once she took hold of the doctor's hand when he questioned +her, and cried, but made no reply. On another occasion she was +affectionate to her son, kissed him, although she paid no attention +to her daughter who accompanied the son. Later she said to the +nurses, "He is the best son that ever lived." But more and more +she became disinterested, totally inaccessible, resistive, had to be +tube-fed. In this condition she remained for five and a half +years. At the end of that time she died of tubercular pneumonia.</p></div> + +<p><!-- Page 223 --><span class='pagenum'><a name="Page_223" id="Page_223">[223]</a></span></p> + +<h2>CHAPTER XII<br /> +<span class="sm">DIAGNOSIS OF STUPOR</span></h2> + +<p>In any functional psychosis an offhand diagnosis +is dangerous. When one deals with such a condition +as stupor, however, the problem is exacting, for, +although "stupor" may be seen at a glance, what is +seen is really only a symptom or a few symptoms. +"Stupor," then, is more of a descriptive than a diagnostic +term. The real problem is to determine the +psychiatric group into which the case should be +placed. This is a difficult task, for the differential +diagnosis rests on the observation and utilization +of minute and unobtrusive details. A correct interpretation +can be only reached by obtaining a +complete history of the onset and observing the +behavior and speech of the patient for a long +period, usually of weeks, sometimes of months. +With these precautionary words in mind, it may +be well to summarize briefly the diagnostic problems +in connection with benign stupor.</p> + +<p>In the first place one naturally considers the differentiation +from conditions of organic stupor or +coma. Since psychotic stupors never develop without +some signs of mental abnormality, the history +is usually a sufficient basis for final judgment.<!-- Page 224 --><span class='pagenum'><a name="Page_224" id="Page_224">[224]</a></span> +In case no anamnesis is obtainable the functional +nature of the trouble may be recognized by the absence +of those physical signs which characterize the +organic stupors. One sees no violent changes in respiration, +pulse or blood-pressure, such as are present +in the intoxication comas of diabetes or nephritis. +There is no characteristic odor to the +breath, and the urine is relatively normal. The unconsciousness +of trauma or apoplexy is accompanied +by focal neurological signs. Even in aerial concussion +(so frequently seen in the war) where no one +part of the brain is demonstrably affected more than +another, there are neurological evidences of what +one might call "physiological" unconsciousness. +The eyes roll independently, the pupils fail to react +to light. On the other hand, there are definite symptoms +characteristic of the functional state. Mental +activity is evidenced by a muscular resistiveness or +retention of urine. Even in states of complete relaxation +the eyes move in unison, the pupils react +to light, and almost universally the corneal reflex is +present. The patient appears in a deep sleep rather +than actually unconscious.</p> + +<p>The post-epileptic sleep may resemble a stupor +strongly. But this condition is temporary and the +situation and appearance of the patient betrays the +fact that he has just had a convulsion. Rarely, protracted +stuporous states occur in epilepsy which +closely resemble the conditions described in this +book. In fact it is probable the true stupors may<!-- Page 225 --><span class='pagenum'><a name="Page_225" id="Page_225">[225]</a></span> +occur in epilepsy just as in dementia prcox or +manic-depressive insanity.</p> + +<p>There is usually little difficulty in the discrimination +of hysterical stupor. Occasionally it shows, +superficially, a similarity to the manic-depressive +type. Fundamentally, there is a wide divergence +between the two processes, in that in the hysterical +form a dissociation of consciousness takes place, +the patient living in a reminiscent, imaginary or +artificially suggested environment, while in a true +stupor there is a withdrawal of interest as a whole +and a consequent diffuse reduction of all mental +processes. This difference is sooner or later manifested +by the appearance in the hysteric of conduct +or speech embodying definite and elaborated ideas.</p> + +<p>As has been stated fully in the last chapter (to +which the reader is referred), the stupor of dementia +prcox is to be differentiated from that of manic-depressive +insanity by the inconsistency of the +symptoms in the former and the appearance of dementia +prcox features during the stupor, such as +inappropriate affect, giggling, or scattering. Further, +the nature of the disorder is usually manifest +before the onset of the stupor as such.</p> + +<p>Sometimes very puzzling cases occur in more advanced +years when it is difficult to say whether one +is dealing with involution melancholia or stupor. +Such patients show inactivity, considerable apathy +and wetting and soiling, and with these a whining +hypochondria, negativism, and often a rather mawkish +sentimental death content without the dramatic<!-- Page 226 --><span class='pagenum'><a name="Page_226" id="Page_226">[226]</a></span> +anxiety which usually characterizes the involution +state. In these cases the diagnosis is bound to be +a matter of taste. In our opinion it is probably +better to regard these as clinically impure types. +They may be looked on as, fundamentally, involution +melancholias (the course of the disease is protracted, +if not chronic) in whom the regressive process +characteristic of stupor is present as well as +that of involution.</p> + +<p>Great difficulties are also met with in the manic-depressive +group proper. So often a stupor begins +with the same indefinite kind of upset as does another +psychosis that the development may furnish +no clew. Any condition where there is inactivity, +scanty verbal productivity and poor intellectual performance +resembles stupor. This triad of symptoms +occurs in retarded depressions, in absorbed +manic states and in perplexities. Negativism and +catalepsy are never well developed except in stupor. +So if these symptoms be present the diagnosis is +simplified. But they are often absent from a typical +stupor. Let us consider these three groups separately.</p> + +<p>The most important difference between stupor +and depression lies in the affect. Although inactive +and sometimes appearing dull the depressive individual +is not apathetic but is suffering acutely. He +feels himself wicked, paralyzed by hopelessness, and +finds proof of his damnation in the apparent change +of the world to his eyes and in the slowness of his +mind. But he is acutely aware of these torments.<!-- Page 227 --><span class='pagenum'><a name="Page_227" id="Page_227">[227]</a></span> +The stupor patient, on the other hand, does not care. +He is neither sad nor happy nor anxious. This +contrast is revealed not only by the patients' utterances +but by their expressions. The stuporous face +is empty, that of the other lined with melancholy. +The intellectual defect, too, is different. In retarded +depression the patient is morbidly aware of difficulty +and slowness, but on urging often performs tests +surprisingly well. In the stupor, however, one is +faced with an unquestionable defect, a sheer intellectual +incapacity.</p> + +<p>In Chapter VIII the differential diagnosis between +perplexity and stupor has already been +touched upon. Here again the affect is a point of +contrast. The patient has not too little emotion +but too much. The feeling of intangible, puzzling +ideas and of an insecure environment causes the +subject distress, of which complaint is made and +which can be witnessed in the furrowed brow and +constrained expression. There is also, as we have +seen, a rich ideational content in these cases, if one +can get at it. The mind is not a blank, as in the +stupor, or concerned only with delusions of death.</p> + +<p>Finally, there are the absorbed manic states. +These are the most difficult, inasmuch as the patient +is often so withdrawn and so introverted that at any +given interview there may be no objective evidence +of mood or ideas. Here the development of the +psychosis is often an aid to diagnosis. The patient +passes through phases of hypomania to great exultation, +the flight becomes less intelligible, with this<!-- Page 228 --><span class='pagenum'><a name="Page_228" id="Page_228">[228]</a></span> +the activity diminishes until finally expression in any +form disappears. If this sequence has not been observed, +continued observation tells the tale. The +patient still has his ideas and may be seen smiling +contentedly over them (not vacuously as does the +schizophrenic) or he may break into some prank or +begin to sing. Any protracted familiarity with the +case leads to a conviction that the patient's mind is +not a blank, but that his attention is merely directed +exclusively inward. Then, too, when his ideas are +discovered, it is found that they are not exclusively +occupied with the topic of death.</p> + +<p><!-- Page 229 --><span class='pagenum'><a name="Page_229" id="Page_229">[229]</a></span></p> + +<h2>CHAPTER XIII<br /> + +<span class="sm">TREATMENT OF STUPOR</span></h2> + +<p>In dealing with cases of benign stupor the first +duty of physician and nurse is naturally the physical +hygiene of the patient. More is needed to be done +in the bodily care of these persons than for most of +the inmates of our hospitals for the insane. It is +perhaps no exaggeration to claim that a deeply +stuporous patient needs as much attention as a suckling +babe. In the first place, the patient must be +fed. It is important for mental recovery that the +individual in stupor should be stimulated to effort +as much as possible. Consequently there is an economy +of time in the long run in taking pains to get +the patient to feed himself in so far as that is possible. +He should be led to the table and assisted +in handling his own spoon and cup. If this is not +practicable, he should then be spoon-fed, and if this +in turn is found to be out of the question, tube-feeding +should be resorted to. But this last should +never be looked on as a permanent necessity, but +only as a method of maintaining the patient's health +until such time as he may be capable of independent +taking of nourishment. In exactly the same way it +is of prime importance to get the patient to attend<!-- Page 230 --><span class='pagenum'><a name="Page_230" id="Page_230">[230]</a></span> +to the natural habits of excretion. He should be +led to the toilet or to a chair commode, and efforts +to this end should be persistent, just as are those +of a good child's nurse who has the ambition of +making her charge develop normal habits. Naturally +those who retain urine and feces should be +watched to see that this retention does not last long +enough to menace health. The physical aspects of +treatment are exhausted with consideration for +cleanliness. On account of the stupor patients' inactivity +and frequent tendency to wetting and soiling, +this is a particularly important consideration. +It goes without saying that the perineal region +should be kept scrupulously clean. If any infections +are to be avoided, eyes, nose and mouth should also +be cleansed frequently. A patient who is so indifferent +as to keep the eyelids open for such a long +time that the sclera dry and ulcerate is also apt to +let flies settle and produce serious ophthalmic disease.</p> + +<p>Less obvious and more important are the measures +undertaken for the mental hygiene of the case. +On account of the tendency present in so many patients +for sudden action while in the midst of an apparently +deep and permanent inactivity, it is necessary +that these cases be not isolated but remain +under constant observation. This is particularly +true of those who have demonstrated impulsive suicidal +explosions.</p> + +<p>Not only on the basis of the psychological theory +of the stupor process, but from the observed phe<!-- Page 231 --><span class='pagenum'><a name="Page_231" id="Page_231">[231]</a></span>nomena +of recovery, we gather that mental stimulation +is of first importance if an amelioration of +the condition is to be attempted. If the stupor reaction +be a regression, which is essentially a withdrawal +of interest and energy rather than a fixation +on a false object, then excitement is desirable and interest +must be reawakened. The withdrawal is +temporary (inasmuch as the psychosis is benign), +but just as a normal person wakes more readily on +a clear sunshiny day than when it rains, so the more +cheering the environment the more rapid the recovery.</p> + +<p>Consequently, although trying to those in charge, +persistent attention should be given the patient. +Feeding and hygienic measures probably have considerable +value in this work. As soon as it is at all +possible the patients should be got out of bed and +dressed. When up, efforts should be directed towards +making them do something, even if it be something +as simple as pushing a floor polisher. On account +of their lack of enthusiasm the stupor cases +are often omitted from the list of those given occupation +and amusement. Even if they go through +the motions of work or play with no sign of interest, +such exercise should not be allowed to lapse. Then, +too, the environment should be changed when practicable. +A patient may improve on being moved +to another building.</p> + +<p>Perhaps the most potent stimulus that we have +observed is that of family visits. In most manic-depressive +psychoses visits of relations have a<!-- Page 232 --><span class='pagenum'><a name="Page_232" id="Page_232">[232]</a></span> +bad effect. The patients become excited, treat the +visitors rudely, perhaps even assault them, and all +their symptoms are aggravated. But the stupor +needs excitement, and an habitual emotional interest +is more apt to arouse him than an artificial one. +In another point the situation differs. As a rule +manic-depressive patients have delusional ideas or +attitudes in connection with their nearest of kin, +so that contact with these stirs up the trouble. +The stupor regression going beneath the level of +such attachments leaves family relationships relatively +undisturbed. Hence, while the visit of a husband +is likely to produce nothing but vituperation +or blows from a manic wife, the stuporous woman +may greet him affectionately and regain thereby +some contact with the world.</p> + +<p>So many cases begin recovery in this manner that +it cannot be mere chance. One patient's improvement, +for instance, dated definitely from the day a +nurse persuaded her to write a letter home. It is +striking, too, how quickly a patient, while somewhat +dull and slow, will brighten up when allowed to return +home. A similar improvement under these +circumstances is often seen in partially recovered +cases of involution melancholia, in whom a psychological +regression similar to that of stupor takes +place. Such experiences make one wonder whether +perhaps these alone of all our insane patients would +not recover more quickly at home than in hospitals, +provided nursing care could be given them.</p> + +<p>This is a mere suggestion. Before treatment can<!-- Page 233 --><span class='pagenum'><a name="Page_233" id="Page_233">[233]</a></span> +be rational the nature of any disease process must +be known, and we do not pretend to have done more +as yet than outline the probable mental pathology +of the benign stupors. The next step is to put +theory into practice and experiment widely with +various means to see if by appropriate stimulation +the average duration of these psychoses cannot be +reduced. It is largely with the hope of inducing +other psychiatrists to carry on such work that this +book is written. There is no other manic-depressive +psychosis which, theoretically, offers such hope of +simple psychological measures being of therapeutic +value.</p> + +<p><!-- Page 234 --><span class='pagenum'><a name="Page_234" id="Page_234">[234]</a></span></p> + +<h2>CHAPTER XIV<br /> + +<span class="sm">SUMMARY OF THE STUPOR REACTION</span></h2> + +<p>Having discussed in detail the various symptoms +and theoretic aspects of the benign stupors, it may +be well to have these observations and speculations +summarized.</p> + +<p>It being established that stupors occur as a temporary +form of insanity<a name="FNanchor_12_14" id="FNanchor_12_14"></a><a href="#Footnote_12_14" class="fnanchor">[12]</a> psychiatry is faced at once +with the problem of describing these conditions accurately +in order to ascertain their nosological position. +To this end we first examined typical cases of +deep stupor and found that the clinical picture is +made up of the following symptoms: In the foreground +stands <em>poverty of affect</em>. The patients are +almost unbelievably apathetic, giving no evidence by +speech or action of interest in themselves or their environment, +unmoved even by painful stimuli. Their +faces are wooden masks; their voices as colorless +when words are uttered. In some cases sudden mood +reactions break through at rare intervals. The second +cardinal symptom is <em>inactivity</em>. As a rule there +is a complete cessation of both spontaneous and reactive +movements and speech. So profound may this<!-- Page 235 --><span class='pagenum'><a name="Page_235" id="Page_235">[235]</a></span> +inhibition be that swallowing and blinking of the +eyes are often absent. The trouble is not a paralysis, +however, for reflexes without psychic components +are unaffected. Possibly related to the inactivity +is the preservation of artificial positions +which is called <em>catalepsy</em>, a fairly frequent phenomenon. +A tendency opposite to the inactivity is +seen in <em>negativism</em>. This perversity is present in +all gradations from outbursts of anger with blows +and vituperation to sullen, or even emotionless, muscular +rigidity. This last occurs most often when the +patient is approached but may be seen when observations +are made at a distance. Frequently <em>wetting</em> +and <em>soiling</em> are due to negativism, when the patient +has been led to the toilet but relaxes the sphincters +so soon as he leaves it. A constant feature is a +<em>thinking disorder</em>. On recovery memory is largely +a blank even for striking experiences during the +psychosis and, when accessible during the stupor +to any questioning, a failure of intellectual functions +is apparent. An <em>ideational content</em> may be gathered +while the stupor is incubating, during interruptions, +or from the recollections of recovered patients. +Its peculiarity is a preoccupation with the +theme of death, which is not merely a dominant +topic but, often, an exclusive interest. Probably to +be related to this is a tendency, present in some +cases, to sudden suicidal impulses, that are as apparently +planless and unexpected as the conduct of +many catatonics. Finally the disease is prone to +exhibit certain <em>physical</em> peculiarities. A low fever<!-- Page 236 --><span class='pagenum'><a name="Page_236" id="Page_236">[236]</a></span> +is common and so are skin and circulatory anomalies. +A loss of weight is the rule, and menstruation +is almost always suppressed.</p> + +<p>As to the frequency of stupor no figures are available, +for the simple reason that the diagnosis in large +clinics has not been made with sufficient accuracy +to justify any statistics. Most of these cases are +usually called catatonia, depression, allied to manic-depressive +insanity or allied to dementia prcox. +The majority of the stupors reported in this book +were in women, but this is merely the result of +chance, since it has been easier in the Psychiatric +Institute to study functional psychoses in the female +division, while the male ward has been reserved +largely for organic psychoses. The majority of the +patients seem to be between 15 and 25 years of age, +so that it is, presumably, a reaction of youthful +years. In our experience most cases occur among +the lower classes, which agrees with the opinion of +Wilmanns who found this tendency among prisoners.</p> + +<p>This gives a brief description of the deep stupor. +But even our typical cases did not present this picture +during the entire psychosis. They showed +phases when, superficially viewed, they were not in +stupor but suffered from the above symptoms as +tendencies rather than states. There are also many +psychoses where complete stupor is never developed. +This gives us our justification for speaking +of the <em>stupor reaction</em>, which consists of these symptoms +(or most of them) no matter in how slight a<!-- Page 237 --><span class='pagenum'><a name="Page_237" id="Page_237">[237]</a></span> +degree they may be present. The analogy to mania +and hypomania is compelling. The latter is merely +a dilution of the former. Both are forms of the +manic reaction. We consequently regard stupor and +partial stupor as different degrees of the same psychotic +process which we term the stupor reaction. +To understand it the symptoms should be separately +analyzed and then correlated.</p> + +<p>The most fundamental characteristic of the stupor +symptoms is the change in affect which can be +summed up in one word—apathy. It is fundamental +because it seems as if the symptoms built around +apathy constitute the stupor reaction. The emotional +poverty is evidenced by a lack of feeling, +loss of energy and an absence of the normal urge +of living. This is quite different from the emotional +blocking of the retarded depression, for in the latter +the patient shows either by speech or facial expression +a definite suffering. The tendency to reduction +of affect produces two effects on such emotions as +internal ideas or environmental events may stimulate. +Exhibitions of emotion are either reduced or +dissociated. For instance, anxiety is frequently +diminished to an expression of dazed bewilderment; +or, isolated and partial exhibitions of mood occur, as +when laughter, tears or blushing are seen as quite +isolated symptoms. This latter—the dissociation of +affect—seems to occur only in stupor and dementia +prcox. It should be noted, however, that inappropriateness +of affect is never observed in a true benign +stupor. A final peculiarity is the tendency to<!-- Page 238 --><span class='pagenum'><a name="Page_238" id="Page_238">[238]</a></span> +interruption of the apathetic habit, when the patient +may return to life, as it were, for a few moments +and then relapse.</p> + +<p>Closely related to the apathy, and probably +merely an expression of it, is the inactivity which +is both muscular and mental. It exists in all gradations +from that of flaccidity of voluntary muscles, +with relaxation of the sphincters, and from states +where there is complete absence of any evidence of +mentation to conditions of mere physical and psychic +slowness. After recovery the stupor patient +frequently speaks of having felt dead, paralyzed +or drugged.</p> + +<p>By far the commonest cause of emotional expression +or interruption in the inactivity is negativism. +This is a perversity of behavior which seems to express +antagonism to the environment or to the +wishes of those about the patient. In the partial +stupors it is seen as active opposition and cantankerousness. +In the more profound conditions it is +represented by muscular resistiveness or rigidity, +or refusal to swallow food when placed in the mouth. +Occasionally, too, the patient may even in a deep +stupor retain urine so long that catheterization is +necessary. All the explanations which one may +gather from the patients' own utterances, mainly +retrospective, seem to point to negativism expressing +a desire to be left alone. The appearance of +perverse behavior in aimless striking or mere muscular +rigidity seems to be an example of dissociation +of affect.</p> + +<p><!-- Page 239 --><span class='pagenum'><a name="Page_239" id="Page_239">[239]</a></span></p><p>Catalepsy is an important symptom because, although +it occurred in slightly less than a third of our +cases, it seems to be a peculiarity of the stupor reaction +found but rarely in other benign psychoses. +It seems never to occur without there being some +evidence of mental activity, and, consequently, we +are forced to conclude that it is of mental rather +than of physical origin. Just what it means psychically +it is impossible to state without much more +extended observations. We conjecture tentatively, +however, that the retention of fixed positions is in +part merely a phenomenon of perseveration, and in +part an acceptance of what the patient takes to be +a command from the examiner, and sometimes a +distorted form of muscular resistiveness.</p> + +<p>The intellectual processes suffer more seriously +in stupor than in any other form of manic-depressive +insanity. Not only do the deep stupors betray +no evidence of mentation during the acme of the +psychosis, but retrospectively they usually speak of +their minds being a blank. Incompleteness and +slowness of intellectual operations are highly characteristic +features of the partial stupors and of the +incubation period of the more profound reactions. +The features of this defect are a difficulty in grasping +the nature of the environment, a slowness in +elaborating what impressions are received, with resulting +disorientation, poor performance of any set +tests and incomplete memory for external events +when recovery has taken place. At times the thinking +disorder may develop with great suddenness or<!-- Page 240 --><span class='pagenum'><a name="Page_240" id="Page_240">[240]</a></span> +improve as quickly, and a tendency to isolated evidences +of mental acuity is another example of the +inconsistency which is so highly characteristic of +stupor. We should note, however, that these sporadic +exhibitions of mentality are always associated +with brief emotional awakening.</p> + +<p>When we turn to examine the fragmentary utterances +of stupor patients, we are surprised by the +narrowness and uniformity of the ideational content. +It seems to be confined to thoughts of death +or closely related conceptions. Thirty-five out of +thirty-six consecutive cases at one time or another +referred literally to death. It is commonest during +the onset, as all but five of these patients spoke of +it during the incubation of their psychoses. Hence +we conclude that death ideas and stupor are consecutive +phenomena in the same fundamental process. +As two-thirds of the series interrupted the stupor to +speak of death or to attempt suicide, we assume +that this relationship persists. Only a quarter gave +any retrospective account of these fancies, so we +presume that their psychotic experiences were repressed +with recovery.</p> + +<p>The usual form in which the idea appears is as +a delusion of going to die or, literally, of being dead. +It may appear as being in Heaven or Hell. A theoretically +important group is that which includes the +patients who, in addition, speak of being in situations +such as under the water or underground, +which we have mythological and psychological evidence +to believe are formulations of a rebirth<!-- Page 241 --><span class='pagenum'><a name="Page_241" id="Page_241">[241]</a></span> +fantasy. Not rarely, preoccupation with death is +expressed in sudden impulsive suicidal attempts.</p> + +<p>The affective setting of these different formulations +is important. A delusion of literal death occurs +with complete apathy. The wish to die is apt +to appear without the usual accompaniment of +sadness or distress but still with considerable +energy when impulsive suicidal attempts are made. +A prospect of death, particularly when there is anticipation +of being killed, is apt in manic-depressive +insanity to occur in a setting of anxiety. Similarly +one ordinarily observes fear in the patient who has +delusions of drowning or burial. In the stupor cases, +however, this painful affect seems to be reduced to +a mere dazed bewilderment or feeble exhibitions of +a desire for safety, such as the slow swimming movements +of a patient who thought she was under the +water. When these ideas of danger become allied +to everyday interests—husband or child imperiled, +etc.—a weak affect in the form of depression is apt +to occur.</p> + +<p>Physical symptoms are more common than in any +other benign psychosis. Of these the most nearly +constant is a low fever, the temperature running between +99 and 101. Twenty-eight out of thirty-five +cases had this slight elevation with a tendency for it +to occur immediately at the beginning of marked +stupor symptoms. Although the evidence does not +positively exclude any possibility of infection, it +speaks distinctly against this view. A possible explanation +is that the low fever is a secondary symp<!-- Page 242 --><span class='pagenum'><a name="Page_242" id="Page_242">[242]</a></span>tom. +The suprarenal glands may function insufficiently +as a consequence of the emotional poverty, +since all emotions which have been experimentally +studied seem to stimulate the production of adrenalin. +Without this normal hormone for the activity +of the sympathetic nervous system, there would be a +disturbance of skin and circulatory reactions that +would interfere with the normal heat loss. Suggestive +evidence to support this view comes from the +frequency with which the extremities are cyanotic +or cold, the skin greasy, sweating profuse or absent, +and so on. Further observations are necessary to +confirm or disprove this hypothesis, but we feel inclined +to accept it tentatively because it is plausible +and consistent with the view that stupor is essentially +a psychogenic type of reaction. Another +physical anomaly, which is presumably of endocrine +origin, is the suppression of the menses. This probably +results from lowered nutrition. In some cases +it ensues directly on a psychic crisis before any +nutritional change can have taken place. Finally, +among the symptoms of possible physical origin, +epileptoid attacks were described in two of our +cases. This is chiefly of interest in that such phenomena +are extremely rare in the benign psychoses.</p> + +<p>We believe that the mental symptoms summarized +above constitute a specific psychotic type of reaction +capable of appearing in any severity from mere +lethargy and indifference to profound stupor. Since +the prognosis is good, we feel obliged to classify this +with the manic-depressive reactions. Further justi<!-- Page 243 --><span class='pagenum'><a name="Page_243" id="Page_243">[243]</a></span>fication +for this grouping is found in the occurrence +of the stupor reaction as a phase in many manic-depressive +psychoses. A patient may swing from +mania to stupor as from mania to depression, and +when the partial stupors are recognized as milder +forms of the same process, it seems to be a frequent +type of reaction.</p> + +<p>If stupor be a reaction type, its laws must be +psychological. According to the view of modern +psychopathology, the essence of insanity is regression +with indolent thinking as opposed to progressive +and energetic mentation. One can look on +stupor as being a profound regression. Effort is +abandoned (apathy and inactivity), while the ideational +content expresses a desire for a retreat from +the world in death. It is possible to think of this +regression as a return to the mental habit of the +suckling period, when spontaneous effort is at its +minimum. This, too, is the time when petulance and +tantrums are frequent expression of a wish to be left +alone, which may account for the negativism as a +consistent symptom of the same regressive progress.</p> + +<p>Just as we regress in sleep, to rise refreshed for a +new day's duties, so the stupor case often shows excessive +energy in a hypomanic phase before complete +normality is reached. This corresponds again +to the age-old association of the ideas of death and +rebirth which we see together so frequently in +stupor. It is the psychology of wiping the slate +clean for a fresh start.</p> + +<p>The development and symptoms of stupor furnish<!-- Page 244 --><span class='pagenum'><a name="Page_244" id="Page_244">[244]</a></span> +evidence in support of the hypothesis of this type of +regression. Dissatisfaction of any kind is the setting +in which the psychosis begins and the commonest +precipitating factor is some reminder of death. That +loss of energy appears with the stupor is evident +from the inactivity and apathy, while the thinking +disorder can be shown to be the result of the same +loss. The different "levels" of the stupor reaction +also conform to a theory of regression. First there +is mere indifference and quietness; then appear +false ideas when normality is so far abandoned as +to mean a loss of the sense of reality; withdrawal of +interest from the environment, with its consequent +centering of self, leads to the next stage—that of the +spoiled child reaction; then follows the exclusion of +the world around in the dramatization of death; +finally, in the deepest stupor, mentation is so far +abandoned that we can gather no evidence of even +this delusion being present.</p> + +<p>Atypical features in stupor have to do mainly with +interruptions, interludes as it were, of elation, +anxiety or perplexity. These are explicable as +awakenings from the nothingness of stupor into +imaginations such as characterize the other manic-depressive +psychoses. When such tendencies are +present, the co-existence of the stupor process may +tone down the emotional response or prevent its +complete repression so that insufficient or dissociated +affects appear. A combination of the stupor +tendency to apathy with the mood of another reac<!-- Page 245 --><span class='pagenum'><a name="Page_245" id="Page_245">[245]</a></span>tion +is probably the only combination of affects to +be met with in psychiatry.</p> + +<p>The stupor reaction, then, is a simple regression, +with a limitation of energy, emotion and ideational +content, the last being confined to notions of death. +All functional psychoses are regressions. How do +the others differ from this? We need only answer +this question in so far as it concerns the clinical +states resembling benign stupors. Stupors occur +frequently in catatonic dementia prcox. In this +disease there is a regression of interest to primitive +fantastic thoughts, and with this a perversion of +energy and emotion. This corrupts the purity of the +stupor picture so that inconsistencies, such as empty +giggling, atypical delusions and scattered speech, +occur. Other impurities are to be found in the +frequent orientation of the dementia prcox stupor +patient which is discovered to be astonishingly good, +or in free speech associated with apathy and inactivity. +Such symptoms usually appear quite early and +should enable one to make a positive diagnosis +within a short time after patient comes under observation. +As a matter of fact, in many if not most +cases there is a slow onset characterized by the +pathognomonic symptoms of dementia prcox before +the actual stupor sets in.</p> + +<p>Other psychoses superficially resembling stupor +are the perplexity and absorbed manic (manic +stupor) states. We have reason to believe that both +these conditions are essentially the result of absorption +in kaleidoscopic ideas. Their appearance<!-- Page 246 --><span class='pagenum'><a name="Page_246" id="Page_246">[246]</a></span> +is that of inactivity and indifference to the outside +world, just as a dreamer seems placid and apathetic. +But these reactions are not without emotion which +may sometimes be obvious, and the richness of the +mental content is sooner or later manifest.</p> + +<p>Finally, from a practical standpoint, an important +peculiarity of benign stupor is the tendency for response +to stimulation in amelioration of the process. +Close attention to these patients is advisable, therefore, +not merely for the sake of their physical health, +but also because any attention tends to keep them +mentally alive or revive their waning energy. Visits +of relations often initiate recovery in a striking way. +From occurrences such as these, psychiatrists +should gain hints for valuable therapeutic experiments.</p> + +<p>So much for the technical, psychiatric aspects of +the stupor problem. We have frequently spoken of +it, however, as a psychobiological reaction. If this +be a sound view, similar tendencies should appear +in everyday life, the psychotic phenomena being +merely the exaggerations of a fundamental type of +human and animal behavior. Shamming of death in +the face of danger and animal catalepsy come to +mind at once, but since we know nothing of the associated +affective states we should be chary of using +them even as analogies. We are on safer ground in +discussing problems of human psychology.</p> + +<p>It is evident that there are psychological parallels +between the stupor reaction and sleep, while future +work may show physiological similarities as well.<!-- Page 247 --><span class='pagenum'><a name="Page_247" id="Page_247">[247]</a></span> +Apathy towards the environment, inactivity and a +thinking disorder are common to both. But sleep +reactions do not occur in bed alone. Weariness produces +indifference, physical sluggishness, inattention +and a mild thinking disorder such as are seen +in partial stupors. The phenomena of the midday +nap are strikingly like those of stupor. The individual +who enjoys this faculty has a facility for retiring +from the world psychologically and as a result +of this psychic release is capable of renewed activity +(analogous to post-stuporous hypomania) that cannot +be the result of physiological repair, since the +whole affair may last for only a few minutes.</p> + +<p>In everyday life there are more protracted states +where the comparison can also be made. When life +fails to yield us what we want, we tend to become +bored—a condition of apathy and inactivity, forming +a nice parallel to stupor inasmuch as external +reminders of reality and demands for activity are +apt to call out irritability. A form of what is really +mental disease, although not called insanity, is permanent +boredom, a deterioration of interest, energy +and even intelligence by which many troubled souls +solve their problems. A sudden withdrawal from +the world we call stupor. When the same thing +happens insidiously, the condition is labeled according +to the financial and social status of the victim. +He is a bum, a loafer, a mendicant or, more politely, +a disillusioned recluse. Frequently this undiagnosed +dement has satisfied himself with a weak, cynical +philosophy that life is not worth while.</p> + +<p><!-- Page 248 --><span class='pagenum'><a name="Page_248" id="Page_248">[248]</a></span></p><p>It is but a step from valueless life to death and +the same tendency which makes the patient fancy he +is dead, leads the tired man to sleep, the poet to +sigh in verse for dissolution, and the myth maker +to fabricate rebirth. The religions of the world are +full of this yearning, which reaches its purest expression +in the belief and philosophy of Nirvana. +The ideational content of stupor has also its analogue +in crime. The desire for perpetuation of relationships +unprosperous in this world is not seen only +in the delusion of mutual death. One can hardly +pick up a newspaper without reading of some unhappy +man or woman who has slain a disillusioned +lover and then committed suicide.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_12_14" id="Footnote_12_14"></a><a href="#FNanchor_12_14"><span class="label">[12]</span></a> Kirby, George H.: "The Catatonic Syndrome and Its Relation +to Manic-Depressive Insanity." <cite>Jour. of Nervous and Mental Disease</cite>, +Vol. XL, No. 11, 1913.</p></div> +</div> + +<p><!-- Page 249 --><span class='pagenum'><a name="Page_249" id="Page_249">[249]</a></span></p> + +<h2><a name="CHAPTER_XV" id="CHAPTER_XV">CHAPTER XV</a><br /> + +<span class="sm">THE LITERATURE OF STUPOR<a name="FNanchor_C_15" id="FNanchor_C_15"></a><a href="#Footnote_C_15" class="fnanchor">[C]</a></span></h2> + +<p>The cases of benign stupor which we report here +are not clinical curiosities. Taking the symptoms as +the products of a reaction type, the latter is really +quite common. One, therefore, asks what other +psychiatrists have done with this material. How +have they described these stupors, how classified +them? This chapter, essentially an appendix, attempts +to give a brief answer to this inquiry. No +attempt is made to catalogue all that has been written +on or around this subject but only to mention +typical reports and viewpoints.</p> + +<p>The French, beginning with Pinel in the 18th +Century, were the first to write extensively of +stupor. An excellent paper by Dagonet<a name="FNanchor_13_16" id="FNanchor_13_16"></a><a href="#Footnote_13_16" class="fnanchor">[13]</a> appeared +in 1872, in which such literature as had appeared up +to that time is discussed. He defines "Stupidity" +as a form of insanity in which "delirious" ideas +may or may not be present, which has for its characteristic +symptoms a state of more or less manifest<!-- Page 250 --><span class='pagenum'><a name="Page_250" id="Page_250">[250]</a></span> +stupor and a greater or less incapacity to cordinate +ideas, to elaborate sensations experienced and accomplish +voluntary acts necessary for adaptation. +This would seem to include our "partial stupor," as +well as the more marked cases.</p> + +<p>He quotes an excellent definition from Louyer +Villermay (Dict. des sc. md. t. LIII, p. 67). "Stupor +is a term applied to stupefaction of the brain. +It is recognizable by the diminution or enfeeblement +of internal sensation and by a greater difficulty in +exercising memory, judgment and imagination. It +is accompanied by a general numbness and a weakness +of feeling and movement. The patient, then, +has an indefinite and stupid expression, he understands +questions put to him with difficulty, and +answers them with effort or not at all. He seems +overwhelmed with sleep, he forgets to withdraw his +tongue after showing it to the doctor, he complains +of no uncomfortable sensation, of no illness, he +seems to take no interest in what goes on about him.... +The stupor patient is a fool who does not speak, +in this being more tolerable than the one who speaks +[delightful naivet!]. One who is dumbfounded by +surprise or fright is also to be called stuporous."</p> + +<p>Dagonet says stupor results from various causes, +such as exhaustion, or emotional and intellectual +factors. Clinically it varies in kind and degree according +to the situation in which it develops. When +it develops during normal mental health, it disappears +when its cause does. In insanity it appears +in the course of a psychosis of some duration, of<!-- Page 251 --><span class='pagenum'><a name="Page_251" id="Page_251">[251]</a></span> +which it seems a part, an exaggeration of some +symptom of the general condition. Evidently he +views stupor as a type of reaction: as a more or less +complete suspension of the operation of intellectual +faculties, a more or less sudden subtraction of +nervous forces. This reaction can result from a +fright or the memory of it, a brain lesion or trauma, +the action of narcotics, exhausting fevers, excessive +grief, the terrors of alcoholic hallucinations, epileptic +seizures, profound anemia and nervous exhaustion +consequent on sexual excess. He is careful to +say that both symptoms and treatment vary with +the varied etiologies.</p> + +<p>He credits Pinel with being the first to call attention +to stupor. This author claimed that some +persons with extreme sensibility could be so upset +by any violent emotion as to have their faculties +suspended or obliterated. He noted, too, that +stupors frequently terminated in manic phases of +20 to 30 days' duration. Pinel also emphasized the +apathy of these cases. Esquirol called stupor +"acute dementia," a term which persisted in French +literature for a long time. He described an interesting +circular case where alternations between +mania and typical stupor took place. He mentions +too the dangerous, impulsive tendencies of many +patients. Georget emphasized the fact which Pinel +had also noted, that retrospectively the stupor patient +says his mind was a blank during the attack. +In 1835 Etoc-Demazy published on the subject. He +regarded stupor not as a separate form of insanity<!-- Page 252 --><span class='pagenum'><a name="Page_252" id="Page_252">[252]</a></span> +but a complication ensuing on monomania or mania. +He recognized the partial as well as complete stupor. +He thought the condition was due to cerebral +edema, as did other writers of that period. Dagonet +remarks about this last—a lesson not learned in +fifty years by the profession—that demonstrable +edema does <em>not</em> produce the typical symptoms of +stupor. Baillarger in 1843 (Annales Mdico-psychologiques) +was the first whose ambition to simplify +psychiatric types led to denial of a separate kind +of reaction. He claimed that stupor was not a form +of insanity but an extension of a "dlire mlancholique." +As Dagonet remarks, every symptom by +which he characterizes stupor is a psychiatric symptom +and insanity can consist just as well in the +diminution as the perversion or exaltation of normal +faculties. Some of Baillarger's cases had false +ideas, some apparently none at all. Dagonet thinks +this justifies two types, one a dream-like state and +another where no ideas are present, although he +admits one may be an exaggeration of the other. +Brierre de Boismont (Annales Mdico-psychologique, +1851, p. 442) compares these two kinds of +stupors to deep sleep when intelligence is completely +suspended and to sleep with dreams. (These two +types would correspond to our "absorbed mania" +and true deep stupor.) He urges strongly the +separation of stupor from melancholia as an entirely +different type of reaction, in this connection citing +the views pro and con of various authors. Of these<!-- Page 253 --><span class='pagenum'><a name="Page_253" id="Page_253">[253]</a></span> +Delasiauve is particularly cogent in discriminating +stupor from melancholia on the grounds of the difference +of the emotional reactions and of the intellectual +disorder and the real paucity of thought in +the former psychosis.</p> + +<p>After quoting these and other authors, Dagonet +offers an explanation for the diversity of opinion. +He says that stupor following another psychosis +may retain some of its symptoms, so that a mixture +obtains, as often in medicine. He then gives excellent +descriptions of three types: the deep stupor +with paralysis of the faculties, the cases that are +absorbed in false ideas, and ecstatic cataleptics.</p> + +<p>The remainder of his paper is concerned with +cases and discussions about them. He cites examples +of stupor following fear or other emotional +shocks, following grave injuries such as the loss of +a limb, following head trauma and with typhoid +fever. As to the last he points out that delirious +features are prominent. Many authors have assigned +sexual excesses as a cause of stupor. The +psychosis, Dagonet says, is not pure but more a +mixture of hypochondria and depression. Relationship +with mania is next considered. He says that +stupor may succeed, alternate with or precede +mania. His cases seem mainly to have been what +we call absorbed manics or manic stupors. In fact, +he uses the last term. The commonest introductory +psychosis, he claims, is depression, but from his +brief case reports it would seem that most of his<!-- Page 254 --><span class='pagenum'><a name="Page_254" id="Page_254">[254]</a></span> +patients were not stuporous, in the narrow sense of +the term, but severely retarded depressions. In fact, +in perusing his case material comprising "stupors" +in the course of many types of functional insanity, +or as a complication of epilepsy or general paralysis, +it is evident that in practice he does not follow +the discriminative definitions of the earlier portion +of his paper. For him, apparently, patients who +are markedly inaccessible to examination from +whatever cause are "stuporous." He closes with +excellent remarks on physical and psychic treatment. +As to prognosis he has nothing to say beyond +the opinion that most of the cases recover.</p> + +<p>If Dagonet be accepted as summarizing the early +French work, we can conclude that their generalizations +were on the whole quite sound. These were: +that stupor is an abnormal mental reaction, usually +psychogenic but often the result of exhaustion, that +it consists in a paralysis of emotion, will and intelligence; +that the prognosis is usually good; that +mental stimulation may produce recovery. What +remained to be done after this work was the refinement +in detail of these generalizations, particularly +in respect to the differentiation of prognostically +benign and malignant types. But other Frenchmen +did not take up this work, apparently, for the brilliant +psychopathologists of the next generations +attended to stupor only in so far as it was hysterical.</p> + +<p>An Englishman, however, soon took up the task, +adding more exactness to his formulations. New<!-- Page 255 --><span class='pagenum'><a name="Page_255" id="Page_255">[255]</a></span>ington<a name="FNanchor_14_17" id="FNanchor_14_17"></a><a href="#Footnote_14_17" class="fnanchor">[14]</a> +published his important paper in 1874. A +nascent stage of stupor, he thinks, is a common reaction +to great exhaustion, "such as hard mental +work, prolonged or acute illness, dissipation, etc." +Such conditions, like the grave psychotic forms, he +regarded as due to physical exhaustion of the brain +cells, but, since he thought psychic stress could produce +this exhaustion, this "organic" view did not +bias his general formulations. He makes a division +into two stupors: Anergic Stupor and Delusional +Stupor. The former may be primary, being generally +caused by a sudden intense shock (Esquirol's +"Acute Dementia"), or secondary (a) to convulsions +of any kind, (b) to mania in women, (c) to any +other prolonged nervous exhaustion. The delusional +form results from (a) intense melancholia, (b) from +general paralysis in which it may be intercurrent, +(c) from epileptic seizures. When one examines his +points of difference between these two types, it becomes +clear that Newington really gave an excellent +differentiation of benign and malignant stupor—in +fact, it is the only serious attempt at such discrimination +prior to this present work. What is more +remarkable is the fact that, although he clearly saw +the clinical differences, he failed to see that the two +types differed prognostically. His description is +given in a table sufficiently concise to justify its +quotation <i lang="la">in extenso</i>.</p> + +<p><!-- Page 256 --><span class='pagenum'><a name="Page_256" id="Page_256">[256]</a></span></p> + +<table class="symp" summary="Differences between Anergic and Delusional stupor" width="95%"> + +<tr><th></th><th><i>ANERGIC STUPOR</i></th> <th><i>DELUSIONAL STUPOR</i></th></tr> + +<tr><th class="rhead"><i>Etiology</i>—</th> +<td>Hereditary and + individual liability to + sudden loss of <i lang="la">vis nervosa</i>.</td> + +<td>Hereditary.</td></tr> + +<tr><th class="rhead"><i>Onset</i>—</th> + +<td>Rapid.</td> + +<td>Usually insidious, may be almost +instantaneous.</td></tr> + +<tr><th class="rhead"><i>Symptoms</i>—</th> +<td>Intellect greatly + impaired.</td> +<td>Conduct shows reasoning power.</td> +</tr> + +<tr><th class="rhead"><i>Memory</i>—</th> +<td>Seems to be swept + away as far as possible.</td> + +<td>Found after recovery to have +been preserved to a great +extent.</td></tr> + +<tr><th class="rhead"><i>Emotional Capacity</i>—</th> +<td>Nil or + almost so. Tears frequent + but due to relaxation of + sphincter muscles. Features + relaxed, eyes vacant and not + constantly fixed.</td> + +<td>Evidence of grief, fear, etc., in +facial expressions and wringing +and clasping of hands. +Tears rare. Great contraction +of features [grimacing?]. +Eyes fixed on one +point, usually upwards or +downwards, or else obstinately +closed.</td> +</tr> + +<tr><th class="rhead"><i>Volition</i>—</th> +<td>Almost absent.</td> + +<td>Frequently great stubbornness, +refusal to do what is +wanted. On the other hand, +intense determination in +following out own plan.</td></tr> + +<tr><th class="rhead"><i>Motor System</i>—</th> +<td>Weak and uncertain. + Patient has to be + led about and if placed on a + seat or in some position does + not move. ("Cataleptoid" + condition.)</td> + +<td>But little interfered with, +independently of sheer asthenia, +produced by patient's + conduct. May stand behind +door or kneel on floor in +constrained position even for +days.</td></tr> + +<tr> +<th class="rhead"><!-- Page 257 --><span class='pagenum'><a name="Page_257" id="Page_257">[257]</a></span> +<i>Sensory System</i><br /> +<i>Reflex System</i>—</th> + +<td><span class="xlg">}</span> Both dull.</td> + +<td>Ditto. There seems to be a +much greater ability to bear +severe pain.</td></tr> + +<tr><th class="rhead"><i>Pupils</i>—</th> +<td>Dilated.</td> +<td>Tendency to contraction.</td></tr> + +<tr><th class="rhead"><i>Sleep</i>—</th> +<td>Generally good.</td> +<td>Intense sleeplessness.</td></tr> + +<tr><th class="rhead"><i>General bodily condition</i>—</th> +<td> Emaciation, sometimes extreme, + usually rapid, with + rapid recovery of flesh. + Often not much loss of + weight, though whole tone is + lowered.</td> + +<td>Affected <i lang="la">pari passu</i> with +mental state and seems + governed by it.</td></tr> + +<tr><th class="rhead"><i>Vascular System</i>—</th> +<td>Pulse slow, + sometimes almost imperceptible. + Cyanotic appearance, edema + and iciness of extremities. + Great decrease of vitality + in peripheral structures, + as shown by asthenic + eruptions and production of + vermin.</td> + +<td>Pulse weak and often quick +and thready. Complexion +anemic and sallow. The +other appearances may be +present but come on later +and are less marked.</td></tr> + +<tr><th class="rhead"><i>Digestive System</i>—</th> +<td>Tongue + clean or if furred it is moist. + Appetite <em>apathetic</em>, bowels + not irregular, but habits + very dirty.</td> + +<td>Tongue dry, small and furred. +Refusal of food. Great +constipation. Dirtiness of +habits rare.</td></tr> + +</table> + +<p>If one compares these data with those given in +the chapter on Malignant Stupors, it is seen that in +the main Newington has made the same discrimination +as we have. He is certainly wrong in denying +"negativism" to his anergic type. Probably, too, +he attempts too fine a distinction between the<!-- Page 258 --><span class='pagenum'><a name="Page_258" id="Page_258">[258]</a></span> +physical symptoms of the two groups. His conclusions +are interesting: that in the anergic cases there +is an <em>absence</em> of cerebration, while amongst the delusional +there is an abnormal <em>presence</em> of intense but +perverted cerebration. This is not unlike our own +view. He thinks the difference in memory is the +most important differential point. Sex is important +in determining the nature of the stupor, for he found +the anergic type following mania in females only. +He observed such an end to manic attacks in 6 out +of 36 cases. All his cases were under 30 and he regards +the prognosis as good on the whole. As to +treatment he emphasizes the necessity for "moral +pressure" as a stimulus and cites a case of rapid +improvement after a change of scene.</p> + +<p>Since 1874 very little advance has been made by +British psychiatrists, as seen by a perusal of Clouston's<a name="FNanchor_15_18" id="FNanchor_15_18"></a><a href="#Footnote_15_18" class="fnanchor">[15]</a> +summary in 1904. He regards sex exhaustion +as a highly frequent cause, although Dagonet had +shown 32 years before that sex abuse does not produce +a true stupor. He thinks stupor usually follows +depression or mania and says that "the 'Confusional +Insanity' of German and American authors is just +a lesser degree of stupor." Omitting his stupors in +general paralysis and epilepsy he makes three clinical +divisions: <em>melancholic or conscious stupor</em>, which +is not a product of delusions, although delusions of +death or great wickedness may be present, impulsiveness +and fits may be observed; <em>anergic or<!-- Page 259 --><span class='pagenum'><a name="Page_259" id="Page_259">[259]</a></span> +unconscious stupor</em>, which corresponds roughly to +our deep, benign stupor; and <em>secondary stupor</em> after +acute mental disease, which resembles our partial +stupor. He warns against a rash diagnosis of dementia +in this last group. His views on the importance +of mental causation and the relation to manic-depressive +insanity may be gathered from these +sentences: "The condition of the mental portion of +the convolutions in stupor is probably analogous to +the stupidity of a nervous child when terrified or +bullied." "Stupor is frequently one of the stages +of alternating insanity following the exalted condition. +It is more apt to occur in those where the +exalted period is acutely maniacal. The stupor is +usually melancholic in form." Since he claims that +the anergic is a "very curable form of mental disease," +while only 50% of the melancholic cases recover, +it seems clear that this division is not +prognostically final. The "melancholic" is evidently +Newington's "delusional" without his more accurate +discrimination of symptoms.</p> + +<p>From the standpoint of accurate description the +opinion may be ventured that there is a gap in the +literature from the early French writers and Newington +up to the paper by Kirby, which has been discussed +in the first chapter. This gap is filled by +literature of the German schools and their adherents +in other countries. German psychiatry has been +concerned mainly with classification or the elaborate +examination of certain symptoms. Inevitably such +a program militates against detached objective clini<!-- Page 260 --><span class='pagenum'><a name="Page_260" id="Page_260">[260]</a></span>cal +description. It is hard to record symptoms that +interfere with classification. German psychiatry has +tended to make the insane patient a type rather +than an individual. Hence the gap in the descriptive +literature of stupor.</p> + +<p>The necessity of establishing the possibility of +some stupors having a good prognosis has arisen +from Kraepelin's work. He can rightly be viewed +as the father of modern psychiatry because he introduced +a classification based on syndromes and +taught us to recognize these disease groups in their +early stages. Inevitably with such an ambitious +scheme as the pigeon-holing of all psychotic phenomena +some mistakes were made. Most of these +appear in the border zone between dementia prcox +and manic-depressive insanity. The latter group +being narrowly defined, the former had to be a waste +basket containing whatever did not seem to be a +purely emotional reaction. Clinical experience soon +proved that many cases which, according to Kraepelin's +formul, were in the dementia prcox group, +recovered. Adolf Meyer was one of the first to protest +and offered categories of "Allied to Manic-Depressive +Insanity" or "Allied to Dementia Prcox," +as tentative diagnostic classifications to include +the doubtful cases.</p> + +<p>Difficulties with stupor furnish an excellent example +of the confusion which results from the adoption +of rigid terminology. The earlier psychiatrists +were free to regard a patient in stupor as capable +of recovery as well as deterioration. When Kahl<!-- Page 261 --><span class='pagenum'><a name="Page_261" id="Page_261">[261]</a></span>baum +included stupor with "Catatonia," the situation +was not changed, for he did not claim a hopeless +prognosis for this group. But when Kraepelin made +catatonia a subdivision of dementia prcox, all +stupors (except obvious phases of manic-depressive +insanity) had to be hysterical or malignant. Faced +with this dilemma psychiatrists have either called +recoveries "remissions" or, like E. Meyer, claimed +that one-fifth or one-fourth of catatonics really get +well.</p> + +<p>As a matter of fact it seems clear that stupor is a +psychobiological reaction that can occur in settings +of quite varied clinical conditions. It is not necessary +to detail publications describing stupors in +hysteria, epilepsy, dementia prcox or in the organic +psychoses. It may be of interest, however, to cite +some examples of acute, benign stupors and the discussion +of them which appear in the literature of +recent years.</p> + +<p>An important group is that of stupors occurring +as prison psychoses. Stern<a name="FNanchor_16_19" id="FNanchor_16_19"></a><a href="#Footnote_16_19" class="fnanchor">[16]</a> mentions that acute +stupors are found in this group. Wilmanns<a name="FNanchor_17_20" id="FNanchor_17_20"></a><a href="#Footnote_17_20" class="fnanchor">[17]</a> examined +the records for five years in a prison and +discovered that there were two forms of psychotic +reaction, a paranoid and a stupor type. It is interesting +psychologically that the former appeared +largely among prisoners in solitary confinement,<!-- Page 262 --><span class='pagenum'><a name="Page_262" id="Page_262">[262]</a></span> +while the stupors developed preponderantly among +those who were not isolated. The stupors recovered +more quickly. He describes the psychosis thus: +The prisoner becomes rather suddenly excited, destructive +and assaultive; then soon passes into an +inactive state, where he lies in bed, mute, with open +expressionless eyes. He is clean, however; eats +spontaneously and attends to his own hygienic +needs. Some cases are roused by transport from +the jail to the hospital but sink into lethargy again +when they reach their beds. Physically, they show +disturbances of sensation which vary from analgesia +to hypesthesia. There are a rapid pulse, positive +Romberg sign, exaggerated reflexes, fibrillary +twitching of the tongue and tremor of the hands. +Recovery takes place gradually. They begin to +react to physical stimuli and to answer questions, +although still inhibited, until consciousness is quite +clear. When speech begins, it is found that they are +usually disoriented for place and time as the result +of an amnesia which sets in sharply with the excitement. +This memory defect gradually improves <i lang="la">pari +passu</i> with the other symptoms.</p> + +<p>Two attacks in the same prisoner of what seem to +have been typical stupor are reported by Kutner<a name="FNanchor_18_21" id="FNanchor_18_21"></a><a href="#Footnote_18_21" class="fnanchor">[18]</a> +and Chotzen.<a name="FNanchor_19_22" id="FNanchor_19_22"></a><a href="#Footnote_19_22" class="fnanchor">[19]</a> The patient was a recidivist of unstable +mental make-up. At the age of 34 he was sent<!-- Page 263 --><span class='pagenum'><a name="Page_263" id="Page_263">[263]</a></span> +to prison for three years. Shortly after confinement +began, he became stuporous, being mute and negativistic, +soiling, refusing food and showing stereotypy. +On being shifted to another institution he appeared +suddenly much better, although he remained +apathetic and dull for some months. A striking +feature was a complete amnesia, not merely for the +stupor but also for his trial and entrance to the +prison. At the age of 42, he was again incarcerated. +A practically identical picture again developed, with +recovery when his environment was changed, and +with a similar amnesia. Recovery seemed to be +complete and there were no hysterical stigmata. +The interesting features of this case are that a +typical stupor seems to have been precipitated by +imprisonment, while the retroactive amnesia covering +a painful period of the patient's life reminds one +of hysteria.</p> + +<p>A case which is more difficult to interpret is reported +briefly by Seelig.<a name="FNanchor_20_23" id="FNanchor_20_23"></a><a href="#Footnote_20_23" class="fnanchor">[20]</a> A man of 20 with bad +inheritance tried to steal 100 marks. When sent to +jail he became ill shortly before his trial was due +and was sent to a hospital. There he seemed anxious, +was shy, and gave slow answers, with initial +lip motions and had to be urged to take hold of +objects. All this sounds more like a pure depression +than a stupor. But he also had paralogia. This +might make one think of a Ganser reaction on the +background of depression. S., however, calls it an<!-- Page 264 --><span class='pagenum'><a name="Page_264" id="Page_264">[264]</a></span> +hysterical stupor, although he agreed with Moeli +that it was hard to differentiate from a catatonic +state.</p> + +<p>Lwenstein<a name="FNanchor_21_24" id="FNanchor_21_24"></a><a href="#Footnote_21_24" class="fnanchor">[21]</a> reports an interesting case of a +dgnr who had had hysterical attacks. He suddenly +developed stupor symptoms, which lasted with +interruptions for nearly two years. After recovery +and during the interruptions the patient explained +his mutism, refusal to swallow, his filthiness and +general negativism as all occasioned by delusions. +He was commanded by God to act thus, the attendants +were devils, and so on. He spoke, too, of being +under hypnotic influence. In addition there were +other delusions such as that he had killed his +brother. The attack came on with the belief that he +was going to die, otherwise none of the ideas were +typical of the stupors we have studied. Another +incongruous symptom was that he did not seem to +be really apathetic, he reacted constantly to the environment. +The author comments on the absence of +senseless motor phenomena, such as would be expected +in a "catatonic." His complete memory of +the psychosis also speaks against the usual form of +stupor. It seems possible that this psychosis was +neither hysterical nor a benign stupor in our sense, +but, rather, an acute schizophrenic reaction such as +one occasionally sees. From the account which Lwenstein +gives, one gathers that the patient was absorbed +in a wealth of imaginations.</p> + +<p><!-- Page 265 --><span class='pagenum'><a name="Page_265" id="Page_265">[265]</a></span></p><p>Gregor<a name="FNanchor_22_25" id="FNanchor_22_25"></a><a href="#Footnote_22_25" class="fnanchor">[22]</a> tells of a stupor which is unusual in that +it consisted only of symptoms connected with inactivity, +which did not affect the intellectual processes. +The patient was a rubber worker who suddenly developed +a depression with self-accusation and +convulsions. She was soon admitted to a clinic and +then showed mutism and catalepsy. Later she became +totally immobile with no apparent psychic +reactions, and soiled. Gregor studied pulse, respiration +and respiratory volume in their reflex manifestations +and found nothing unusual. Next he +tried to discover if there were voluntary alterations +in respiration. He discovered that the respiratory +curve could be changed by calling out words to her, +by odors associated with suggestions, menaces, etc. +[This is suggestive of the dissociation of affect, +which we have discussed.] After two months she +recovered, <em>with complete recollection of the stupor +period</em>. It was then proven that the absence of +reactions was not the same as the lack of perception +of stimuli.</p> + +<p>Froederstrm<a name="FNanchor_23_26" id="FNanchor_23_26"></a><a href="#Footnote_23_26" class="fnanchor">[23]</a> reports a case that suggests hysteria, +where the stupor lasted for 32 years. A girl +at the age of 14 fell on the ice, had a headache, went +to bed and stayed there for 32 years. She lay there<!-- Page 266 --><span class='pagenum'><a name="Page_266" id="Page_266">[266]</a></span> +immobile, occasionally spoke briefly and took nourishment, +when it was put at a definite place at the +edge of the bed. At first (according to a late statement +of her brothers) this consisted only of water +but was soon changed to two glasses of milk a day. +After being in this state for ten years she was placed +in a hospital for two weeks, where she was mute, +did not react to pin pricks and had to be fed. It +seems that at home she secretly looked after herself, +for she kept her hair and nails in condition. Sometimes +she sat up and stared at the ceiling.</p> + +<p>After attending to the patient for 30 years, her +mother died. The patient cried for several days +when told of it, and after this she took nourishment +of her own accord. Two years later a brother died. +Again she cried on hearing the news. Her father, +who looked after her when the mother was dead, also +died. Then a governess came into the home, who +noticed that furniture was moved about when she +was alone.</p> + +<p>At the age of 46 she suddenly woke up and asked +at once for her mother. She claimed total amnesia +for the period of her stupor, including the stay at +the hospital. She could summon memories of her +childhood, however. Her brothers she did not recognize +and said, "They must be small." She recalled +the fall on the ice and coming home with +headache, toothache and pain in the back. Her general +knowledge was limited but she could read and +write. Her expression and appearance was that of +a young person, only her atrophic breasts and the<!-- Page 267 --><span class='pagenum'><a name="Page_267" id="Page_267">[267]</a></span> +fat on her buttocks betraying her age. She had been +well for four years at the time the report was made.</p> + +<p>He thinks that a certain tendency to exaggeration +and simulation speak for hysteria. We would be +more inclined to view the fact that she looked after +herself in spite of complete amnesia as evidence of +hysteria.</p> + +<p>Another protracted case suggestive of hysteria is +that reported by Gadelius.<a name="FNanchor_24_27" id="FNanchor_24_27"></a><a href="#Footnote_24_27" class="fnanchor">[24]</a> The patient was a +tailor, 32 years old, who had always been rather +taciturn and slow. A year before admission he began +to have ideas of persecution and to shun people. Then +he developed a stereotyped response, "It is nice +weather," whenever he was addressed. A month +before admission inactivity set in. He would sit +immobile in his chair with closed eyes and relaxed +face; he resisted when an attempt was made to put +him to bed. His color was pale.</p> + +<p>He was taken to hospital on November 1, 1882, +where he was observed to be immobile and to have +little reaction to pin pricks. When a limb was raised, +it fell limply. However, he would leave bed to go to +the toilet. Tube-feeding became necessary, but when +the tube was inserted in his nose, he woke up. He +then showed an amnesia not merely for his illness +but for his whole life: he did not know his father, +that he was married or that he had a mother. To<!-- Page 268 --><span class='pagenum'><a name="Page_268" id="Page_268">[268]</a></span>wards +the end of November, he became limp again +and answered, "I don't know" to most questions. +In December, however, he improved again and for +a few months these variations occurred. From +April, 1883, to May, 1886, he was in deep stupor, +almost absolutely immobile and close to being completely +anesthetic even with strong Faradic currents. +Towards the end of this period he walked +about <em>whenever he thought he was not watched</em>. He +was very cautious about this and became motionless +any time he became aware of observation. (Gadelius +thinks this was not simulation but the expression of +an automatism on the basis of a vague fixed idea.)</p> + +<p>This condition persisted apparently for five years +more, by the end of which time the anesthesia had +turned into a hyperesthesia. A year later he began +to eat. It was now found that he had an amnesia +for his illness and former life, so that he did not +even recognize a needle or pair of scissors. He knew +that he was born in the month of February and retained +some facility in calculation, in speech, walking +and usual motions. Then he regained all his +memories and resumed his trade as tailor. He was +discharged in June, 1893, nearly eleven years after +admission.</p> + +<p>It seems safe to say that elements at least of hysteria +appear in this history, such as the profound +retroactive amnesia and appearance of simulation +in the conduct of the patient. Accurate and rapid +grasp of the environment is necessary for such a +watch as he kept on the eye of his attendants. Men<!-- Page 269 --><span class='pagenum'><a name="Page_269" id="Page_269">[269]</a></span>tal +acuity of this grade combined with amnesia looks +more like an hysterical than a manic-depressive +process.</p> + +<p>Leroy<a name="FNanchor_25_28" id="FNanchor_25_28"></a><a href="#Footnote_25_28" class="fnanchor">[25]</a> describes a case much like ours which is +interesting from a therapeutic standpoint. The patient +was a woman who passed from a severe depression +with hallucinations and anxiety into a long +stupor, from which she recovered completely. There +was no negativism and no affect, although the latter +appeared so soon as contact began to be established. +When well she had a complete amnesia for the onset +of the psychosis. Leroy attributed the recovery, in +part at least, to the thorough attention given the +patient. Kraepelinian rigidity is seen, however, in +the author's refusal to regard the case as "circular" +because of the lack of all cyclic symptoms. He takes +refuge in the meaningless label "Mental Confusion."</p> + +<p>An important group of cases is that of the stupors +occurring during warfare. Considering stupor as +a withdrawal reaction, it is surprising there were so +few of them, although partial stupor reactions as +functional perpetuation of concussion were very +common. The editor saw several typical cases in +young children in London who passed into long +"sleeps" apparently as a result of the air raids.<!-- Page 270 --><span class='pagenum'><a name="Page_270" id="Page_270">[270]</a></span> +Myers<a name="FNanchor_26_29" id="FNanchor_26_29"></a><a href="#Footnote_26_29" class="fnanchor">[26]</a> has given us the best account of stupors in +actual warfare. A typical case was that of a man +who was found in a dazed condition and difficult to +arouse. He could give little information about himself, +could neither read nor write and never spoke +voluntarily. A week later his speech was still limited +and labored and no account of recent events +could be obtained from him. Under hypnosis he was +induced to talk of the accident which had precipitated +this disorder. He became excited in telling +his story, evidently visualizing many of the events. +In several successive sances, more data were obtained +and a cure effected. Myers points out that +in all his cases there was a mental condition which +varied from slight depression to actual stupor, all +had amnesias of variable extent and all had headaches. +The mental content seemed to be confined to +thoughts of bombardment, with a tendency for the +mind always to wander to this topic. The author +thinks that pain is a guardian protecting the patient +from too distressing thoughts. An effort to speak +would cause pain in the throat of a case of mutism +and, sometimes, when a distressing memory was +sought after under hypnosis, physical pain would +wake the sleeper. His view is that pains tend to +preserve the mutism and amnesia, so that there are +"inhibitory processes" causing the stupor, which +prevent the patient from further suffering. He does<!-- Page 271 --><span class='pagenum'><a name="Page_271" id="Page_271">[271]</a></span> +not find either in theory or experience reason to +believe that these conditions are the result of either +suggestion or "fixed ideas." He thinks it natural +that the last symptom of the stupor to disappear +should be mutism, as speech and vision are the +prime factors in communicating with environment. +[As has been noted frequently in this book, mutism +is a common residual symptom of the benign +stupor.] Myers believes that in nearly every instance +mutism follows stupor and is merely an attenuation +of the latter process. When deafness is +associated with mutism, he thinks it is often due +merely to the inattention of the stuporous state.</p> + +<p>In this connection we should mention that Gucci<a name="FNanchor_27_30" id="FNanchor_27_30"></a><a href="#Footnote_27_30" class="fnanchor">[27]</a> +points out that stupor patients with mutism of long +duration may, when requested, read fluently and +then relapse again into complete unreactiveness +towards auditory impressions. This, we would say, +is probably an example of a more or less automatic +intellectual operation occurring when the patient is +sufficiently stimulated, although he cannot be raised +to the point of spontaneous verbal productivity.</p> + +<p>As these scattered reports about benign stupors +are so unsatisfactory, one naturally turns to text-books. +Little more appears in them. Kraepelin +treats stupors occurring in manic-depressive insanity +as falling into two groups, the depressive and<!-- Page 272 --><span class='pagenum'><a name="Page_272" id="Page_272">[272]</a></span> +manic. The former seems to be nearer to our cases, +judging by the statements in his rather sketchy account. +He regards stupor as being the most extreme +degree of depressive retardation. [This possibility +has been discussed in the chapter on Affect.] His +description seems perhaps to include cases which we +would regard as perplexity states or absorbed +manias. Activity is reduced, they lie in bed mute, +do not answer, may retract shyly at any approach, +but on the other hand may not ward off pin pricks. +Sometimes there is catalepsy and lack of will, again +there may be aimless resistance to external interference. +They hold anything put into their hands, +turning it slowly as if ignorant of how to get rid of +it. They may sit helpless before food or may allow +spoon-feeding. Not rarely they are unclean. As to +the mental content, he says they sometimes utter a +few words, which give an insight into confused delusions +that they are out of the world, that their brains +are split, that they are talked about, or that something +is going on in the lower part of the body. The +affect is indefinite except for a certain bewilderment +about their thoughts and an anxious uncertainty towards +external interference. Intellectual processes +suffer. They are disoriented and do not seem to +understand the questions put to them. An answer +"That is too complicated" may be made to some +simple command. Kraepelin thinks that the disorder +is sometimes more in the realm of the will than of +thinking, for one patient could do a complicated calculation +in the same time as a simple addition. After<!-- Page 273 --><span class='pagenum'><a name="Page_273" id="Page_273">[273]</a></span> +recovery the memory for the period of the psychosis +is poor and quite gone for parts of it. Occasionally +there may be bursts of excitement, when they leave +the bed; they may scold in a confused way or sing a +popular song.</p> + +<p>His manic stupor is a "mixed condition," a combination +of retardation with elated mood. The condition +is different from the depressive stupor in that +activity is more frequent, either in constant fumbling +with the bed clothes or in spasmodic scolding, +joking, playing of pranks, assaultiveness, erotic +behavior or decoration. The affect is usually apparent +in surly expression or happy, or erotic, demeanor. +They are usually fairly clear and oriented +and often with good memory for the attack but with +evasive explanations for their symptoms. One cannot +make any classification of the ideas he quotes, +but it is apparent from all his description that the +minds of these "manic stupors" are not a blank but +rather that there is a fairly full mental content.</p> + +<p>Wernicke, unhampered by classifications of catatonia +and manic-depressive insanity with inelastic +boundaries, calls all stupor reactions akinetic psychoses +with varying prognosis. He does not make +Kraepelin's mistake of confusing the apathy of +stupor with the retardation of depression, stating +distinctly that the processes are different.</p> + +<p>Bleuler also has grasped this discrimination. He +points out that the thinking disorder in what he +terms "Benommenheit" (dullness) differentiates +such conditions from affectful depression with re<!-- Page 274 --><span class='pagenum'><a name="Page_274" id="Page_274">[274]</a></span>tardation. +He writes, of course, mainly of dementia +prcox,<a name="FNanchor_28_31" id="FNanchor_28_31"></a><a href="#Footnote_28_31" class="fnanchor">[28]</a> but makes some remarks germane to our +problem. In the first place he denies the existence +of stupor as a clinical entity, except perhaps as the +quintessence of "Benommenheit", it is the result of +total blocking of mental processes. Consequently, +he says, one can observe the external features of +stupor in all akinetic catatonics, in marked depressive +retardation, when there is a lack of interest, +affect or will, in autism, with twilight states, as a +result of negativism or, finally, when numerous +hallucinations distract the patient's attention into a +world of fancy. He notes that in all stupors (with +the exception, perhaps, of "Benommenheit") the +symptoms may disappear with appropriate psychic +stimulation or that some reaction, no matter how +larval, may be observed. He speaks, for instance, +of the visits of relatives waking the patient up.</p> + +<p>His only real group is "Benommenheit," which +he separates out as a true clinical entity. This seems +to correspond roughly with our "Partial Stupors." +It is essentially an affectless, thinking disorder, +usually acute, sometimes chronic, occurring among +schizophrenics. He believes that it is the result of +some organic process (intracranial pressure or +toxin). Activity is much reduced or absent; they +have poor understanding, answer slowly or confusedly; +their actions are sometimes as ridiculous as +those of people in panic (e.g., throwing a watch out<!-- Page 275 --><span class='pagenum'><a name="Page_275" id="Page_275">[275]</a></span> +of the window when the house is on fire); the defect +is best seen in writing, for large elisions are found +in sentences. He was able to analyze only one case +and she retained her affect; it was even labile and +marked. One suspects that such a case might, perhaps, +not really find a place in the "Benommenheit" +group even as Bleuler himself describes it.</p> + +<p>With the exception of Kirby, whose work has already +been discussed in the introduction, we have +been able to find only one author who has attempted +any symptomatic discrimination of the recoverable +and malignant catatonic states. Raecke<a name="FNanchor_29_32" id="FNanchor_29_32"></a><a href="#Footnote_29_32" class="fnanchor">[29]</a> made a +statistical study and found that 15.8% recovered, +10.8% improved, 54.4% remained in institutions, +while 30% died. With the etiology mainly exogenous +20% recovered and 14.3% improved. A good +outcome was seen in 30.2% of hereditary cases, +while only 22.7% did well in the non-hereditary +group. His most important contribution is in his +formulation of good and bad symptoms. He thinks +that dull, apathetic behavior with uncleanliness and +loss of shame are not so unfavorable as has been +thought. Malignant symptoms are grimacing with +prolonged negativism but without essential affect +anomaly, decided echopraxia and echolalia and +protracted catalepsy. We would agree with this, +although command automatisms have not been +prominent either in our benign or malignant +stupors.</p> + +<p><!-- Page 276 --><span class='pagenum'><a name="Page_276" id="Page_276">[276]</a></span></p><p>Two writers have made special observations that +should be confirmed and amplified before their significance +can be established. Whitwell<a name="FNanchor_30_33" id="FNanchor_30_33"></a><a href="#Footnote_30_33" class="fnanchor">[30]</a> thinks that +in addition to a diminished activity of the heart +there exists a pathological tension. Ziehen says that +he also has frequently seen angiospastic pulse-curves +in exhaustion stupor or acute dementia, but +that other pulse pictures may be seen as well. Any +such studies should be correlated rigorously with the +clinical states before they can have any meaning. +Wetzel<a name="FNanchor_31_34" id="FNanchor_31_34"></a><a href="#Footnote_31_34" class="fnanchor">[31]</a> tested the psychogalvanic reflex in stupors +and in normal persons who simulated stupors. He +found them different.</p> + +<p>Only one publication has come to our attention in +which an attempt is made at psychological interpretation +of various symptoms in stupor. Vogt<a name="FNanchor_32_35" id="FNanchor_32_35"></a><a href="#Footnote_32_35" class="fnanchor">[32]</a> derives +much from a restriction of the field of consciousness. +Only one idea is present at a time, hence +there is no inhibition and impulsiveness occurs. +Similarly, if the idea appear from without, it, too, +is not inhibited, which produces the suggestibility +that in turn accounts for catalepsy. Stereotypy and +perseveration are other evidences of this narrowness +of thought content. Negativism is a state, he +says, of perseverated muscular tension. [This +would apply only to muscular rigidity.] So far as it<!-- Page 277 --><span class='pagenum'><a name="Page_277" id="Page_277">[277]</a></span> +goes, this view seems sound. Of course it leaves +the problem at that interesting point, Why the restriction +of consciousness?</p> + +<p>If stupor be a psychobiological reaction, it should +occur, occasionally, in organic conditions just as the +deliria of typhoid fever may contain many psychogenic +elements. Gnauck<a name="FNanchor_33_36" id="FNanchor_33_36"></a><a href="#Footnote_33_36" class="fnanchor">[33]</a> reports such a case. The +patient, a woman, was poisoned by carbon dioxide. +At first there was unconsciousness. Then, as she +became clearer, it was apparent that she was clouded +and confused. She soiled. Neurological symptoms +were indefinite; enlargement of the left pupil, difficult +gait and exaggerated tendon reflexes. Months +later she was still apathetic, although her inactivity +was sometimes interrupted by such silly acts as +cutting up her shoes. After five months she recovered +with only scattered memories of the early part +of her psychosis. What seems like a typical stupor +content was recalled, however. She thought she was +standing in water and heard bells ringing.</p> + +<p>Stupor-like reactions are not infrequent in connection +with or following fevers. Bonhoeffer<a name="FNanchor_34_37" id="FNanchor_34_37"></a><a href="#Footnote_34_37" class="fnanchor">[34]</a> describes +a type that follows a febrile Daemmerzustand +of a few hours or a day at most. The affect +suddenly goes, disorientation sets in. Although +outbreaks of anxiety may be intercurrent, the dominant +picture is of stupor. Reactions are slowed,<!-- Page 278 --><span class='pagenum'><a name="Page_278" id="Page_278">[278]</a></span> +often there is catalepsy. Sometimes there is a retention +defect and confabulation to account for the +recent past. Again the retention may be good. In +the foreground stands a strong tendency to perseveration. +This may affect speech to the point of +an apparent aphasia or produce paragraphia. +Plainly organic aphasia and focal neurological +symptoms are sometimes seen.</p> + +<p>As Knauer<a name="FNanchor_35_38" id="FNanchor_35_38"></a><a href="#Footnote_35_38" class="fnanchor">[35]</a> has gone thoroughly into the question +of the febrile stupors, the reader is referred to +his paper for a digest of the literature on this topic. +Mention has already been made in Chapter IX to +this publication, where the close resemblance of +these rheumatic, to our benign functional, stupors +has been noted. Discrimination seems to be possible +only on the basis of delirium-like features being +added in the organic group.</p> + +<div class="footnotes"> +<h4>Footnotes:</h4> + +<div class="footnote"><p><a name="Footnote_C_15" id="Footnote_C_15"></a><a href="#FNanchor_C_15"><span class="label">[C]</span></a> This chapter has been written mainly from material in Dr. +Hoch's notes which was manifestly incomplete. No claim is made +for its exhaustiveness.</p> +<p class="ralign"><i>The Editor.</i></p> + +</div> + +<div class="footnote"><p><a name="Footnote_13_16" id="Footnote_13_16"></a><a href="#FNanchor_13_16"><span class="label">[13]</span></a> Dagonet, M. H.: "De la Stupeur dans les Maladies Mentales et +de l'Affection mentale dsigne sous le Nom de Stupidit." <cite>Annales +Medico-Psychologiques</cite>, T. VII, 5e Serie, 1872.</p></div> + +<div class="footnote"><p><a name="Footnote_14_17" id="Footnote_14_17"></a><a href="#FNanchor_14_17"><span class="label">[14]</span></a> Newington, H. Hayes: "Some Observations on Different Forms +of Stupor, and on Its Occurrence after Acute Mania in Females." +<cite>Journal of Mental Science</cite>, Vol. XX, 1874, p. 372.</p></div> + +<div class="footnote"><p><a name="Footnote_15_18" id="Footnote_15_18"></a><a href="#FNanchor_15_18"><span class="label">[15]</span></a> Clouston: "Mental Diseases." J. & A. Churchill, 1904.</p></div> + +<div class="footnote"><p><a name="Footnote_16_19" id="Footnote_16_19"></a><a href="#FNanchor_16_19"><span class="label">[16]</span></a> Stern: "Ueber die akuten Situations-psychosen der Kriminellen." +Abstracted, <cite>Zeitschr. f. d. ges. Neurol. u. Psychiatrie</cite>, Referate Bd. +V, S. 554.</p></div> + +<div class="footnote"><p><a name="Footnote_17_20" id="Footnote_17_20"></a><a href="#FNanchor_17_20"><span class="label">[17]</span></a> Wilmanns, K.: "Statische Untersuchungen ber Gefngnisspsychosen." +<cite>Allgemeine Zeitschr. f. Psychiatrie</cite>, Bd. LXVII, S. 847.</p></div> + +<div class="footnote"><p><a name="Footnote_18_21" id="Footnote_18_21"></a><a href="#FNanchor_18_21"><span class="label">[18]</span></a> Kutner: "Ueber katatonischer Zustandsbilder bei Degenerierten." +<cite>Allgemeine Zeitschr. f. Psychiatrie</cite>, Bd. LXVII, S. 375.</p></div> + +<div class="footnote"><p><a name="Footnote_19_22" id="Footnote_19_22"></a><a href="#FNanchor_19_22"><span class="label">[19]</span></a> Chotzen: "Fall von degenerativem Stupor." Abstracted, +<cite>Zeitschr. f. d. ges. Neur. u. Psychiatrie</cite>, Referate, Bd. VI, S. 1077.</p></div> + +<div class="footnote"><p><a name="Footnote_20_23" id="Footnote_20_23"></a><a href="#FNanchor_20_23"><span class="label">[20]</span></a> Seelig: "Psychiatrischer Verein in Berlin, 1904." <cite>Neurol. +Centralbl.</cite>, 1904, S. 421.</p></div> + +<div class="footnote"><p><a name="Footnote_21_24" id="Footnote_21_24"></a><a href="#FNanchor_21_24"><span class="label">[21]</span></a> Lwenstein: "Beitrag zur Differentialdiagnose des katatonische +u. hysterische Stupors." <cite>Allg. Zeitschr. f. Psychiatrie</cite>, Bd. LXV.</p></div> + +<div class="footnote"><p><a name="Footnote_22_25" id="Footnote_22_25"></a><a href="#FNanchor_22_25"><span class="label">[22]</span></a> Gregor: "ber die Diagnose psychischer Prozesse im Stupor." +Leipzig Meeting, 1907. Reported in <cite>Neurol. Centralbl.</cite>, 1907. S. +1083.</p></div> + +<div class="footnote"><p><a name="Footnote_23_26" id="Footnote_23_26"></a><a href="#FNanchor_23_26"><span class="label">[23]</span></a> Froederstrm: "La Dormeuse d'Okno. 32 ans de Stupeur, +Gurison complte. Nouvelles Iconographies de la Salptrire," +1912, No. 3. Reviewed by E. Bloch, <cite>Neur. Centralbl.</cite>, 1913, S. 852, +and by Forster, <cite>Zeitschr. f. d. ges. Neur. u. Psychiatrie</cite>, Referate, +Bd. VI, S. 510.</p></div> + +<div class="footnote"><p><a name="Footnote_24_27" id="Footnote_24_27"></a><a href="#FNanchor_24_27"><span class="label">[24]</span></a> Gadelius: "Ett ovanligt fall af stupor med nra 9-arig oafbruten +tvangsmatning; uppvaknande; total amnesi; helsa" (<cite>Hygiea</cite>, 1894, +LVI., Part 2, No. 10, p. 355). Abstracted by Walker Berger, <cite>Neurol. +Centralbl.</cite>, 1895, S. 186.</p></div> + +<div class="footnote"><p><a name="Footnote_25_28" id="Footnote_25_28"></a><a href="#FNanchor_25_28"><span class="label">[25]</span></a> Leroy: "Un cas de stupeur, guri au bout de deux ans et +demi." <cite>Bull. de la Soc. Clin. de Md. Ment.</cite>, III, 276, 1910. Abstracted +in <cite>Zeitschr. f. d. ges. Neurol. u. Psychiatrie</cite>, Referate, Bd. +II, S. 495.</p></div> + +<div class="footnote"><p><a name="Footnote_26_29" id="Footnote_26_29"></a><a href="#FNanchor_26_29"><span class="label">[26]</span></a> Myers, Charles S.: "Contributions to the Study of Shell Shock." +<cite>Lancet</cite>, January 8, 1916, pp. 65-69. <cite>Lancet</cite>, September 6, 1916, pp. +461-467.</p></div> + +<div class="footnote"><p><a name="Footnote_27_30" id="Footnote_27_30"></a><a href="#FNanchor_27_30"><span class="label">[27]</span></a> Gucci, R.: "Sopra una particolarit del mutismo per stupore +communicazione preventive." <cite>Archivio italiano per le malattie +nervose</cite>, 1889, XXVI, 69-108. Reviewed in <cite>Neurol. Centralbl.</cite>, 1889, +S. 659.</p></div> + +<div class="footnote"><p><a name="Footnote_28_31" id="Footnote_28_31"></a><a href="#FNanchor_28_31"><span class="label">[28]</span></a> "Dementia Prcox oder Gruppe der Schizophrenie" Aschaffenburg's +"Handbuch der Psychiatrie."</p></div> + +<div class="footnote"><p><a name="Footnote_29_32" id="Footnote_29_32"></a><a href="#FNanchor_29_32"><span class="label">[29]</span></a> Raecke: "Zur Prognose der Katatonie." <cite>Arch. f. Psychiatrie</cite>, +Bd. XLVII, 1, 1910.</p></div> + +<div class="footnote"><p><a name="Footnote_30_33" id="Footnote_30_33"></a><a href="#FNanchor_30_33"><span class="label">[30]</span></a> Whitwell: "A Study of the Pulse in Stupor." <cite>Lancet</cite>, Oct. +17, 1891. Reviewed by Ziehen, <cite>Neurol. Centralbl.</cite>, 1892, S. 290.</p></div> + +<div class="footnote"><p><a name="Footnote_31_34" id="Footnote_31_34"></a><a href="#FNanchor_31_34"><span class="label">[31]</span></a> Wetzel: "Die Diagnose von Stuporen." Baden-Baden Meeting +of May, 1911. Reported in <cite>Neurol. Centralbl.</cite>, 1911, S. 886.</p></div> + +<div class="footnote"><p><a name="Footnote_32_35" id="Footnote_32_35"></a><a href="#FNanchor_32_35"><span class="label">[32]</span></a> Vogt, Ragner: "Zur Psychologie der Katatonischen Symptome." +<cite>Centralbl. fr Nervenheilkunde</cite>, 1902, S. 433.</p></div> + +<div class="footnote"><p><a name="Footnote_33_36" id="Footnote_33_36"></a><a href="#FNanchor_33_36"><span class="label">[33]</span></a> Gnauck, R.: "Stupor nach Kohlenoxydvergiftung" (<cite>Charit-Annalen</cite>, +1883, p. 409). Reviewed by Moeli, <cite>Neurol. Centralbl.</cite>, 1883, +S. 237.</p></div> + +<div class="footnote"><p><a name="Footnote_34_37" id="Footnote_34_37"></a><a href="#FNanchor_34_37"><span class="label">[34]</span></a> Bonhoeffer: "Die Symptomatischen Psychosen," 1910.</p></div> + +<div class="footnote"><p><a name="Footnote_35_38" id="Footnote_35_38"></a><a href="#FNanchor_35_38"><span class="label">[35]</span></a> Knauer, A.: "Die im Gefolge des akuten Gelenkrheumatismus +auftretenden psychischen Storungen." <cite>Zeitschr. f. d. ges. Neurol. +u. Psychiatrie</cite>, Bd. XXI, S. 491-559.</p></div> +</div> + +<p><!-- Page 279 --><span class='pagenum'><a name="Page_279" id="Page_279">[279]</a></span></p> + +<h2>INDEX</h2> + +<ul> +<li>absorption, <a href="#Page_163">163</a></li> + +<li>activity, reduction of, <a href="#Page_36">36</a>, <a href="#Page_100">100</a>, <a href="#Page_120">120</a></li> + +<li>acute dementia, <a href="#Page_251">251</a></li> + +<li>adaptation, <a href="#Page_107">107</a>, <a href="#Page_192">192</a></li> + +<li>adrenalin, <a href="#Page_180">180</a></li> + +<li>affect, <a href="#Page_9">9</a>, <a href="#Page_22">22</a>, +<a href="#Page_32">32</a>, <a href="#Page_44">44</a>, <a href="#Page_113">113</a>, +<a href="#Page_116">116</a>, <a href="#Page_117">117</a>, <a href="#Page_123"><i>123</i></a>, <a href="#Page_170">170</a></li> + +<li>affect, dissociation of, <a href="#Page_128">128</a>, <a href="#Page_201">201</a>, <a href="#Page_205">205</a>, <a href="#Page_237">237</a></li> + +<li>affect, inappropriate, <a href="#Page_216">216</a>, <a href="#Page_237">237</a></li> + +<li>affect, poverty of, <a href="#Page_234">234</a></li> + +<li>affect, shallow, <a href="#Page_127">127</a></li> + +<li>affectlessness, <a href="#Page_171">171</a>, <a href="#Page_172">172</a></li> + +<li>affects, combination of, <a href="#Page_245">245</a></li> + +<li>agitation, <a href="#Page_156">156</a></li> + +<li>akinesis, <a href="#Page_121">121</a></li> + +<li>akinetic psychoses, <a href="#Page_4">4</a>, <a href="#Page_274">274</a></li> + +<li>albuminuria, <a href="#Page_40">40</a></li> + +<li>allied to dementia prcox, <a href="#Page_236">236</a>, <a href="#Page_260">260</a></li> + +<li>allied to manic-depressive, <a href="#Page_236">236</a>, <a href="#Page_260">260</a></li> + +<li>allopsychic, <a href="#Page_135">135</a></li> + +<li>ambivalence, <a href="#Page_147">147</a></li> + +<li>amnesia, <a href="#Page_9">9</a>, <a href="#Page_24">24</a>, <a href="#Page_68">68</a>, +<a href="#Page_70">70</a>, <a href="#Page_267">267</a>, <a href="#Page_269">269</a></li> + +<li>anergic or unconscious stupor, <a href="#Page_258">258</a></li> + +<li>anergic stupor, <a href="#Page_255">255</a>, <a href="#Page_256">256</a></li> + +<li>anesthesia, <a href="#Page_196">196</a>, <a href="#Page_212">212</a>, <a href="#Page_268">268</a></li> + +<li>anger, <a href="#Page_118">118</a>, <a href="#Page_139">139</a></li> + +<li>angiospastic, <a href="#Page_276">276</a></li> + +<li>animal, turning into, <a href="#Page_171">171</a></li> + +<li>Antus, <a href="#Page_190">190</a></li> + +<li>apathy, <a href="#Page_36">36</a>, <a href="#Page_48">48</a>, +<a href="#Page_112">112</a>, <a href="#Page_122">122</a>, <a href="#Page_123">123</a>, +<a href="#Page_151">151</a>, <a href="#Page_152">152</a>, <a href="#Page_163">163</a>, +<a href="#Page_181">181</a>, <a href="#Page_195">195</a>, <a href="#Page_225">225</a>, <a href="#Page_237">237</a></li> + +<li>apathy, resemblance to absorption, <a href="#Page_202">202</a></li> + +<li>anxiety, <a href="#Page_122">122</a>, <a href="#Page_123">123</a>, <a href="#Page_126">126</a>, +<a href="#Page_137">137</a>, <a href="#Page_153">153</a>, <a href="#Page_162">162</a>, +<a href="#Page_166">166</a>, <a href="#Page_198">198</a>, <a href="#Page_226">226</a></li> + +<li>apoplexy, <a href="#Page_224">224</a></li> + +<li>arteriosclerotic dementia, <a href="#Page_80">80</a></li> + +<li>attention, <a href="#Page_195">195</a></li> + +<li>atypical features, explanation of, <a href="#Page_200">200</a></li> + +<li>autoerotism, <a href="#Page_199">199</a></li> + +<li>automatism, <a href="#Page_268">268</a></li> +</ul> + +<ul> +<li> +Baillarger, <a href="#Page_252">252</a></li> + +<li>behavior, <a href="#Page_195">195</a></li> + +<li>"Benommenheit," <a href="#Page_67">67</a>, <a href="#Page_273">273</a>, <a href="#Page_274">274</a></li> + +<li>bewilderment, <a href="#Page_79">79</a>, <a href="#Page_112">112</a>, +<a href="#Page_120">120</a>, <a href="#Page_126">126</a></li> + +<li>Bleuler, <a href="#Page_67">67</a>, <a href="#Page_273">273</a></li> + +<li>blocking, <a href="#Page_163">163</a></li> + +<li>blood-pressure, <a href="#Page_181">181</a></li> + +<li>blushing, <a href="#Page_9">9</a></li> + +<li>Bonhoeffer, <a href="#Page_277">277</a></li> + +<li>boredom, <a href="#Page_247">247</a></li> + +<li>bowels, interest in, <a href="#Page_217">217</a></li> + +<li>brain tumor, <a href="#Page_5">5</a></li> + +<li>breath, holding, <a href="#Page_62">62</a></li> + +<li>Brierre de Boismont, <a href="#Page_252">252</a></li> + +<li>burial, <a href="#Page_111">111</a>, <a href="#Page_192">192</a></li> +</ul> + +<ul><li>Calculation, <a href="#Page_23">23</a>, <a href="#Page_24">24</a></li> + +<li>Calvary, <a href="#Page_111">111</a></li> + +<li>Cannon, <a href="#Page_180">180</a></li> + +<li>Cases +<ul> +<li> Adele M. (Case 24), <a href="#Page_220">220</a></li> +<li> Alice R., <a href="#Page_135">135</a>, <a href="#Page_140">140</a>, <a href="#Page_192"><i>192</i></a></li> +<li> Anna G. (Case 1), <a href="#Page_6"><i>6</i></a>, <a href="#Page_47">47</a>, <a href="#Page_48">48</a>, +<a href="#Page_68">68</a>, <a href="#Page_74">74</a>, <a href="#Page_77">77</a>, <a href="#Page_109">109</a>, +<a href="#Page_127">127</a>, <a href="#Page_136">136</a>, <a href="#Page_140">140</a>, <a href="#Page_145">145</a>, +<a href="#Page_147">147</a>, <a href="#Page_183">183</a></li> +<li> Anna L. (Case 16), <a href="#Page_135">135</a>, <a href="#Page_149"><i>149</i></a>, <a href="#Page_158">158</a></li> +<li> Anna M., <a href="#Page_135">135</a></li> +<li> Annie K. (Case 5), <a href="#Page_24"><i>24</i></a>, <a href="#Page_69">69</a>, <a href="#Page_72">72</a>, +<a href="#Page_105">105</a>, <a href="#Page_110">110</a>, <a href="#Page_111">111</a>, <a href="#Page_136">136</a>, +<a href="#Page_139">139</a>, <a href="#Page_141">141</a></li> +<li><!-- Page 280 --><span class='pagenum'><a name="Page_280" id="Page_280">[280]</a></span> + Bridget B., <a href="#Page_135">135</a></li> +<li> Caroline de S. (Case 2), <a href="#Page_11"><i>11</i></a>, <a href="#Page_68">68</a>, <a href="#Page_109">109</a>, +<a href="#Page_141">141</a>, <a href="#Page_178">178</a>, <a href="#Page_193">193</a></li> +<li> Catherine H. (Case 23), <a href="#Page_216"><i>216</i></a></li> +<li> Catherine M. (Case 18), <a href="#Page_158"><i>158</i></a></li> +<li> Catherine W. (Case 25), <a href="#Page_221"><i>221</i></a></li> +<li> Celia C. (Case 17), <a href="#Page_155"><i>155</i></a></li> +<li> Celia H. (Case 19), <a href="#Page_167"><i>167</i></a></li> +<li> Charles O., <a href="#Page_143">143</a>, <a href="#Page_144">144</a>, <a href="#Page_178">178</a></li> +<li> Charlotte W. (Case 12), <a href="#Page_83"><i>83</i></a>, <a href="#Page_106">106</a>, <a href="#Page_112">112</a>, <a href="#Page_113">113</a>, +<a href="#Page_116">116</a>, <a href="#Page_127">127</a>, <a href="#Page_136">136</a>, <a href="#Page_141">141</a>, <a href="#Page_144">144</a>, +<a href="#Page_166">166</a>, <a href="#Page_201">201</a></li> +<li> Emma K., <a href="#Page_71">71</a>, <a href="#Page_140">140</a></li> +<li> Harriett C., <a href="#Page_138">138</a></li> +<li> Helen M., <a href="#Page_130">130</a></li> +<li> Henrietta B., <a href="#Page_138">138</a>, <a href="#Page_140">140</a></li> +<li> Henrietta H. (Case 8), <a href="#Page_42"><i>42</i></a>, <a href="#Page_74">74</a>, +<a href="#Page_77">77</a>, <a href="#Page_105">105</a>, <a href="#Page_106">106</a>, <a href="#Page_110">110</a>, +<a href="#Page_111">111</a>, <a href="#Page_115">115</a>, <a href="#Page_136">136</a></li> +<li> Isabella M., <a href="#Page_136">136</a>, <a href="#Page_144">144</a>, <a href="#Page_147">147</a></li> +<li> Johanna B., <a href="#Page_135">135</a>, <a href="#Page_138">138</a></li> +<li> Johanna S. (Case 13), <a href="#Page_91"><i>91</i></a>, <a href="#Page_120">120</a>, <a href="#Page_127">127</a>, <a href="#Page_136">136</a></li> +<li> Josephine G., <a href="#Page_138">138</a></li> +<li> Laura A., <a href="#Page_71">71</a>, <a href="#Page_77">77</a>, <a href="#Page_135">135</a>, +<a href="#Page_138">138</a>, <a href="#Page_140">140</a>, <a href="#Page_142">142</a>, <a href="#Page_193">193</a></li> +<li> Maggie H. (Case 14), <a href="#Page_71">71</a>, <a href="#Page_96">96</a>, <a href="#Page_109">109</a>, <a href="#Page_140">140</a>, <a href="#Page_194">194</a></li> +<li> Margaret C. (Case 10), <a href="#Page_55"><i>55</i></a>, <a href="#Page_75">75</a>, <a href="#Page_78">78</a></li> +<li> Mary C. (Case 7), <a href="#Page_39"><i>39</i></a>, <a href="#Page_42">42</a>, <a href="#Page_71">71</a>, <a href="#Page_74">74</a>, <a href="#Page_77">77</a>, +<a href="#Page_121">121</a>, <a href="#Page_136">136</a>, <a href="#Page_138">138</a>, <a href="#Page_178">178</a>, <a href="#Page_194">194</a></li> +<li> Mary D. (Case 4), <a href="#Page_20"><i>20</i></a>, <a href="#Page_47">47</a>, <a href="#Page_69">69</a>, <a href="#Page_70">70</a>, +<a href="#Page_71">71</a>, <a href="#Page_74">74</a>, <a href="#Page_76">76</a>, <a href="#Page_109">109</a>, <a href="#Page_136">136</a>, <a href="#Page_145">145</a></li> +<li> Mary F. (Case 3), <a href="#Page_14"><i>14</i></a>, <a href="#Page_68">68</a>, <a href="#Page_105">105</a>, <a href="#Page_110">110</a>, <a href="#Page_111">111</a>, +<a href="#Page_115">115</a>, <a href="#Page_140">140</a>, <a href="#Page_142">142</a>, <a href="#Page_164">164</a>, <a href="#Page_183">183</a></li> +<li> Mary G., <a href="#Page_140">140</a>, <a href="#Page_141">141</a></li> +<li> Meta S. (Case 15), <a href="#Page_99"><i>99</i></a>, <a href="#Page_109">109</a>, <a href="#Page_127">127</a>, <a href="#Page_135">135</a></li> +<li> Nellie H. (Case 22), <a href="#Page_214"><i>214</i></a></li> +<li> Pearl F. (Case 9), <a href="#Page_51"><i>51</i></a>, <a href="#Page_75">75</a>, <a href="#Page_142">142</a></li> +<li> Rose S. (Case 21), <a href="#Page_210"><i>210</i></a></li> +<li> Rose Sch. (Case 6), <a href="#Page_35"><i>35</i></a>, <a href="#Page_74">74</a>, <a href="#Page_75">75</a>, <a href="#Page_145">145</a></li> +<li> Rosie K. (Case 11), <a href="#Page_62"><i>62</i></a>, <a href="#Page_75">75</a>, <a href="#Page_105">105</a>, <a href="#Page_112">112</a>, <a href="#Page_178">178</a></li> +<li> Winifred O'M. (Case 20), <a href="#Page_207"><i>207</i></a></li> +</ul> +</li> + +<li>catalepsy, <a href="#Page_13">13</a>, <a href="#Page_21">21</a>, <a href="#Page_31">31</a>, <a href="#Page_32">32</a>, <a href="#Page_36">36</a>, <a href="#Page_86">86</a>, <a href="#Page_94">94</a>, <a href="#Page_95">95</a>, <a href="#Page_102">102</a>, <a href="#Page_115">115</a>, <a href="#Page_128">128</a>, <a href="#Page_143"><i>143</i></a>, <a href="#Page_144">144</a>, +<a href="#Page_145">145</a>, <a href="#Page_147">147</a>, <a href="#Page_209">209</a>, <a href="#Page_211">211</a>, <a href="#Page_235">235</a>, <a href="#Page_239">239</a></li> + +<li>catatonia, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_50">50</a>, <a href="#Page_128">128</a>, <a href="#Page_205">205</a>, <a href="#Page_236">236</a>, <a href="#Page_261">261</a></li> + +<li>catheterization, <a href="#Page_85">85</a>, <a href="#Page_86">86</a>, <a href="#Page_102">102</a></li> + +<li>cemetery, <a href="#Page_105">105</a>, <a href="#Page_112">112</a></li> + +<li>childbirth, <a href="#Page_159">159</a></li> + +<li>childhood, <a href="#Page_188">188</a>, <a href="#Page_195">195</a></li> + +<li>Chotzen, <a href="#Page_262">262</a></li> + +<li>Christ, <a href="#Page_86">86</a>, <a href="#Page_115">115</a></li> + +<li>Christian Science, <a href="#Page_150">150</a></li> + +<li>circular psychosis, <a href="#Page_5">5</a>, <a href="#Page_126">126</a></li> + +<li>circulation, <a href="#Page_180">180</a></li> + +<li>Clark, <a href="#Page_184">184</a></li> + +<li>clouding, <a href="#Page_67">67</a></li> + +<li>Clouston, <a href="#Page_258">258</a></li> + +<li>cocoon, <a href="#Page_109">109</a></li> + +<li>coffin, <a href="#Page_88">88</a>, <a href="#Page_106">106</a>, <a href="#Page_114">114</a></li> + +<li>coma, <a href="#Page_176">176</a>, <a href="#Page_223">223</a></li> + +<li>concussion, aerial, <a href="#Page_224">224</a></li> + +<li>confusion, <a href="#Page_163">163</a></li> + +<li>constipation, <a href="#Page_92">92</a></li> + +<li>convent, <a href="#Page_117">117</a></li> + +<li>convulsive attacks, <a href="#Page_15">15</a></li> + +<li>crime, <a href="#Page_248">248</a></li> + +<li>crucifix, <a href="#Page_88">88</a></li> + +<li>crucifixion, <a href="#Page_86">86</a>, <a href="#Page_106">106</a>, <a href="#Page_114">114</a>, <a href="#Page_161">161</a></li> + +<li>crustaceans, <a href="#Page_148">148</a></li> + +<li>cut-up idea, <a href="#Page_94">94</a></li> + +<li>cyanosis, <a href="#Page_32">32</a>, <a href="#Page_63">63</a>, <a href="#Page_180">180</a></li> +</ul> + +<ul> +<li>Dagonet, <a href="#Page_3">3</a>, <a href="#Page_249">249</a>, <a href="#Page_250">250</a>, <a href="#Page_253">253</a>, <a href="#Page_254">254</a>, <a href="#Page_258">258</a></li> + +<li>death, feigned, <a href="#Page_5">5</a>, <a href="#Page_83">83</a>, <a href="#Page_137">137</a>, <a href="#Page_196">196</a>, <a href="#Page_246">246</a></li> + +<li>death, mutual, <a href="#Page_192">192</a></li> + +<li>death, projected, <a href="#Page_198">198</a></li> + +<li>death, relation with affect, <a href="#Page_110">110</a></li> + +<li>death ideas, <a href="#Page_3">3</a>, <a href="#Page_46">46</a>, <a href="#Page_47">47</a>, <a href="#Page_50">50</a>, <a href="#Page_52">52</a>, <a href="#Page_58">58</a>, <a href="#Page_65">65</a>, <a href="#Page_83">83</a>, <a href="#Page_97">97</a>, <a href="#Page_104"><i>104</i></a>, <a href="#Page_107">107</a>, <a href="#Page_109">109</a>, <a href="#Page_110">110</a>, +<a href="#Page_111">111</a>, <a href="#Page_114">114</a>, <a href="#Page_115">115</a>, <a href="#Page_119">119</a>, <a href="#Page_122">122</a>, <a href="#Page_136">136</a>, <a href="#Page_137">137</a>, <a href="#Page_138">138</a>, <a href="#Page_152">152</a>, <a href="#Page_153">153</a>, <a href="#Page_156">156</a>, +<a href="#Page_159">159</a>, <a href="#Page_163">163</a>, <a href="#Page_166">166</a>, <a href="#Page_187">187</a>, <a href="#Page_190">190</a>, <a href="#Page_191">191</a>, <a href="#Page_192">192</a>, <a href="#Page_199">199</a>, <a href="#Page_212">212</a>, <a href="#Page_225">225</a>, <a href="#Page_235">235</a>, <a href="#Page_240">240</a></li> + +<li>death of others, <a href="#Page_192">192</a></li> + +<li>deep stupor, <a href="#Page_1"><i>1</i></a>, <a href="#Page_6">6</a>, <a href="#Page_41">41</a>, <a href="#Page_199">199</a></li> + +<li>deep stupor, explanation of, <a href="#Page_197">197</a></li> + +<li>Delasiauve, <a href="#Page_253">253</a></li> +<li><!-- Page 281 --><span class='pagenum'><a name="Page_281" id="Page_281">[281]</a></span> +delirium, <a href="#Page_176">176</a></li> + +<li>delusional stupor, <a href="#Page_255">255</a>, <a href="#Page_256">256</a></li> + +<li>delusions, <a href="#Page_165">165</a></li> + +<li>dlire mlancholique, <a href="#Page_252">252</a></li> + +<li>dementia prcox, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_62">62</a>, <a href="#Page_123">123</a>, <a href="#Page_127">127</a>, <a href="#Page_128">128</a>, <a href="#Page_205">205</a>, <a href="#Page_225">225</a></li> + +<li>depression, <a href="#Page_5">5</a>, <a href="#Page_117">117</a>, <a href="#Page_123">123</a>, <a href="#Page_137">137</a>, <a href="#Page_156">156</a>, <a href="#Page_236">236</a>, <a href="#Page_253">253</a></li> + +<li>depression, differentiation of, <a href="#Page_48">48</a>, <a href="#Page_124">124</a>, <a href="#Page_226">226</a></li> + +<li>dermatographia, <a href="#Page_102">102</a>, <a href="#Page_180">180</a></li> + +<li>deterioration, <a href="#Page_210">210</a></li> + +<li>diabetes, <a href="#Page_224">224</a></li> + +<li>diarrhea, <a href="#Page_45">45</a>, <a href="#Page_64">64</a>, <a href="#Page_178">178</a></li> + +<li>dissociation, <a href="#Page_225">225</a></li> + +<li>distress, <a href="#Page_119">119</a>, <a href="#Page_122">122</a>, <a href="#Page_154">154</a>, <a href="#Page_156">156</a>, <a href="#Page_162">162</a></li> + +<li>dreams, <a href="#Page_161">161</a>, <a href="#Page_190">190</a></li> + +<li>drooling, <a href="#Page_132">132</a>, <a href="#Page_181">181</a></li> + +<li>drowning, <a href="#Page_87">87</a>, <a href="#Page_192">192</a></li> +</ul> + +<ul> +<li>Earth, <a href="#Page_107">107</a>, <a href="#Page_111">111</a>, <a href="#Page_190">190</a></li> + +<li>echolalia, <a href="#Page_275">275</a></li> + +<li>echopraxia, <a href="#Page_275">275</a></li> + +<li>ecstasy, <a href="#Page_91">91</a>, <a href="#Page_162">162</a>, <a href="#Page_191">191</a></li> + +<li><i>lan vital</i>, <a href="#Page_123">123</a></li> + +<li>elation, <a href="#Page_44">44</a>, <a href="#Page_91">91</a>, <a href="#Page_123">123</a>, <a href="#Page_127">127</a>, <a href="#Page_151">151</a>, <a href="#Page_157">157</a></li> + +<li>electric chair, <a href="#Page_85">85</a>, <a href="#Page_110">110</a>, <a href="#Page_119">119</a></li> + +<li>electricity, <a href="#Page_150">150</a></li> + +<li><a name="emaciation" id="emaciation">emaciation</a>, <a href="#Page_8">8</a>, <a href="#Page_32">32</a>, <a href="#Page_58">58</a></li> + +<li>emotion, <a href="#Page_62">62</a></li> + +<li>emotion, inconsistency of, <a href="#Page_126">126</a></li> + +<li>emotions and contact with reality, <a href="#Page_164">164</a></li> + +<li>energy, <a href="#Page_187">187</a>, <a href="#Page_194">194</a></li> + +<li>epilepsy, <a href="#Page_5">5</a>, <a href="#Page_183">183</a>, <a href="#Page_199">199</a>, <a href="#Page_224">224</a>, <a href="#Page_242">242</a>, <a href="#Page_254">254</a></li> + +<li>epileptic aura, <a href="#Page_184">184</a></li> + +<li>epileptic confusion, <a href="#Page_80">80</a></li> + +<li>epileptic deterioration, <a href="#Page_80">80</a></li> + +<li>erotic, <a href="#Page_161">161</a></li> + +<li>erotic ideas, <a href="#Page_90">90</a></li> + +<li>Esquirol, <a href="#Page_251">251</a></li> + +<li>Etoc-Demazy, <a href="#Page_251">251</a></li> + +<li>Euripides, <a href="#Page_2">2</a></li> + +<li>excretion, habits of, <a href="#Page_230">230</a></li> + +<li>extroversion, <a href="#Page_195">195</a></li> +</ul> + +<ul> +<li>family visits, <a href="#Page_232">232</a></li> + +<li>father, <a href="#Page_104">104</a>, <a href="#Page_109">109</a>, <a href="#Page_110">110</a></li> + +<li>fear, <a href="#Page_111">111</a></li> + +<li>fever, <a href="#Page_8">8</a>, <a href="#Page_13">13</a>, <a href="#Page_26">26</a>, <a href="#Page_32">32</a>, <a href="#Page_38">38</a>, <a href="#Page_40">40</a>, <a href="#Page_45">45</a>, <a href="#Page_64">64</a>, <a href="#Page_102">102</a>, <a href="#Page_160">160</a>, <a href="#Page_176"><i>176</i></a>, <a href="#Page_235">235</a>, <a href="#Page_241">241</a></li> + +<li>filthiness, <a href="#Page_210">210</a></li> + +<li>fire, <a href="#Page_151">151</a>, <a href="#Page_157">157</a></li> + +<li>flippancy, <a href="#Page_129">129</a></li> + +<li>flushing, <a href="#Page_27">27</a>, <a href="#Page_127">127</a>, <a href="#Page_128">128</a>, <a href="#Page_180">180</a></li> + +<li>food, refusal of, <a href="#Page_99">99</a>, <a href="#Page_104">104</a></li> + +<li>Forel, <a href="#Page_182">182</a></li> + +<li>Froederstrm, <a href="#Page_265">265</a></li> + +</ul> + +<ul> +<li>Gadelius, <a href="#Page_267">267</a>, <a href="#Page_268">268</a></li> + +<li>Ganser reaction, <a href="#Page_263">263</a></li> + +<li>Georget, <a href="#Page_251">251</a></li> + +<li>German psychiatry, <a href="#Page_259">259</a></li> + +<li>Gnauck, <a href="#Page_277">277</a></li> + +<li>giggling, <a href="#Page_206">206</a></li> + +<li>God, <a href="#Page_115">115</a>, <a href="#Page_160">160</a>, <a href="#Page_162">162</a></li> + +<li>Golden Age, <a href="#Page_187">187</a></li> + +<li>Gregor, <a href="#Page_265">265</a></li> + +<li>Gucci, <a href="#Page_271">271</a></li> + +<li>guilt, <a href="#Page_157">157</a></li> +</ul> + +<ul> +<li>hair, loss of, <a href="#Page_32">32</a>, <a href="#Page_58">58</a>, <a href="#Page_180">180</a></li> + +<li>heat production and loss, <a href="#Page_179">179</a>, <a href="#Page_181">181</a>, <a href="#Page_242">242</a></li> + +<li>Heaven, <a href="#Page_87">87</a>, <a href="#Page_88">88</a>, <a href="#Page_104">104</a>, <a href="#Page_106">106</a>, <a href="#Page_108">108</a>, <a href="#Page_109">109</a>, <a href="#Page_111">111</a>, <a href="#Page_114">114</a>, <a href="#Page_115">115</a>, <a href="#Page_117">117</a>, <a href="#Page_118">118</a>, <a href="#Page_160">160</a>, <a href="#Page_162">162</a>, <a href="#Page_166">166</a>, <a href="#Page_171">171</a>, <a href="#Page_191">191</a>, <a href="#Page_240">240</a></li> + +<li>Hell, <a href="#Page_240">240</a></li> + +<li>Hoch, <a href="#Page_164">164</a></li> + +<li>hypermia, <a href="#Page_8">8</a></li> + +<li>hyperesthesia, <a href="#Page_268">268</a></li> + +<li>hypochondria, <a href="#Page_225">225</a>, <a href="#Page_253">253</a></li> + +<li>hypomania, <a href="#Page_243">243</a></li> + +<li>hypnotism (see <a href="#mesmerism">mesmerism</a>), <a href="#Page_145">145</a>, <a href="#Page_213">213</a></li> + +<li>hysteria, <a href="#Page_3">3</a>, <a href="#Page_135">135</a>, <a href="#Page_184">184</a>, <a href="#Page_225">225</a>, <a href="#Page_264">264</a>, <a href="#Page_267">267</a>, <a href="#Page_269">269</a></li> +</ul> + +<ul> +<li>ideational content, <a href="#Page_82">82</a>, <a href="#Page_235">235</a></li> + +<li>immobility, <a href="#Page_85">85</a>, <a href="#Page_94">94</a>, <a href="#Page_196">196</a></li> + +<li>immorality, <a href="#Page_150">150</a></li> + +<li>impulsiveness, <a href="#Page_50">50</a>, <a href="#Page_113">113</a>, <a href="#Page_128">128</a>, <a href="#Page_172">172</a></li> + +<li>impurities in stupor reaction, <a href="#Page_66">66</a></li> + +<li>inaccessibility, <a href="#Page_141">141</a></li> + +<li>inactivity, <a href="#Page_17">17</a>, <a href="#Page_30">30</a>, <a href="#Page_40">40</a>, <a href="#Page_48">48</a>, <a href="#Page_56">56</a>, <a href="#Page_62">62</a>, <a href="#Page_88">88</a>, <a href="#Page_97">97</a>, <a href="#Page_102">102</a>, <a href="#Page_123">123</a>, <a href="#Page_132"><i>132</i></a>, <a href="#Page_152">152</a>, <a href="#Page_163">163</a>, <a href="#Page_194">194</a>, <a href="#Page_225">225</a>, <a href="#Page_234">234</a>, <a href="#Page_238">238</a></li> + +<li>inactivity, patients' explanation of, <a href="#Page_134">134</a></li> + +<li>incest ideas, <a href="#Page_209">209</a></li> + +<li><!-- Page 282 --><span class='pagenum'><a name="Page_282" id="Page_282">[282]</a></span> +inconsistency of reaction, <a href="#Page_134">134</a>, <a href="#Page_214">214</a>, <a href="#Page_215">215</a>, <a href="#Page_245">245</a></li> + +<li>incontinence (see <a href="#wetting"><i>wetting</i></a> and <a href="#soiling"><i>soiling</i></a>), <a href="#Page_52">52</a>, <a href="#Page_57">57</a></li> + +<li>indifference, <a href="#Page_123">123</a>, <a href="#Page_124">124</a>, <a href="#Page_142">142</a></li> + +<li>infantile reactions, <a href="#Page_196">196</a></li> + +<li>infections, <a href="#Page_5">5</a>, <a href="#Page_178"><i>178</i></a>, <a href="#Page_241">241</a></li> + +<li>insight, <a href="#Page_157">157</a></li> + +<li>insomnia, <a href="#Page_39">39</a></li> + +<li>instinct of self-preservation, <a href="#Page_188">188</a>, <a href="#Page_191">191</a>, <a href="#Page_198">198</a></li> + +<li>interest, <a href="#Page_99">99</a>, <a href="#Page_195">195</a></li> + +<li>internal secretions, <a href="#Page_178">178</a></li> + +<li>internal thoughts, <a href="#Page_163">163</a></li> + +<li>interruptions of stupor, <a href="#Page_130">130</a>, <a href="#Page_197">197</a>, <a href="#Page_238">238</a>, <a href="#Page_244">244</a></li> + +<li>introversion, <a href="#Page_164">164</a>, <a href="#Page_227">227</a></li> + +<li>involuntary nervous system, <a href="#Page_178">178</a>, <a href="#Page_180">180</a></li> + +<li>involution melancholia, <a href="#Page_129">129</a>, <a href="#Page_195">195</a>, <a href="#Page_225">225</a>, <a href="#Page_226">226</a></li> +</ul> + +<ul> +<li>jaundice, <a href="#Page_21">21</a></li> + +<li>Jung, <a href="#Page_107">107</a></li> +</ul> + +<ul> +<li>Kahlbaum, <a href="#Page_4">4</a>, <a href="#Page_260">260</a></li> + +<li>Kirby, <a href="#Page_4">4</a>, <a href="#Page_6">6</a>, <a href="#Page_164">164</a>, <a href="#Page_234">234</a></li> + +<li>Knauer, <a href="#Page_175">175</a>, <a href="#Page_278">278</a></li> + +<li>Kraepelin, <a href="#Page_4">4</a>, <a href="#Page_260">260</a>, <a href="#Page_269">269</a>, <a href="#Page_271">271</a>, <a href="#Page_272">272</a>, <a href="#Page_273">273</a></li> + +<li>Kutner, <a href="#Page_262">262</a></li> +</ul> + +<ul> +<li>laughter, <a href="#Page_56">56</a>, <a href="#Page_141">141</a></li> + +<li>Leroy, <a href="#Page_269">269</a></li> + +<li>leucocytosis, <a href="#Page_8">8</a>, <a href="#Page_13">13</a>, <a href="#Page_40">40</a>, <a href="#Page_64">64</a>, <a href="#Page_178">178</a></li> + +<li>levels, principle of, <a href="#Page_198">198</a>, <a href="#Page_244">244</a></li> + +<li>Lwenstein, <a href="#Page_264">264</a></li> +</ul> + +<ul> +<li>MacCurdy, <a href="#Page_2">2</a>, <a href="#Page_184">184</a></li> + +<li>make-up, mental, <a href="#Page_5">5</a></li> + +<li>malignant stupors, <a href="#Page_205"><i>205</i></a></li> + +<li>mania (or manic), <a href="#Page_5">5</a>, <a href="#Page_126">126</a>, <a href="#Page_137">137</a></li> + +<li>mania, absorbed, <a href="#Page_125">125</a>, <a href="#Page_226">226</a>, <a href="#Page_245">245</a></li> + +<li>manic content, <a href="#Page_166">166</a></li> + +<li>manic-depressive insanity, <a href="#Page_149">149</a>, <a href="#Page_167">167</a></li> + +<li>manic-depressive insanity, mixed conditions in, <a href="#Page_202">202</a></li> + +<li>manic-depressive insanity, pathology of, <a href="#Page_174">174</a></li> + +<li>manic episodes, <a href="#Page_191">191</a></li> + +<li>manic stupor, <a href="#Page_125">125</a>, <a href="#Page_245">245</a>, <a href="#Page_253">253</a></li> + +<li>marriage, <a href="#Page_160">160</a>, <a href="#Page_169">169</a></li> + +<li>masturbation, <a href="#Page_196">196</a>, <a href="#Page_209">209</a>, <a href="#Page_219">219</a></li> + +<li>melancholic or conscious stupor, <a href="#Page_258">258</a></li> + +<li>memory (see <a href="#thinking_disorder">thinking disorder</a>), <a href="#Page_40">40</a>, <a href="#Page_67">67</a>, <a href="#Page_168">168</a>, <a href="#Page_195">195</a></li> + +<li>menstruation, <a href="#Page_8">8</a>, <a href="#Page_56">56</a>, <a href="#Page_61">61</a>, <a href="#Page_100">100</a>, <a href="#Page_168">168</a>, <a href="#Page_182"><i>182</i></a>, <a href="#Page_236">236</a>, <a href="#Page_242">242</a></li> + +<li><a name="mesmerism" id="mesmerism">mesmerism</a>, <a href="#Page_86">86</a>, <a href="#Page_114">114</a>, <a href="#Page_117">117</a>, <a href="#Page_141">141</a>, <a href="#Page_144">144</a></li> + +<li>Meyer, Adolf, <a href="#Page_260">260</a></li> + +<li>Meyer, E., <a href="#Page_261">261</a></li> + +<li>midday nap, <a href="#Page_247">247</a></li> + +<li>mixed conditions, <a href="#Page_202">202</a>, <a href="#Page_273">273</a></li> + +<li>Moeli, <a href="#Page_264">264</a></li> + +<li>Moses, <a href="#Page_108">108</a></li> + +<li>mother's body, <a href="#Page_108">108</a></li> + +<li>movement, spontaneous, <a href="#Page_133">133</a></li> + +<li>muscular resistiveness, <a href="#Page_224">224</a></li> + +<li>mutism, <a href="#Page_10">10</a>, <a href="#Page_22">22</a>, <a href="#Page_31">31</a>, <a href="#Page_57">57</a>, <a href="#Page_62">62</a>, <a href="#Page_88">88</a>, <a href="#Page_104">104</a>, <a href="#Page_124">124</a>, <a href="#Page_134">134</a>, <a href="#Page_209">209</a>, <a href="#Page_271">271</a></li> + +<li>mutual death, <a href="#Page_165">165</a>, <a href="#Page_192">192</a>, <a href="#Page_196">196</a>, <a href="#Page_248">248</a></li> + +<li>Myers, <a href="#Page_270">270</a>, <a href="#Page_271">271</a></li> + +<li>mystics, <a href="#Page_3">3</a></li> + +<li>mythology, <a href="#Page_107">107</a>, <a href="#Page_108">108</a>, <a href="#Page_190">190</a>, <a href="#Page_240">240</a></li> +</ul> + +<ul> +<li>negativism, <a href="#Page_5">5</a>, <a href="#Page_31">31</a>, <a href="#Page_52">52</a>, <a href="#Page_56">56</a>, <a href="#Page_65">65</a>, <a href="#Page_128">128</a>, <a href="#Page_138"><i>138</i></a>, <a href="#Page_139">139</a>, <a href="#Page_199">199</a>, <a href="#Page_209">209</a>, <a href="#Page_225">225</a>, <a href="#Page_235">235</a>, <a href="#Page_238">238</a>, <a href="#Page_243">243</a>, <a href="#Page_276">276</a></li> + +<li>negativism, explanation of, <a href="#Page_196">196</a></li> + +<li>nephritis, <a href="#Page_224">224</a></li> + +<li>neuropsychic defect, <a href="#Page_174">174</a></li> + +<li>neurotic, <a href="#Page_150">150</a></li> + +<li>nervous, <a href="#Page_159">159</a></li> + +<li>Newington, <a href="#Page_3">3</a>, <a href="#Page_254">254</a>, <a href="#Page_255">255</a>, <a href="#Page_257">257</a></li> + +<li>Nirvana, <a href="#Page_166">166</a>, <a href="#Page_188">188</a>, <a href="#Page_200">200</a>, <a href="#Page_248">248</a></li> + +<li>nourishment, <a href="#Page_229">229</a>, <a href="#Page_242">242</a></li> +</ul> + +<ul> +<li>Œdipus, <a href="#Page_165">165</a></li> + +<li>œstrous cycle, <a href="#Page_182">182</a></li> + +<li>onset, <a href="#Page_96">96</a></li> + +<li>onset, depressive, <a href="#Page_99">99</a></li> + +<li>ophthalmic disease, <a href="#Page_230">230</a></li> + +<li>Orestes, <a href="#Page_2">2</a></li> + +<li>organic delirium, <a href="#Page_175">175</a></li> + +<li>organic dementia, <a href="#Page_67">67</a></li> + +<li>organic stupor, <a href="#Page_223">223</a></li> +<li><!-- Page 283 --><span class='pagenum'><a name="Page_283" id="Page_283">[283]</a></span> +orientation (see <a href="#thinking_disorder">thinking disorder</a>), <a href="#Page_9">9</a>, <a href="#Page_53">53</a>, <a href="#Page_154">154</a>, <a href="#Page_156">156</a>, <a href="#Page_159">159</a>, <a href="#Page_170">170</a>, <a href="#Page_245">245</a></li> + +<li>Osiris, <a href="#Page_108">108</a></li> +</ul> + +<ul> +<li>pain, <a href="#Page_133">133</a></li> + +<li>Papanicolaou, <a href="#Page_182">182</a></li> + +<li>paragraphia, <a href="#Page_80">80</a></li> + +<li>paralysis, feeling of, <a href="#Page_105">105</a></li> + +<li>paralysis, general, <a href="#Page_5">5</a>, <a href="#Page_254">254</a></li> + +<li>partial stupor, <a href="#Page_34"><i>34</i></a>, <a href="#Page_206">206</a></li> + +<li>perplexity, <a href="#Page_125">125</a>, <a href="#Page_152">152</a>, <a href="#Page_153">153</a>, <a href="#Page_154">154</a>, <a href="#Page_155">155</a>, <a href="#Page_156">156</a>, <a href="#Page_160">160</a>, <a href="#Page_162">162</a>, <a href="#Page_164">164</a>, <a href="#Page_165">165</a>, <a href="#Page_169">169</a>, <a href="#Page_172">172</a>, <a href="#Page_208">208</a>, <a href="#Page_226">226</a>, <a href="#Page_245">245</a></li> + +<li>perplexity, differentiation of, <a href="#Page_227">227</a></li> + +<li>perseveration, <a href="#Page_145">145</a>, <a href="#Page_148">148</a>, <a href="#Page_276">276</a></li> + +<li>personality, <a href="#Page_1">1</a></li> + +<li>perversity, <a href="#Page_138">138</a></li> + +<li>physical disease, <a href="#Page_175">175</a></li> + +<li>physical symptoms, <a href="#Page_174"><i>174</i></a>, <a href="#Page_176">176</a></li> + +<li>Pinel, <a href="#Page_249">249</a>, <a href="#Page_251">251</a></li> + +<li>poison, <a href="#Page_97">97</a>, <a href="#Page_172">172</a></li> + +<li>primitive ideas, <a href="#Page_108">108</a></li> + +<li>prison, <a href="#Page_105">105</a>, <a href="#Page_169">169</a></li> + +<li>prognosis, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_206"><i>206</i></a></li> + +<li>prostitution, <a href="#Page_157">157</a>, <a href="#Page_161">161</a></li> + +<li>psychoanalysis, <a href="#Page_161">161</a></li> + +<li>psychobiological reaction, <a href="#Page_246">246</a></li> + +<li>psychogalvanic reflex, <a href="#Page_276">276</a></li> + +<li>psychological explanation, <a href="#Page_186">186</a></li> + +<li>psychological factors, <a href="#Page_175">175</a></li> + +<li>pulse, <a href="#Page_63">63</a>, <a href="#Page_92">92</a>, <a href="#Page_128">128</a>, <a href="#Page_180">180</a></li> +</ul> + +<ul> +<li>Rank, <a href="#Page_107">107</a></li> + +<li>reality, <a href="#Page_107">107</a>, <a href="#Page_187">187</a></li> + +<li>recuperation, <a href="#Page_189">189</a></li> + +<li>rebirth, <a href="#Page_107"><i>107</i></a>, <a href="#Page_110">110</a>, <a href="#Page_114">114</a>, <a href="#Page_115">115</a>, <a href="#Page_119">119</a>, <a href="#Page_120">120</a>, <a href="#Page_121">121</a>, <a href="#Page_122">122</a>, <a href="#Page_187">187</a>, <a href="#Page_189">189</a>, <a href="#Page_190">190</a>, <a href="#Page_191">191</a>, <a href="#Page_240">240</a></li> + +<li>regression, <a href="#Page_187">187</a>, <a href="#Page_188">188</a>, <a href="#Page_191">191</a>, <a href="#Page_192">192</a>, <a href="#Page_194">194</a>, <a href="#Page_198">198</a>, <a href="#Page_199">199</a>, <a href="#Page_243">243</a></li> + +<li>religious visions or ideas, <a href="#Page_2">2</a>, <a href="#Page_162">162</a></li> + +<li>resentment, <a href="#Page_98">98</a></li> + +<li>resistiveness, <a href="#Page_54">54</a>, <a href="#Page_97">97</a>, <a href="#Page_102">102</a>, <a href="#Page_112">112</a>, <a href="#Page_127">127</a>, <a href="#Page_129">129</a>, <a href="#Page_133">133</a>, <a href="#Page_141">141</a>, <a href="#Page_147">147</a>, <a href="#Page_156">156</a>, <a href="#Page_211">211</a>, <a href="#Page_225">225</a></li> + +<li>respiration, <a href="#Page_180">180</a></li> + +<li>resurrection, <a href="#Page_159">159</a></li> + +<li>restlessness, <a href="#Page_53">53</a>, <a href="#Page_120">120</a>, <a href="#Page_169">169</a></li> + +<li>retention of urine, <a href="#Page_224">224</a>, <a href="#Page_230">230</a></li> + +<li>rheumatism, <a href="#Page_175">175</a></li> + +<li>rigidity, muscular, <a href="#Page_142">142</a>, <a href="#Page_179">179</a></li> + +<li>Romberg sign, <a href="#Page_262">262</a></li> + +<li>rousing, <a href="#Page_176">176</a></li> +</ul> + +<ul> +<li>sadness, <a href="#Page_111">111</a>, <a href="#Page_113">113</a>, <a href="#Page_121">121</a>, <a href="#Page_122">122</a>, <a href="#Page_124">124</a></li> + +<li>St. Catherine of Siena, <a href="#Page_2">2</a></li> + +<li>St. Paul, <a href="#Page_2">2</a></li> + +<li>saliva, <a href="#Page_30">30</a>, <a href="#Page_63">63</a>, <a href="#Page_181">181</a></li> + +<li>scattered speech, <a href="#Page_207">207</a>, <a href="#Page_208">208</a></li> + +<li>schizophrenia, <a href="#Page_67">67</a>, <a href="#Page_214">214</a></li> + +<li>seclusiveness, <a href="#Page_207">207</a></li> + +<li>secondary stupor, <a href="#Page_259">259</a></li> + +<li>Seelig, <a href="#Page_263">263</a></li> + +<li>self-injury, <a href="#Page_50"><i>50</i></a>, <a href="#Page_57">57</a></li> + +<li>sexual excess, <a href="#Page_251">251</a>, <a href="#Page_253">253</a>, <a href="#Page_258">258</a></li> + +<li>sexual ideas, <a href="#Page_209">209</a>, <a href="#Page_219">219</a></li> + +<li>sexual sensations, <a href="#Page_209">209</a></li> + +<li>ship, <a href="#Page_87">87</a>, <a href="#Page_106">106</a>, <a href="#Page_118">118</a></li> + +<li>sick, <a href="#Page_136">136</a></li> + +<li>skin, dry, <a href="#Page_180">180</a></li> + +<li>skin, greasy, <a href="#Page_43">43</a>, <a href="#Page_180">180</a></li> + +<li>sleep, <a href="#Page_188">188</a>, <a href="#Page_189">189</a>, <a href="#Page_247">247</a></li> + +<li>slowing of thought, <a href="#Page_125">125</a></li> + +<li>slowness, <a href="#Page_85">85</a>, <a href="#Page_119">119</a>, <a href="#Page_160">160</a></li> + +<li>smearing of feces, <a href="#Page_142">142</a></li> + +<li>smiling, <a href="#Page_127">127</a></li> + +<li>social status, <a href="#Page_236">236</a></li> + +<li><a name="soiling" id="soiling">soiling</a>, <a href="#Page_30">30</a>, <a href="#Page_132">132</a>, <a href="#Page_172">172</a>, <a href="#Page_196">196</a>, <a href="#Page_225">225</a>, <a href="#Page_230">230</a>, <a href="#Page_235">235</a></li> + +<li>somatopsychic, <a href="#Page_135">135</a></li> + +<li>sphincters, control of, <a href="#Page_133">133</a></li> + +<li>spirits, <a href="#Page_89">89</a></li> + +<li>spoiled child reaction, <a href="#Page_129">129</a>, <a href="#Page_139">139</a></li> + +<li>starvation, <a href="#Page_182">182</a></li> + +<li>stereotypy, <a href="#Page_276">276</a></li> + +<li>Stern, <a href="#Page_261">261</a></li> + +<li>stimulation, mental, <a href="#Page_231">231</a>, <a href="#Page_246">246</a></li> + +<li>Stockard, <a href="#Page_179">179</a>, <a href="#Page_182">182</a></li> + +<li>stubbornness, <a href="#Page_142">142</a></li> + +<li>stupidity, <a href="#Page_93">93</a></li> + +<li>stupor, diagnosis of, <a href="#Page_223"><i>223</i></a> +<ul> +<li> hysterical, <a href="#Page_225">225</a></li> +<li> malignant, <a href="#Page_205"><i>205</i></a>, <a href="#Page_206">206</a></li> +<li> organic, <a href="#Page_223">223</a></li> +<li> reaction, <a href="#Page_35"><i>35</i></a>, <a href="#Page_236">236</a></li> +<li> relation to manic-depressive insanity, <a href="#Page_173">173</a></li> +</ul></li> + +<li>sudden mental loss, <a href="#Page_71">71</a></li> + +<li>suggestibility, <a href="#Page_145">145</a>, <a href="#Page_198">198</a>, <a href="#Page_276">276</a></li> + +<li><!-- Page 284 --><span class='pagenum'><a name="Page_284" id="Page_284">[284]</a></span> +suicidal impulses, <a href="#Page_50"><i>50</i></a>, <a href="#Page_84">84</a>, <a href="#Page_104">104</a>, <a href="#Page_116">116</a>, <a href="#Page_118">118</a>, <a href="#Page_128">128</a>, <a href="#Page_172">172</a>, <a href="#Page_230">230</a>, <a href="#Page_235">235</a>, <a href="#Page_240">240</a></li> + +<li>suicide, <a href="#Page_188">188</a></li> + +<li>sulkiness, <a href="#Page_129">129</a></li> + +<li>sullenness, <a href="#Page_142">142</a></li> + +<li>suprarenals, <a href="#Page_242">242</a></li> + +<li>swallowing, <a href="#Page_133">133</a></li> + +<li>sweating, <a href="#Page_63">63</a>, <a href="#Page_102">102</a>, <a href="#Page_179">179</a>, <a href="#Page_180">180</a></li> + +<li>swimming movements, <a href="#Page_94">94</a></li> + +<li>syncopal attacks, <a href="#Page_64">64</a></li> +</ul> + +<ul> +<li>tears, <a href="#Page_95">95</a>, <a href="#Page_98">98</a>, <a href="#Page_117">117</a>, <a href="#Page_128">128</a>, <a href="#Page_153">153</a></li> + +<li>tense of ideas, <a href="#Page_116">116</a></li> + +<li><a name="thinking_disorder" id="thinking_disorder">thinking disorder</a>, <a href="#Page_22">22</a>, <a href="#Page_31">31</a>, <a href="#Page_37">37</a>, <a href="#Page_39">39</a>, <a href="#Page_41">41</a>, <a href="#Page_45">45</a>, <a href="#Page_48">48</a>, <a href="#Page_59">59</a>, <a href="#Page_67"><i>67</i></a>, <a href="#Page_75">75</a>, <a href="#Page_124">124</a>, <a href="#Page_125">125</a>, <a href="#Page_148">148</a>, <a href="#Page_152">152</a>, <a href="#Page_157">157</a>, <a href="#Page_235">235</a>, <a href="#Page_239">239</a>, <a href="#Page_247">247</a></li> + +<li>thinking disorder, explanation of, <a href="#Page_195">195</a></li> + +<li>tongue, coated, <a href="#Page_13">13</a></li> + +<li>toxins, <a href="#Page_175">175</a></li> + +<li>trauma, <a href="#Page_5">5</a>, <a href="#Page_224">224</a></li> + +<li>treatment, <a href="#Page_229"><i>229</i></a></li> +</ul> + +<ul> +<li>ulceration of eyes, <a href="#Page_133">133</a></li> + +<li>unconscious ideas, <a href="#Page_163">163</a> +<ul> +<li> motives, <a href="#Page_186">186</a></li> +</ul></li> + +<li>unconsciousness, physiological, <a href="#Page_199">199</a>, <a href="#Page_224">224</a>, <a href="#Page_277">277</a></li> + +<li>underground, <a href="#Page_240">240</a></li> + +<li>understanding, <a href="#Page_67">67</a></li> + +<li>uneasiness, <a href="#Page_93">93</a>, <a href="#Page_94">94</a>, <a href="#Page_95">95</a>, <a href="#Page_121">121</a></li> + +<li>unfaithfulness, <a href="#Page_97">97</a></li> + +<li>unhappiness, <a href="#Page_192">192</a></li> + +<li>urine, retention of, <a href="#Page_31">31</a></li> +</ul> + +<ul> +<li>Villermay, <a href="#Page_250">250</a></li> + +<li>Vogt, <a href="#Page_276">276</a></li> + +<li>vomiting, <a href="#Page_45">45</a></li> +</ul> + +<ul> +<li>water, <a href="#Page_94">94</a>, <a href="#Page_95">95</a>, <a href="#Page_106">106</a>, <a href="#Page_107">107</a>, <a href="#Page_114">114</a>, <a href="#Page_120">120</a></li> + +<li>weakness, <a href="#Page_137">137</a>, <a href="#Page_160">160</a></li> + +<li>wealth, <a href="#Page_169">169</a></li> + +<li>wedding ring, <a href="#Page_117">117</a></li> + +<li>weight (see <a href="#emaciation">emaciation</a>), <a href="#Page_38">38</a>, <a href="#Page_52">52</a>, <a href="#Page_61">61</a></li> + +<li>Wernicke, <a href="#Page_3">3</a>, <a href="#Page_273">273</a></li> + +<li><a name="wetting" id="wetting">wetting</a>, <a href="#Page_30">30</a>, <a href="#Page_40">40</a>, <a href="#Page_132">132</a>, <a href="#Page_151">151</a>, <a href="#Page_170">170</a>, <a href="#Page_172">172</a>, <a href="#Page_196">196</a>, <a href="#Page_225">225</a>, <a href="#Page_230">230</a>, <a href="#Page_235">235</a></li> + +<li>Wetzel, <a href="#Page_276">276</a></li> + +<li>whining, <a href="#Page_171">171</a>, <a href="#Page_225">225</a></li> + +<li>Whitwell, <a href="#Page_276">276</a></li> + +<li>Wilmanns, <a href="#Page_261">261</a></li> + +<li>womb, <a href="#Page_108">108</a></li> + +<li>worry, <a href="#Page_110">110</a></li> + +<li>writing, <a href="#Page_27">27</a></li> +</ul> + +<ul> +<li>Ziehen, <a href="#Page_276">276</a></li> +</ul> + +<div class="tn"> +<h4>Transcriber's Note:</h4> + +<p>The following corrections have been made:</p> + +<ul> +<li><a href="#Page_1">p. 1</a>: antequated to antiquated (antiquated methods)</li> +<li>pp. <a href="#Page_11">11</a>, <a href="#Page_97">97</a>, <a href="#Page_100">100</a>: period to colon (Under Observation:)</li> +<li><a href="#Page_53">p. 53</a>: extra 'when' removed (from 'In June, 1914, when she was seen +smiling at times.' to 'In June, 1914, she was seen smiling at times.')</li> +<li><a href="#Page_64">p. 64</a>: period to colon (Physical condition during the stupor:)</li> +<li><a href="#Page_84">p. 84</a>: 24 italicized to match other dates (October 24)</li> +<li><a href="#Page_91">p. 91</a>: missing blank line added between Case 12 and 13</li> +<li><a href="#Page_93">p. 93</a>: aswer to answer (in answer to questions)</li> +<li><a href="#Page_145">p. 145</a>: diaeresis added to coperation to match other instances</li> +<li><a href="#Page_150">p. 150</a>: fatiguable to fatigable (nervous and fatigable)</li> +<li><a href="#Page_153">p. 153</a>: phenomenom to phenomenon (unusual phenomenon for a stupor +patient)</li> +<li><a href="#Page_159">p. 159</a>: comma added (correcting his grammar, and cried easily.)</li> +<li><a href="#Page_161">p. 161</a>: missing "in" added (appeared in the statement that her father)</li> +<li><a href="#Page_171">p. 171</a>: missing open quote added (she wants to go "to the river,")</li> +<li><a href="#Page_198">p. 198</a>: funadmental to fundamental (most fundamental symptoms)</li> +<li><a href="#Page_211">p. 211</a>: salivia to saliva (drooling saliva)</li> +<li><a href="#Page_220">p. 220</a>: inaccesibility to inaccessibility (disinterestedness and +inaccessibility)</li> +<li><a href="#Page_252">p. 252</a>: dimunition to diminution (just as well in the diminution)</li> +<li><a href="#Page_256">p. 256</a>: or to of (relaxation of sphincter muscles)</li> +<li>p. 262, <a href="#Footnote_19_22">Footnote 19</a>: v. to u. (Zeitschr. f. d. ges. Neur. u. +Psychiatrie)</li> +<li>p. 265, <a href="#Footnote_23_26">Footnote 23</a>: Zeitsch. to Zeitschr. to match other instances (Zeitschr. f. d. +ges. Neur. u. Psychiatrie)</li> +<li>p. 271, <a href="#Footnote_27_30">Footnote 27</a>: Archivo to Archivio (Archivio italiano per le +malattie nervose)</li> +<li><a href="#Page_280">p. 280</a>, Index: catherization to catheterization</li> +<li><a href="#Page_282">p. 282</a>, Index: ophtalmic to ophthalmic (ophthalmic disease)</li> +</ul> + +<p>Irregularities in capitalization (e.g. Dementia vs. dementia) and +hyphenation (e.g. off-hand vs. offhand) have not been corrected. A +repetitive sentence on p. 46 (Then she became stupid, although neither +sad nor happy. Then, she claimed, she got stupid, but neither sad nor +happy.), and two spaced em-dashes on p. 87 have also been retained. +Minor punctuation errors (e.g. missing period, missing close or open +quote where intended placement is clear) have been corrected without +note. The abbreviations "p.m.", "e.g." and "i.e." have been +standardized, with no space.</p> + +</div> + + + + + + + + +<pre> + + + + + +End of the Project Gutenberg EBook of Benign Stupors, by August Hoch + +*** END OF THIS PROJECT GUTENBERG EBOOK BENIGN STUPORS *** + +***** This file should be named 30065-h.htm or 30065-h.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/3/0/0/6/30065/ + +Produced by Bryan Ness, S.D., and the Online Distributed +Proofreading Team at http://www.pgdp.net (This book was +produced from scanned images of public domain material +from the Google Print project.) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Benign Stupors + A Study of a New Manic-Depressive Reaction Type + +Author: August Hoch + +Release Date: September 22, 2009 [EBook #30065] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK BENIGN STUPORS *** + + + + +Produced by Bryan Ness, S.D., and the Online Distributed +Proofreading Team at http://www.pgdp.net (This book was +produced from scanned images of public domain material +from the Google Print project.) + + + + + + + + + + BENIGN STUPORS + + + THE MACMILLAN COMPANY + + NEW YORK . BOSTON . CHICAGO . DALLAS + ATLANTA . SAN FRANCISCO + + MACMILLAN & CO., Limited + + LONDON . BOMBAY . CALCUTTA + MELBOURNE + + THE MACMILLAN CO. OF CANADA, Ltd. + + TORONTO + + + + + BENIGN STUPORS + + _A STUDY OF + A NEW MANIC-DEPRESSIVE REACTION TYPE_ + + BY + + AUGUST HOCH, M.D. + + LATE DIRECTOR OF THE PSYCHIATRIC INSTITUTE OF THE + NEW YORK STATE HOSPITALS, WARD'S ISLAND, NEW + YORK. LATE PROFESSOR OF PSYCHIATRY, CORNELL + UNIVERSITY MEDICAL COLLEGE, NEW YORK + + New York + THE MACMILLAN COMPANY + 1921 + + _All rights reserved_ + + + PRINTED IN THE UNITED STATES OF AMERICA + + + Copyright, 1921, + By THE MACMILLAN COMPANY + Set up and printed. Published July, 1921. + + + Press of + J. J. Little & Ives Company + New York, U. S. A. + + + TO + MY FORMER COLLEAGUES + IN THE + NEW YORK STATE HOSPITAL SERVICE + + + + +EDITOR'S PREFACE + + +A word should be said as to the origin and history of this book. When +the late Dr. Hoch became Director of the Psychiatric Institute of the +New York State Hospitals in 1910, he found there an interest in just the +kind of psychiatric research which it was his ambition to further. His +predecessor, Adolf Meyer, had developed the conception that the +psychoses should be looked on as psychobiological reactions rather than +rigid nosological entities and had inculcated the habit of scrupulously +thorough examination and record of what the patient said and did. Meyer +had broken away from the sterile habit of making diagnoses in accordance +with the set terms used to label symptoms; and his work and that of his +assistants thus led to a collection of valuable material which could +serve as a useful starting point for the keen clinical investigation of +Hoch. Specifically, attention had already been fixed on the study of the +so-called functional psychoses, comprising what are generally termed +Dementia Praecox and Manic-Depressive Insanity. An urgent problem in +this field was to separate different reaction types in order to discover +which were recoverable and which chronic or progressive. In order to +understand psychological reactions, interrelation rather than mere +coincidence of symptoms must be studied and, to aid in this, free use +was made of the fundamental principles of unconscious mentation as +exposed in the theories of Freud and his followers. + +Almost at the outset it had been discovered that many patients presented +clinical pictures that would not fit into existing diagnostic pigeon +holes. Dr. George H. Kirby, whose skill and industry had made the most +valuable contributions to the archives of the Institute, published in +1913 a brief paper in which he pointed out, not only that many cases +with "catatonic" symptoms recovered, but also that clinically the +behavior of stupor showed it to be related to manic-depressive insanity +as well as dementia praecox. Dr. Hoch took up the problem at this point. +Using Dr. Kirby's material and adding to it his earlier observations as +well as current cases, he endeavored to work out the essentials of the +stupor reaction. It was his ambition to describe stupor not only in its +psychiatric bearing but also as a life reaction. + +The significance of this task is to be realized only when one considers +the general import of the functional psychoses. They are, biologically, +failures of adaptation. The chronic and deteriorating cases give up the +struggle permanently, while the temporary insanities lay bare the soul +of man as he catches a glimpse of unreality but turns back to face the +world as it is. When one realizes that emotional disturbances are +characteristic of the benign psychoses, it is easy to imagine how much +such studies may ultimately illuminate the problems of normal life. + +The technical value of this work to psychiatry is more immediate. +Kraepelin laid the foundations for systematic classification with his +dementia praecox and manic-depressive groups. But the rigidity of the +latter, allegedly descriptive, term has confused the problem of +classifying many benign psychoses. It was Hoch's ambition to prove that, +although elation and depression were the commonest mood anomalies in +this group, they had no more theoretic importance than anxiety, +distressed perplexity or apathy. These other moods, although less +frequent, are just as characteristic of the psychoses in this group. In +other words, the name "Anxiety-Apathy Insanity" would be as appropriate, +theoretically, as Kraepelin's term. In 1919 Hoch and Kirby published a +report on the perplexity cases. This present book was designed to show +that the symptom complex centering around apathy is as distinct as that +which is recognized by all psychiatrists as mania with its predominant +characteristic of elation. + +In 1917 ill health forced Dr. Hoch to resign from his official duties. +He retired to California with the purpose of adding to psychiatric +literature the fruits of his long experience and unrivaled judgment. His +first task was this book. In the midst of this work came a sudden +collapse. As I had been in close touch with his researches, cooperating +in psychological speculations, and was free to devote some time to it, +he asked shortly before his death that I complete the book. This +obligation is incommensurate with the debt I owe for years of +inspiration, tuition and criticism. + +The task has been mainly literary. I found the first five chapters +practically completed, while it has not been difficult, as a rule, to +discover from his copious notes what his intentions were as to the +details of the following chapters. I have been greatly aided by the +assistance of Dr. Adolf Meyer and of Dr. Kirby. The latter has been good +enough to read the entire manuscript, making invaluable suggestions and +criticisms. + + John T. MacCurdy. + +New York. + + + + +TABLE OF CONTENTS + + + CHAPTER PAGE + + EDITOR'S PREFACE vii + + I. INTRODUCTION AND TYPICAL CASES OF DEEP + STUPOR 1 + + II. THE PARTIAL STUPOR REACTIONS 34 + + III. SUICIDAL CASES 50 + + IV. THE INTERFERENCES WITH THE INTELLECTUAL + PROCESSES 67 + + V. THE IDEATIONAL CONTENT OF THE STUPOR 82 + + VI. AFFECT 123 + + VII. INACTIVITY, NEGATIVISM AND CATALEPSY 132 + + VIII. SPECIAL CASES: RELATIONSHIP OF STUPOR TO + OTHER REACTIONS 149 + + IX. THE PHYSICAL MANIFESTATIONS OF STUPOR 174 + + X. PSYCHOLOGICAL EXPLANATION OF THE STUPOR + REACTION 186 + + XI. MALIGNANT STUPORS 205 + + XII. DIAGNOSIS OF STUPOR 223 + + XIII. TREATMENT OF STUPOR 229 + + XIV. SUMMARY OF THE STUPOR REACTION 234 + + XV. THE LITERATURE OF STUPOR 249 + + INDEX 279 + + + + +BENIGN STUPORS + +CHAPTER I + +INTRODUCTION AND TYPICAL CASES OF DEEP STUPOR + + +The fact that psychiatry lags in development and recognition behind +other branches of medicine is due in part to the crudity of its clinical +methods. The evolution of interest in science is from simple, obvious +and tangible problems to more intricate and impalpable researches. +Refined laboratory work has been done in psychiatric clinics, +particularly along histopathological lines, but clinical studies follow +antiquated methods. The internist does not say, "The patient has sugar +in his urine, therefore he has diabetes and therefore he will die." He +finds a glycosuria and looks for its cause. If this symptom is found to +be related to others in such a way as to justify the diagnosis of +diabetes, a therapeutic problem arises, that of adjusting the chemistry +of the body. The prognosis depends not on the disease but the +interreaction of the organism and the morbid process. Both in diagnosis +and treatment an individual factor, the patient's metabolism, is of +prime importance. Now in psychiatry, although the personality is +diseased, this personal factor has been almost entirely neglected. +Text-books furnish us with composite pictures which are called diseases, +not with descriptions of reactions brought about by the interplay of +personal and environmental factors. Educated people are not satisfied +with novels that fail to depict real characters. Clinical psychiatry, +however, has been content with the dime-novel type of character +delineation. This is all the more disappointing, inasmuch as the study +of insanity should contribute largely to our knowledge of everyday life. +This defect can only be remedied by looking on every case as a problem +in which the origin of each symptom is to be studied and its relation +traced to all other symptoms and to the personality as a whole. This is +an ambitious task and we do not pretend to any great achievement, merely +to a beginning. + +No better psychoses could be chosen for a preliminary effort than benign +stupors. Every psychiatrist has seen them, although they are wrongly +diagnosed as a rule, and they play no small role in the world's history. +Euripides represents Orestes as having a stupor which is pictured as +accurately as any modern psychiatrist could describe an actual case.[1] +St. Paul is chronicled as falling to the ground, being thereafter blind +and going without food or drink for three days. While apparently +unconscious he had a religious vision. St. Catherine of Siena had +several unquestionable stupors, which are fairly well described. In +fact the mystics in general seem to have had communion with God and the +saints most often when they seemed unconscious to bystanders.[2] The +obsession with death, which seems so intimate a part of the stupor +reaction, is a fundamental theme in poetry, religion and philosophy. The +psychology of this interest is, speaking broadly, the psychology of +stupor. So, from a general standpoint, our problem is related to the +study of one of the most potent ideas which move the soul of man. + +Psychiatrically, stupors have long remained an unsolved riddle. In the +century prior to 1872 (See the digest of Dagonet's publication in +Chapter XV) French psychiatrists wrote some good descriptions of stupor +and offered brilliant, though sketchy generalizations about the +condition. Two years later an English psychiatrist (Newington, See +Chapter XV) improved on the French work. Little light has been thrown on +the subject since then. The researches of the later French School showed +that stupor often occurs in the course of major hysteria, but this left +many of these episodes obviously not hysterical. When serious attempts +were made at classification, this ubiquitous symptom complex was hard to +handle. Wernicke wisely refrained from attempting more than a loose +descriptive grouping. He called all conditions with marked inactivity +and apathy "akinetic psychoses" and said that some recovered, some did +not. Taxonomic zeal began to blind vision when Kahlbaum formulated his +"Catatonia" and included stupor in the symptom complex. The condition +which we call stupor occurs in the course of many different types of +mental disease. It is true that it is frequent in catatonia but is not +exclusively there. Mongols have black hair and straight hair, but one +cannot therefore say that any black and straight haired man is a Mongol. +Fortunately Kahlbaum prevented serious error by leaving the prognosis of +his catatonia open. When Kraepelin included it in his large group of +Dementia praecox, however, it implied that stupor could not be an acute, +recoverable condition.[3] He unquestionably advanced psychiatry greatly +but his scheme was too ambitious to be accurate. Many observers saw +patients, classified as dements according to Kraepelin's formulae, +return, apparently normal, to normal life. Finally Kirby[4] published a +series of cases which showed decisively that this classification was too +rigid. + +Since his paper is the foundation for this present study, it should be +reviewed carefully. He first points out that Kraepelin's "Dementia +praecox" includes much more than it should with its inevitably bad +prognosis. He shows how others have found patients with catatonic +symptom complexes proceed to recovery and speaks of these symptoms +occurring in epilepsy and even in frankly organic conditions, such as +brain tumor, general paralysis, trauma and infections. Kirby's first +claim is that there are probably fundamentally different catatonic +processes, deteriorating and non-deteriorating. Lack of knowledge has +prevented us from understanding the meaning of the symptoms and hence +making the discrimination. He points out that stupor seems to represent +an attitude of defense, similar to feigned death in animals, and that in +a number of his cases it was clear that the stupor symbolized the death +of the patient. Apparent negativism, he found to be often a consciously +assumed attitude of aversion towards an unpleasant emotional situation. +In cases where there had been no prodromal symptoms pointing definitely +to dementia praecox the outcome was almost always good. To discriminate +the cases with good outlook from those with bad, he discerned no +difference in the stupors themselves, but observed that the mental +make-up and initial symptoms differed sufficiently for diagnosis to be +made. His most important point is, perhaps, that these benign stupors +showed a definite relationship to manic-depressive insanity in that some +patients passed directly from stupor to typical manic excitement, while +in others a "catatonic" attack replaced a depression in a circular +psychosis. + +Kirby introduces, then, the idea of stupor being a type of reaction +which can occur either in dementia praecox or in manic-depressive +insanity. The matter cannot be left there, in fact it raises new +problems: what constitutes the reaction? how are the various symptoms +interrelated? are they different in deteriorating and acute cases? what +is the teleological significance of the reaction? if it be an integral +part of the manic-depressive group, how does it affect our conceptions +of what manic-depressive insanity is? More than five years have been +spent in endeavors to answer these questions and the results of the +study are now presented. + +Naturally the first point to be settled is: what constitutes the stupor +reaction itself. We can say at the outset that it is seen in the purest +form in benign cases, hence they make up the material of this book. To +discover the symptoms of the disorder one cannot do better than to study +them in their most glaring form in deep stupors, where consistently +recurring phenomena may be assumed to be essential to the reaction. + + + CASE 1.--_Anna G._ Age: 15. Admitted to the Psychiatric + Institute July 25, 1907. + + _F. H._ The mother and two brothers were living and said to + be normal. The father died of apoplexy when the patient was + seven. + + _P. H._ The patient was sickly up to the age of seven, but + stronger after that. It is stated that she got on well at + school, though she was somewhat slow in her work. She was + inclined to be rather quiet, even when a child, a bit shy, + but she had friends and was well liked by others. After + recovery she made a frank, natural impression. She was + always rather sensitive about her red hair. She began to + work a year before admission and had two positions. The + last one she did not like very well, because, she alleged, + the girls were "too tough." + + Three weeks before admission she came home from work and + said a girl in the shop had made remarks about her red + hair. She wanted to change her position, but she kept on + working until six days before admission. At that time her + mother kept her at home as she seemed so quiet, and when + the mother took her out for a walk she wanted to return, + because "everybody was looking" at her. For the next two + days she cried at times, and repeatedly said, "Oh, I wish I + were dead--nobody likes me--I wish I were dead and with my + father" (dead). She also called to various members of the + family, saying she wanted to tell them something, but when + they came she would only stare blankly. For a day she + followed her mother around, clung to her, said once she + wanted to say something to her, but only stared and said + nothing. + + Four days before admission she became quite immobile, lay + in bed, did not speak, eat or drink. She also had some + fever. + + The patient herself, when well, described the onset of her + psychosis as follows: She knew of no cause except that her + brother, some time before the onset (not clear how long), + was run over by an automobile and had his foot hurt. She + claimed that while still working she lost her ambition, + lost her appetite, did not feel like talking to any one; + that when she went out with her mother it merely seemed to + her that people stared at her. The day before she went to + the Observation Pavilion her cousin came to see her, and + she thought she saw, standing beside this cousin, the + latter's dead mother. She also thought there was a fire, + and that her sister was sweeping little babies out of the + room. Then, she claimed, she felt afraid (this still on the + day before going to the Observation Pavilion) because she + had repeated visions of an old woman, a witch. This woman + said, "I am your mother, and I gave you to this woman + (i.e., patient's real mother) when you were a baby." She + also was afraid her mother was "going away." + + At the _Observation Pavilion_ she was described as + constrained, staring fixedly into space, mute, requiring to + be dressed and fed. + + _Under Observation:_ 1. For five months the patient + presented a marked stupor. She was for the most part very + inactive, totally mute, staring vacantly, often not even + blinking, so that for a time the conjunctivae were dry. She + did not swallow, but held her saliva; did not react to pin + pricks or feinting motions before her eyes. Sometimes she + retained her urine, again wet and soiled the bed. Often + there was marked catalepsy, and the retention of very + awkward positions. As a rule she was quite stiff, offering + passive resistance towards any interference. She had to be + tube-fed at first. Later she was spoon-fed, and then would + swallow, in spite of the fact that during the interval + between her feeding she would let saliva collect in her + mouth. For a time she had a tendency to hold one leg out of + bed, and when it was put back would stick the other out. + Sometimes she walked of her own accord to the toilet chair, + but on one occasion wet the floor before she got there. + + During the first month after admission, this stupor was + interrupted for two short periods by a little freer action: + she walked to a chair, sat down, smiled a little, fanned + herself very naturally when a fan was given to her, though + even then did not speak. + + There was, as a rule, no emotional reaction, but after some + months she several times wept when her mother came, though + without speaking. Once when taken to the tub she yelled. + + Her _physical condition_ during this stupor was as follows: + She menstruated freely on admission, then not again until + she was well. Several times she had rises of temperature to + 102 deg. or 103 deg. with a high pulse and respiration; + again a respiration of 40, with but slight rise of + temperature, though the pulse had a tendency to go to 130 + and over. She was apt to show marked skin hyperaemia + wherever touched. With the fever there was found a + leucocytosis of from 11,900 to 15,000, with marked increase + of polynuclear leucocytes (89%). She got very emaciated, so + that four months after admission she weighed 68 lbs. + (height 5' 2"). + + 2. About five months after admission she was often seen + smiling, and again weeping, and she began to talk a little + to the nurses, though not to the doctors. She also began to + eat excessively of her own accord, and rapidly gained + weight, so that by January she weighed 98-1/2 lbs., a gain + of 30 lbs. in two months. Yet she continued to be sluggish. + + 3. For two more months she was apathetic and appeared + disinterested, often would not reply, again, at the same + interview, she would do so promptly and with natural voice. + This condition may be illustrated by the summary of a note + made on January 29, 1908, which is representative of that + period. It is stated that she sat about apathetically all + day, appeared sluggish, but was fairly neat about her + appearance and cleanly in her habits. There was at no time + any evidence of affect, except when asked by the examiner + to put out her tongue so that he could stick a pin in it + she blushed and hid her face. When asked whether she + worried about anything, she denied this. When questions + were asked, she sometimes answered promptly and in normal + voice, again simply remained silent in spite of repeated + urging. On the whole, it seemed that simple impersonal + questions were answered promptly; whereas difficult + impersonal questions or questions which referred to her + condition were not answered at all. She proved to be + oriented. Thus she gave the day of the week, month, year, + the name of the hospital, names of the doctors and nurses + promptly. She also counted quickly and did a few simple + multiplications quickly. But she was silent when asked + where the hospital was located, how long she had been here, + whether she was here one or six months, how she felt. + Questions in regard to the condition she had passed + through, or involving difficult calculations, she did not + answer. However, some questions regarding her condition + asked in such a way that they could be answered by "yes" or + "no" were again answered quite promptly. Thus when asked + whether her head felt all right she said, "Yes, sir." (Is + your memory good?) "Yes." (Have you been sick?) "No, sir." + (Are you worried?) "No." + + 4. This apathy cleared up too, so that by the middle of + March she was bright, active and smiled freely. With the + nurses she was rather talkative and pleased, though this + was not marked. Towards the physician only was she natural + and free. She then gave the _retrospective account_ of the + onset detailed above. When questioned about her condition + she claimed not to remember the Observation Pavilion, + although recalling vaguely going there in a carriage. She + was almost completely amnesic for a considerable part of + her stay in the Institute. She claimed it was only in + November or December that she began to know where she was + (five months after admission). In harmony with this is the + fact that she did not recall the tube- and spoon-feeding + which had to be resorted to for about four months of this + period. No ideas or visions were remembered. As to her + mutism she said, "I don't think I could speak," "I made no + effort," again "I did not care to speak." She claimed that + she remembered being pricked with a pin but that she did + not feel it. She remembered yelling when taken to the tub + (towards end of the marked stupor) and claimed she thought + she was to be drowned. + + When she went home (March 24, 1908) she got into a more + elated condition. She was talkative, conversed with + strangers on the street, said to her mother that she was + now sixteen years old and wanted "a fellow." When the + mother would not allow her to go out, she said it would be + better if they both would jump out of the window and kill + themselves. She then was sent back to the hospital. In the + first part of this period after her return, she was + somewhat elated and overtalkative, though she did not + present a flight of ideas, and was well behaved. She soon + got well, however, and was discharged, four months after + her readmission, fully recovered. + + After that, it is claimed, she was perfectly well and + worked successfully most of the time with the exception of + a short period in the spring of 1909, when she was slightly + elated. + + In 1910 she had a subsequent attack, during which she was + treated at another hospital. From the description this + again seems to have been a typical stupor (immobility, + mutism, tendency to catalepsy, rigidity). According to the + account of the onset sent by that hospital (it was obtained + from the mother), this attack began some months before + admission, with complaints of being out of sorts, not being + able to concentrate and fearing that another attack would + come on. Finally the stupor was said to have been + immediately preceded by a seizure in which the whole body + jerked. She made again an excellent recovery. + + The patient was seen about two years after this attack, and + described the development of the psychosis as follows: She + claimed she began to feel "queer," "nervous," "depressed," + got sleepless. Then (this was given spontaneously) she + suddenly thought she was dying and that her father's + picture was talking to her and calling her. "Then I lost my + speech." As after the first attack, she claimed not to have + any recollection of what went on during a considerable part + of the stupor but recalled that she began to talk after her + brother visited her. It is not clear how she was during the + period immediately following the stupor. + + She made a very natural impression and came willingly to + the hospital in response to a letter and was quite open + about giving information. + + + CASE 2.--_Caroline DeS._ Age: 21. Admitted to the + Psychiatric Institute June 10, 1909. + + _F. H._ The father died of apoplexy when patient was nine. + The mother had diabetes. A paternal uncle was queer, + visionary. + + _P. H._ The patient was always considered natural, bright, + had many friends, and was efficient. + + Some months before admission the patient's favorite + brother, who is a Catholic, became engaged to a Protestant + girl, and spoke of changing his religion. The family and + the patient were annoyed at this, and the patient is said + to have worried about it, but was otherwise quite natural + until seven days before admission. Then, at the engagement + dinner of the brother, the psychosis broke out. She refused + to sit down to the table, and then suddenly began to sing + and dance, cry and laugh and talk in a disconnected manner. + Among other things, she said "I hate her," "I love you, + papa" (father is dead), "Don't kill me." She struck her + brother. She was in a few days taken to the Observation + Pavilion. + + The patient stated after recovery that what worried her was + that the brother would marry a Protestant and that he would + leave home (favorite brother). + + At the _Observation Pavilion_ she was excited, shouted, + screamed, laughed, called out "Don't kill me," again + "Brother, brother," "You are my brother" (to doctor). + + _Under Observation:_ 1. On admission, and for two weeks, + the patient presented a marked excitement, during most of + which she was treated in the continuous bath. She tossed + about, threw the sheets off, beat her breasts and abdomen, + put her fingers into her mouth, bit the back of her hands, + waved her arms about, sometimes with peculiar gyration, + etc., at the same time shouting, singing, again praying, + laughing or crying, sometimes fighting the nurses and + resisting them. She also talked quite a little as a rule, + but there were periods when, although excited, she would + not talk or answer questions. She was very little + influenced in her talk by the environment. When on one + occasion asked if she had any trouble, she said: "No--I + don't want, somebody else gave me a book--all right I love + myself, Uncle Mike too--all right too--all right I am in + Bellevue--I love everybody except the Jews all right, all + right--give me water, give me milk, give me seltzer--white + horse uncle--Holy Father, he is killing me, I want my + mother," or "Wait a minute, say, that's a lie--oh no, Holy + water--no I didn't wash the water away--oh, she forgets, I + am sick--mother why don't you come--look at the baby, they + knocked my head against the wall--wait a minute, isn't that + terrible?--I was married--I was so--I forgot--April fool--I + kiss you seven kisses and one more--I love papa and mamma, + I like others too--I am papa's angel child--yes I confess I + love him, but I don't want to die myself." On another + occasion, when asked where she was, she said: "I am at the + ball--I am going to Heaven--don't shoot me" (affectless). + (Why are you afraid?) "Because you see--high water (in the + tub)--white horse." (What about the water?) "My name is + Caroline--if you love me, father, tickle me under my feet," + or, rolling her eyes up, "Oh, isn't that awful, that ring, + that diamond, that is the key to Heaven." + + 2. For about ten days she was somewhat different. She + became quieter and at first lay muttering unintelligibly, + saying some things about being killed, but speaking little, + often restlessly tossing about and tremulous. She had to be + tube-fed. On one day (July 1) she smiled more and talked + more, said to the physician "You have been arrested for + me--you arrested the first man that I ever--New York + State--let me see that book" (note pad). Then she went on: + "Oh, I am all apart--diamonds--they didn't know--must I + keep them clean?--what is your name?--that is another thing + I would like to know." But when asked what house she was in + she said: "This is the same Ward's Island" and then added, + "How long have I been here?--there is my picture up there + (register), who is that? (listening) it's Ida ..." She + began to sing softly. Then again she whined. "O mamma, + mamma!" When asked how long she had been here, she said: + "Since Decoration Day, when my father went in my sister's + house, nobody could catch up with me--somebody blackened + her eyes." When asked whether she was sick, she said "No, + insane." + + Although, as was stated, she said at one time, "This is the + same Ward's Island," usually questions regarding + orientation were not answered, as she gave few relevant + replies, but she repeatedly said spontaneously that she was + in "Hoboken or Bellevue," and called the nurse by the name + of a former teacher. A few days after this state had + developed she had a fever. Once this rose to 104 deg. The + fever lasted two weeks, coming down gradually. It was + associated with a leucocytosis of 15,000 on June 29 (no + differential count) and with coated tongue. No Widal (two + examinations). No diazo (July 1). + + 3. Then while the temperature still lasted she developed a + stupor which persisted for about a year. During this time + her temperature rose to 100 deg. without ascertainable + cause. She lay for the most part motionless, changing her + position but rarely; her expression was stolid; she + retained and drooled saliva, wet and soiled herself. She + never answered any questions; showed no interest whatever. + At times she was quite stiff and very resistive but never + cataleptic. Her extremities were cold and cyanotic. She had + to be tube-fed throughout. During this time she lost much + hair. + + After some months she occasionally gazed about furtively, + or later watched everything when unaware of being observed; + at this time she also smiled occasionally at amusing + things, or perhaps said "yes" or "no" to questions, but + usually was stolid when interrogated. + + Then about nine months after admission, while in the + condition just described, she developed a lobar pneumonia. + During it she remained the same. But during convalescence + she began to speak and eat. + + 4. A period followed lasting six months during which she + was up and about, but sat or stood around a good deal. On + the other hand, she helped the nurses a little when urged. + Her face was often stolid, again she looked about. At times + (even nearly to the end) she drooled and soiled. She said + little. At no time was she resistive. On other occasions + she smiled or laughed, not always on provocation, or she + showed little playful tendencies, such as throwing a pillow + about the room, tearing leaves from the plants, taking the + doctor's arm and walking down the hall, asking him to kiss + her. At such times she often looked quite bright, keen, + alert and amused. Towards the end she would give at times + playful answers, such as "I came to-day," or "This is the + Hall of Fame." This tapered off, so that by December, 1910, + she was perfectly well. + + _Retrospectively_, the patient claimed not to remember the + upset at the dinner, or what happened afterward, although + recalling the trip to the Observation Pavilion. She denied + any memory of the journey to the hospital, but could tell + what ward she came to. How well the condition after that + was recalled, was not inquired into, except that she could + or would not explain further the utterances during the + first period. For the stupor period it is stated that she + remembered many external facts, but it is not clear in + which period they occurred. + + _Catamnestic Note._ May, 1913: She has worked efficiently, + and is said to have been perfectly well. + + + CASE 3.--_Mary F._ Age: 21. Admitted to the Psychiatric + Institute June 28, 1902. + + _F. H._ The mother died when the patient was five. The + father was living, an alcoholic and reckless man. Four + brothers and sisters died in infancy. + + _P. H._ The patient was the only surviving child. She was + brought up in a convent and orphan asylum until 11, when + her father remarried. At 12 she had to go to work, hence + she had but little education. She was bright, efficient, + well liked by her employers (in one position five years). + As to her peculiarities, she was thought to be, perhaps, a + little headstrong, and was also described as always very + exact, rather quick-tempered and inclined to be irritable + when crossed. + + She was married six months before admission and had a _baby + three weeks before admission_. The husband stated that when + the father found out she was pregnant, he spoke of killing + him. He frequently upbraided both husband and wife, though + he lived with them. Even after the child was born he + continued to be disagreeable. + + The patient was rather low spirited and quieter after her + marriage. She worried over her illegitimate pregnancy and + the scolding from her father. But nothing was thought of + all this, and it did not interfere with her activity. The + birth was normal. She had no flow, no unfavorable symptoms, + and sat up on the twelfth day. She is said to have appeared + natural mentally. + + A week before admission the family returned from the + christening, having left the patient apparently well. They + now found her sitting in her chair, limp, with closed eyes, + giving no answer to questions. Only after about twenty + minutes could she be aroused. After her father had given + her milk with whiskey in it, she claimed he had poisoned + her. In the evening she was bright and lively, singing and + dancing with the others, but in the night she woke up her + husband, seemed frightened, said somebody was in the room + and that he should get a priest as she was going to die. + The husband went to sleep again. The next forenoon the + patient claimed she had been frightened all night and + thought her father was going to kill her husband. + + On the second day, while sitting at breakfast, she groped + about for the bread plate for some time and then said she + had been blind for a short time. During the day she had + frequent spells in which she would close her eyes, become + perfectly quiet and difficult to rouse. Sometimes at the + beginning of these spells she would say "I am going." She + was then taken to her aunt and walked there, a distance of + a few blocks. She was there for two days before going to + the Observation Pavilion. In this time she is said to have + been quiet for the most part, often apparently sleeping or + staring. Once she said she was "rather dirty, filthy." Once + she tried to get out of the window, said it was a door and + that she wanted to get out and take a walk. Above all, she + had, in these two days, repeated peculiar seizures which + the aunt and the husband described as follows: When sitting + on a chair she would close her eyes, clench her fists, + pound the side of the chair, get stiff, slide on the floor, + then thrash her arms and legs about and move the head to + and fro. She frothed at the mouth. After the attack, which + lasted a few minutes, she breathed heavily for a while. + Once she wiped off the froth with a handkerchief and gave + the latter to the aunt, saying "Burn that, it is poison." + Before the attack she sometimes said that it got dark over + her eyes and that her face felt funny, again that she had a + pain in the stomach which worked towards her right + shoulder. There was no cry in the beginning of the attack, + but once she wet herself. + + After recovery the patient herself told the development of + her psychosis thus: + + There was trouble between the father and the husband, and + she was afraid of her father. On the day of the christening + she took sick: a queer feeling came over her and she + wondered whether she was going to die, "Then I seemed to + lose myself, and when I came to I found my family standing + around me." Her father gave her whiskey and she thought it + was poison. "That night I had spells of dancing and + singing, it must have been something I took, perhaps the + liquor." The same night she was frightened, thought her + father might do some harm, and had a vision of a person in + white standing at her bed. After that she had repeated + spells in which she knew nothing until "I came to again." + "It was a queer trembling." + + At the _Observation Pavilion_ she was described as in a + state of "intense mental depression," taking no interest in + things going on about her. She spoke, however; said she + wanted to die, that she had imagined her father had given + her poison, that every one was against her, and that people + were talking about her. + + 1. _On admission_ the patient had a slightly elevated + temperature, which soon subsided, full breasts but without + inflammation. Sordes were not mentioned. + + For a few days she was essentially somewhat restless, + getting out of bed, disarranging her clothes, wandering + about--all in a rather deliberate, aimless way, sometimes + vaguely resistive, again with free movements. She looked, + dazed, sometimes stared straight ahead and looked "dreamy." + Occasionally there was a tendency to close her eyes. With + the restlessness she looked at times "a little + apprehensive," or shrank away when approached. She spoke + slowly, with initial difficulty, but answered quite a + number of questions. The mental content of this period was + displayed in the following utterances: She would ask for a + priest, or say "Have I done something?" or "Do people want + something?" or, when asked why she was here, she said "I + have done damage to the city, didn't I?" (What have you + done?) "I don't know." Or she spoke of people watching her. + When asked the day, she said "Judgment Day," yet she knew + the month. Once when asked what the place was she said, + "This is the hereafter." When asked what had happened at + home, she said: "Voices told me I was to be killed." She + was not clearly oriented, called the place Bellevue, asked + "Isn't this a hospital?" yet again said, "Ward's Island, + where they work." On the day of admission she thought she + came "the day before," but knew she had come in a boat. + When asked her address, she said slowly, "Didn't I live at, + etc.," giving the address correctly. To the physician she + said, "Are you my brother?" And on another occasion, "My + God! You are Charlie" (brother). It was difficult to get + her to eat, and she had to be spoon-fed. + + 2. Then she became more preoccupied, the restlessness was + much less in evidence, it became necessary to tube-feed + her, she retained her urine, answered a few questions, and + when asked where she was, she said, "Calvary, ain't it?" + (What house?) "Heaven, ain't it?" She still called the + physician by the name of her brother. After a few days this + gave way to a more marked stupor which lasted nearly two + years. This was characterized most frequently by a complete + inactivity. She usually lay or sat motionless, sometimes + with mouth partly open, letting the flies crawl over her + face, gazing in one direction, soiling, wetting, resisting + moderately or markedly any interference, and had to be + tube-fed. But this was not the invariable state. The most + constant feature was her mutism, but even that was a few + times interrupted. Thus, when after a visit from her uncle + (towards the end of July, 1902) she tried to get out of the + window and was prevented, she swore at the nurse. Or in + August, 1902, when she got into another patient's bed and + was taken out, she resisted and said promptly: "I think it + is a damned shame I can't get into my own bed." But this + was the extent of her talk for a year and a half. Nor was + she always totally inactive. In the middle of July, 1902, + she sometimes tried to get out of bed, wandered about, got + into other patients' beds. It was on such an occasion that + the above incident happened. In August, 1902, she sometimes + tried to get out when the door was opened, and we have + seen that she tried to get out of the window, but she did + not change her placid expression at such times. Her motive + was not known. On two occasions towards the end of 1902, + when she was taken to a dance and was made to take part, + she waltzed with considerable animation but did not speak. + This was quite striking in that these incidents occurred in + a setting of marked inactivity (i.e., a condition in which + she had to be pushed to the table, pushed to the closet). + She did not soil any more, but she sometimes drooled and + had to be spoon-fed. However, on a third occasion when this + was tried, she had to be dragged around. Finally, though + her facial expression showed at times a preoccupied + staring, she more often looked around, sometimes quite + freely and often looked up promptly enough when accosted. + But there was very little evidence of any affect at any + time. We have seen that twice she swore a little when + opposed. On another occasion she slapped a patient when the + latter helped her. Twice she was seen crying a little + without apparent provocation, but she did not laugh, and + the only suggestion of pleasurable emotion was that at the + two dances mentioned she could be led into a certain + animation. Usually, even when she got less resistive + towards the end, she was essentially apathetic. + + Once in January, 1903, she could be made to write her name + but wrote her maiden name. In the end of 1903 she improved + gradually (a condition not well observed), so that by + December she answered some questions in a low tone. Even in + April, 1904, she was still described as apathetic, though + she had begun to do some work. + + 3. Then she improved markedly and began to work, looked + after herself in a natural way, spoke freely, was entirely + oriented and her mood generally presented nothing striking. + But her mental attitude was still peculiar when she was + questioned. She seemed somewhat inattentive, sulky, + sneering. Thus, when asked why she was here, she said, "You + will have to ask those who brought me here." + + She denied ever having been pregnant, said the nurses on + the ward had spoken of her having had a child and that they + had showed her a child (one was born on that ward about + August, 1903) but that it was not hers. She thought it was + wrong for the nurses to speak on the ward of her having + been pregnant. Again questioned about her marriage, she + first said she had not been married, again that she was + married "a year ago" (was in the hospital then). Again she + spoke of her husband as her "gentleman friend," claimed she + called herself Mary M. (maiden name) until a girl friend + wrote her a letter addressed to Mrs. F. From then on, she + called herself by her married name. But she thought that + probably they sometimes spoke of her marriage in fun. If + she were Mrs. F. she would be living in Mr. F.'s house. + + On June 29, when again asked about her marriage, she said + she was to have been married in December (correct date). + (Were you?) "So they say." (Do you remember it?) "In a + way." (When was the baby born?) "You will have to ask + somebody more superior to me, more experienced." Then, when + further questioned about the age of the baby, she said, + "The baby I saw in the ward was about a year old," and she + claimed not to remember ever having a baby. When asked why + she had come here she said, "Well, I don't know, perhaps + you know better, through sickness I guess," and later: + "Well, don't you ever get a cold and want doctors to + examine you?" (What kind of a place?) "This is a nice place + for sensible people who have enough knowledge to know and + realize what they come for." But she knew the name of the + place, the date, the names of persons. + + Questioned about the trouble with her father or her + husband's trouble with him, she denied it, "If he did (sc. + have any trouble), I don't remember." About her not + speaking, she said, in answer to questions, "I didn't know + what I was here for, what was the object in keeping me + here"; and to other questions about her condition, "I don't + know, those who examined me can tell you more about that." + Finally, she said in reply to the question, why she came + here, "I don't remember _unless it was through fire_," but + would not explain what she meant. + + In the beginning of July, she again said that she had no + recollection of her marriage. + + She then improved a great deal and finally appeared very + natural, gave the retrospective account noted in the + history, had a clear appreciation of the fact that she was + married and had a child. She claimed that she had + previously forgotten about her marriage and thought she was + still merely keeping company with Mr. F. She claimed not to + remember coming to the hospital, did not know what ward + she came to, who the doctor and nurses were, in fact + claimed that it was about a year before she knew where she + was. But she remembered having been tube-fed. She could not + say why she did not speak. But she appreciated that she had + been ill. + + Ten years after discharge the husband, in answer to an + inquiry, stated that she had been perfectly well and had + had no trouble at three successive childbirths. + + + CASE 4.--_Mary D._ Age: 20. Admitted to the Psychiatric + Institute September 17, 1907. + + _F. H._ The grandfather and the father of the patient were + alcoholics. The father died three years before the + patient's admission; he was killed in an accident. The + mother stated that she herself was nervous, but she made a + normal impression. + + _P. H._ The patient was described as bright at school and + efficient in her work as a dressmaker, but she was rather + quiet, inclined to stay at home and had not much + inclination to consort with the other sex. She was rather + proud. As an example of this is stated the fact that she + was always somewhat sensitive, because the family lived in + the basement of the house in which her mother was + janitress. She did not menstruate until 16. It was about + this time that her father was killed in an accident. She + was considerably upset by this, talked a good deal about + the way he was killed, but did not break down. The patient + on recovery stated that it worried her because the father + died without having any chance to get a priest. + + Six weeks before admission the patient was given a + vacation, as there was not work enough in the shop, but she + worked at home. + + Two or three weeks before admission her appetite failed + somewhat, and ten days before admission, without any + appreciable cause, she began to sleep badly, seemed + somewhat nervous, became a little "fidgety" and said she + worried because her mother had to work so hard. Later she + began to speak about people saying that the ambulance would + come for her and she heard voices saying "You will be + dead." It is not known in what emotional setting these + remarks were made. Her mother took her to a dispensary. On + the way she asked the mother where she was going and said + "I can't tell the number and I don't know where I am going. + I think I am losing my mind." She also said she could not + understand any more what she read. She was put to bed. She + then talked less, appeared stupid, and was inclined to + refuse food. + + Four days before admission she claimed that she could see + her dead father beckoning to her, again she said a certain + young man was God. She was sent to the Observation + Pavilion. On the day she went there she was reported to + have shown a slight jaundice. + + The patient, after her recovery, added to the above account + of the mother, that about two weeks before admission, for + no reason which she could state, she began to feel quiet, + and that after that her father's death began to prey on her + mind, and that later she had a vision of her father. She + claimed that in this period she had no fear but that her + head felt dizzy and her vision seemed dim. + + At the _Observation Pavilion_ the patient was described as + constrained, refusing food, mute, resistive of attention, + sometimes muttering to herself and having the appearance of + uneasiness. + + _Under Observation:_ 1. On admission the patient had a + slight jaundice, which disappeared in a few days, and the + bile test in the urine was negative on admission. She was + rather thin, but otherwise in good physical condition. Her + temperature was 99.2 deg. + + For three months the patient was very inactive, moving very + little. She had to be dressed and undressed, when taken out + of bed. She often was markedly constrained, either lying + with her head raised from the pillow, or for long periods + of time holding her arms or hands in rather constrained + positions on her body. But there was at no time any + catalepsy when tested by moving her arms. In the beginning, + however, before she lay so persistently with her head + raised, she was found holding it up from the pillow after + her hair had been fixed. Again, she did not correct other, + rather uncomfortable, positions in which she had been left. + There was also at times a slight or occasionally a somewhat + more marked resistance in her arms and neck, but this never + amounted to a pronounced resistance. She sometimes did not + react to pin pricks, sometimes flinched a little, never + warded off the pin, indeed she would put out her tongue + repeatedly when asked to do so in order to have a pin stuck + into it. She very often wet and soiled, once even + immediately after she had been taken to the closet, on + which occasion she did not urinate. Her face was usually + dull, vacant and immobile, but sometimes, when questioned + or when something obtrusive happened, a little puzzled. + Occasionally she looked slowly about or followed people + with her eyes. There was no evidence of any affect as a + rule, but not infrequently she smiled, even quite freely at + times, when the physician came to her or on other + appropriate occasions. For example, once when a nurse came + into the ward whom she had known outside she flushed and + smiled a little. Once when the mother came to see her a few + tears appeared, the only time this occurred. + + Although for the most part immobile, when she did move, she + was distinctly slow. When asked to do certain things, she + usually did not comply, but now and then, after urging, + would show her tongue after delay, or merely open her + mouth; or she would bring the hand forward slowly when the + physician offered his hand in greeting. Once she fumbled + with her braids slowly. When out of bed, she stood about + aimlessly or sometimes walked somewhat slowly. + + She was almost entirely mute, but a few times she returned + a greeting quite promptly, or on another occasion + (September 23) she said quite promptly, when asked how she + felt, "I feel better. I took off my clothes" (correct--she + had been up and put to bed again). Again she sometimes + answered simple questions by "yes" or "no," though + sometimes in a contradictory and rather aimless manner, but + promptly enough. Once she said to her mother, "I can't, I + have to remain here." There were some other replies which + we shall presently take up. Several times it was possible + to make her write. On these occasions she wrote her name + promptly, or might write only after much delay or stopping + in the middle of a word. + + This leads us to her capacity to think, the defect of which + was perhaps most clear in her writing. Thus, though having + been told to write her name, and having written it quickly + enough, when, immediately after it, she was asked to write + her address or the name of the hospital, she had to be + urged much, and then wrote each time merely a repetition of + her name, this time much more slowly. On October 13, when + she was asked to write her name, she wrote it correctly; + then for the address she wrote the house number correctly, + but for 90th street she wrote "90theath"; and, urged again + for the address, she added "Dr. Wyeth." Again when asked to + write the word "watch" she was slow, and finally put down + "10." When on October 23 she was asked to write "Manhattan + State Hospital," she wrote "Manhatt Hhospshosh," and for + "Ward's Island" (which she was told), "Ww Iland." Then she + was asked to write "I wish to go home." She wrote "I wish + to go home, go West." Here again the first part was written + promptly. + + We now can add some of the other replies which she gave. + Once she was asked "Do you know where you are?" She + promptly said, "Yes." (Where?) No reply. On another + occasion, at the initial examination, she said she was home + or "in papa's house." Once when asked "Do you know me?" she + said "Yes." (What is my name?) "Miss D." (her name). On the + occasion on which she had stated that she had taken off her + clothes, she was asked "Where have you taken off your + clothes?" She made the irrelevant reply, "That was the girl + the one I had." + + 2. Then she improved somewhat. On January 5 she walked + about a little more, though slowly, and still looked + slightly puzzled when questioned. She spoke more readily, + counted promptly though once stopped in the middle of the + exercise. In calculation she multiplied correctly 3 x 7, + but for 4 x 9 repeated the 21, and when given 9 x 9 she did + not answer. A few days later, though she lay again + motionless with her head raised as before, and, as she had + sometimes done, smiled brightly when accosted, she gave few + replies, but when asked to write down the month she slowly + wrote "December." Asked to write it the second time, she + did it promptly. She also replied promptly by saying "Yes" + when asked whether Christmas, and again whether New Year's, + had passed, but did not reply to the questions how long ago + Christmas, or how long ago New Year's, had occurred. On + January 23 she was decidedly more free and prompt in her + replies, yet she still wet and soiled (in fact this did not + cease until the end of the month, when great improvement + occurred). At this time she gave quite a number of + calculations promptly, about an equal number wrongly. She + knew where she was, knew the names of a number of people + about her, but thought she had been here about two weeks + (four months), and gave the year and the date, the latter + as the 28th of January. When then told that it was + Thursday, January 23, and that she must remember it, and + asked five minutes later what she had been told, she again + said "January 28" and left out Thursday. To some questions + to which she did not know the answers, since she had an + amnesia for the time of their occurrence (the incidents of + coming here), she simply remained silent. Even on February + 7, when she was much freer, helped the nurses, and said + herself she was "smarter," she had difficulty in thinking, + said she was 17 (21), gave the date of her birth correctly, + but the current year as 1909 (1908) and still insisted she + was 17. She then did the calculations on paper, and with + considerable difficulty got correctly "22." But she could + not straighten out the discrepancy. At that time, also, she + still wrote "Hospitital," calculated even simple + multiplications with some mistakes, could not get the point + of a story, and to retention tests gave poor results. + Indeed, even seven days later, when she wrote a very + rational letter and appeared quite natural, she made some + omissions in her writing, and a few mistakes in spelling. + + However, she now improved rapidly, and by March 31 she made + a very natural impression, was frank, free, had good + insight, calculated well, etc., understood a story, + retention was good. + + She then gave the retrospective account embodied in the + history, and in addition told that she had no recollection + of going to the Observation Pavilion, the coming here, or + the first part of her stay, including presentation of the + case at a staff meeting, a physical examination and a blood + examination, and she claimed for a long time not to know + where she was, "I was in a kind of dazed condition." She + also said she could not understand the questions which were + asked her. This probably refers, however, to the second + part, i.e., the partial stupor lasting for two months. She + did not "feel like talking," the limbs "felt stiff-like." + + + CASE 5.--_Annie K._ Age: 22. Admitted to the Psychiatric + Institute January 7, 1907. + + _F. H._ The father was an alcoholic, who died when patient + was a child. A paternal aunt had a nervous breakdown, with + recovery. The mother appeared to be normal. + + _P. H._ The mother stated that the patient was a rather + delicate child. She attended school irregularly, never felt + much interest in it, and was always glad to be at home and + help the mother take care of the other children. On the + other hand, she is said to have been quite lively, rather a + tomboy, with a temper. She left school at 14; learned + dressmaking for a year, but did not get along well. Then + she took several other positions, which she held for about + a year, getting on pretty well. + + She married at 20. Her husband never supported her well and + often beat her. She had to borrow money to get along and + worried much. During pregnancy she seemed to worry more, + had crying spells, and often seemed absorbed in thought. + + Three weeks before admission she gave birth to a child. The + labor was somewhat difficult, but she had no fever. She got + up on the tenth day, and then seemed to lose all interest, + did not attend to the baby, said she was not strong enough. + She sat about, appearing depressed. The mother then took + her and the baby to her house. There she sat or walked + about, said very little. But she repeatedly came to her + mother, said she had something to tell her, or that she had + "done something," although she could never be induced to + say what. Once she came to her and said, "You are not going + to die." She often moaned. Finally, she claimed a neighbor + had been saying she was poisoning the baby. + + The patient herself gave, after recovery, the onset as + follows: When she married she knew her husband was not what + he should be, but not that he was so bad as he proved to + be. He was a gambler, did not support her, and this caused + her much worry. When she became pregnant, eight months + after marriage, this increased her worry, and throughout + the pregnancy she spoke much to a neighbor about her + worries, and said she did not know how she could manage, + pay the doctor, and the like, but she did not say much + about it to her mother (because the latter would have made + such a fuss about it, or would have said, "It serves you + right"). Then the childbirth came. This further accentuated + her worries. She felt her difficult circumstances, wondered + how she could get the necessary money, "I lay there + worrying." And she claimed she did not sleep at all. About + her statement, mentioned by the mother, that she had done + something, she said that she thought she had poisoned the + child by giving it fennel tea, and that she thought a + neighbor who visited her said she had poisoned it. She was + then put to bed again, and one night she had a vision of + her father. This frightened her. She thought this meant he + had come for her and she wanted to die. + + At the _Observation Pavilion_ she was dull, staring, + resisting attempts at passive motions. + + _Under Observation:_ 1. There was nothing noteworthy in her + physical condition, except for a rise of temperature to 100 + deg. occasionally during the first month of her admission. + For the first four months she was often found lying in bed + with her head half raised from the pillow, or standing or + sitting about in constrained positions, immobile, + frequently she let saliva collect in her mouth. She usually + wet and sometimes soiled the bed. Sometimes, when sitting + in a constrained position, she let herself gradually slide + on the floor. She often began to feed herself when urged, + but would not finish, and had to be spoon-fed, as a rule. + She was never tube-fed. She was often quite stiff and + showed marked resistance. This was manifested either when + passive motions were tried, at which times she usually + resisted passively, i.e., she became more tense; or when + there broke through a more active aggression and she would + strike. Above all, the opposition showed itself towards the + nurses' attention; in this she also showed either a + passive, aimless opposition and stiffness, or a more active + one; but even in the latter an open show of angry affect, + or plain irritation, though present at times, was by no + means constant. When it was present, she would strike quite + aimfully; once she struck the nurse and said, "You are the + cause of it all," and once, when the nurse tried to give + her some milk, she said, in an irritated tone, "I wonder + people would not let me alone some time." Again, she bit a + patient who tried to hold her. On another occasion she + quickly jumped up and pulled the hair of a patient who + evidently disturbed her by her noisy shouting. As was + stated, she usually wet the bed, resisted being taken to + the toilet, or when taken there, would not urinate or + defecate, but would do so as soon as she was returned to + bed; or she urinated while standing. The same perverse + opposition was seen when she would refuse a glass of milk, + but grab it when it was taken away and then refuse to let + go. She often would grasp the bedclothes or other things + and hold on aimlessly. + + She rarely spoke, answered almost no questions, complied, + as a rule, not even with the simplest commands. To pin + pricks she did not react except at times by flushing. But + she did not stare, rather looked about, and was at times + easily attracted by noises or happenings about her, and + would then look in that direction not without some + interest. Often there was then an expression of + bewilderment. Her mood, however, was, as a rule, apathetic, + but at times, as stated, she showed some anger. Once she + wept, and a few times she smiled or snickered. As a rule, + this happened without appreciable cause. But once, when a + cheering remark was made, she smiled; or, when her picture + was taken (to show the peculiar constrained attitude with + the head raised from the pillow), she laughed loudly. + + Although she spoke rarely, she made a few utterances in the + first few days. Thus she suddenly said: "I want to see Mr. + N.--what I said to him was not right," or "Listen! there + are the priests calling," or "You are all faking--it is me + that done it--they are all dressing up downstairs," or "I + told you she was not able to nurse the baby," or "I have + nobody, I am lost--I want to know the truth--my mamma," or + she called her sister, "They are dead since last night." + + Even during the more stuporous state she could, a few + times, be made to write a little. Then she either wrote + very slowly and not more than a letter, or if she wrote + more, it was remarkably mixed up. Thus when asked to write + the date, she wrote, "Jane (mother's name) to me to + Chrichst," or when asked to write her name: "Annie take you + ktusto." + + As to her orientation, nothing could be made out as a rule. + At first, however, a few weeks after admission, she spoke + correctly of the month as January and spoke of the Island. + When at that time she was asked if she had a baby, she + said, in an annoyed tone, "I don't know." + + 2. In the beginning of May, i.e., four months after + entrance, her condition changed somewhat, and for two + months she presented the following state: She stood about, + or walked around slowly, usually with her arms folded. She + had a tendency to stand near the door. She had to be + assisted in dressing, pushed rather than led to her meals, + and urged to eat. For the most part, she would not answer + questions, but would either smile in a sneering way, or + just walk away, or say, "Oh, don't bother me," or "I don't + want to talk," and generally her attitude was rather sulky. + Nor was this only towards the physicians but towards the + husband, sister and child as well. When on May 17 the + sister came, she would not speak to her but said "Go away." + The baby she simply pushed away sulkily when it was brought + to her. To the husband she said on May 31, "Go away, you + stink." In the first part of this period, she presented + some bursts of elation, on one occasion turned somersaults, + indulged in a few pranks with laughter, or once, when a + knock at the door was heard, she called out "Holy gee, + cheese it, the cop." But these occurred only in the first + part of the period. On June 1 she spoke to the nurse, said, + "What is the matter with these people, they must be crazy," + asked to go home, and was then by the nurse found to be + oriented, and to know the names of people around her. But + when she was asked about the baby she would not answer, and + questioned whether she was not married, she said "I don't + know." Yet when the physician desired to talk to her, she + was just the same as before and remained so for two more + weeks. Another somewhat isolated occurrence was when on + June 18 she spoke a little to the physician, but she sat in + a constrained position when taken into the office and + answered many questions by "I don't know," namely, those + regarding her condition and feelings, the questions about + orientation, about her mother's address, and her child's + age; but when asked how long she had been married she said + correctly "Two years." + + At the beginning of July she improved quite rapidly, and on + July 5 appeared fairly free and gave a fair retrospective + account, with some urging, and it was thought that she + smiled somewhat too freely. However, on July 27, she seemed + perfectly well, had normal insight, and then gave the + second retrospective account, which, together with the + first, will now be taken up. + + _Retrospectively:_ She claimed to remember things at home, + and at both interviews said she recalled being taken to the + Observation Pavilion. While there she thought she knew + where she was, remembered that she did not talk. She had a + feeling she was going to die and said "I thought I would + die if I kept still." However, the transfer to this + hospital was vague in her mind, as was the entrance on the + ward, and she claimed not to have known for quite a while + where she was. She added that she used to wonder where she + was, how she had gotten here, and how she could get out, + and thought the questions which were asked were queer. + Individual occurrences, too, specifically inquired into + were not recollected, such as an examination in a special + room. Of the mixed-up writing at the end of the second + week, she had no recollection even when it was shown to + her. She did not recall having her picture taken (with eyes + open) two months after entrance. Yet a sudden angry + outburst ten weeks after admission was remembered. She + stated that she struck the patient because the latter + annoyed her by her shouting. She had a general recollection + of being stiff, having her head raised, and of soiling and + drooling, but could not account for it. She felt stubborn. + She also claimed not to have been hungry and not to have + felt pin pricks. + + In regard to ideas which she had, she claimed to be afraid + at first that she would be cut up. She remembered repeated + visions of her father at night, also once of her dead aunt, + who said "Come to me." She thought she was in a cemetery, + all the family were dead, the baby dead. In the beginning, + too, she sometimes heard a priest whom she had known, say + "Be good and God will look after you." + + In regard to the later period, she recalled that she got up + in May and felt cross. She did not answer because she did + not want to be bothered. She pushed the baby away because + she did not think it belonged to her, the husband because + she did not like him. (She did not think she was not + married.) She evidently remembered the visits, thought she + knew where she was, knew she stood near the door "because I + wanted to go home." Besides the idea that the baby was not + hers, she recalled none, and thought she had no + hallucinations. + + She was discharged perfectly well six months after + admission to the hospital. Soon after that, she left the + husband, once had him arrested in 1908 and sent to the + workhouse. She was again examined in 1913, and was found to + be perfectly well, and she stated she had been well since + the discharge. + +These five cases will have to suffice for the present. They were given +in full in spite of the fact that we shall leave out of our present +considerations the history of the cases and certain of the stages, and +confine ourselves to that stage of each case which is best qualified to +give us a good general survey of the essential features of the stupor +reaction. + +These phases are: stage 1 of Case 1, lasting five months; stage 3 of +Case 2, lasting one year; stage 2 of Case 3, lasting two years; stage 1 +of Case 4, lasting three months; stage 1 of Case 5, lasting four months. + +We gather from these descriptions that the essentials of the stupor +reaction are (1) more or less marked interference with activity, often +to the point of complete cessation of spontaneous and reactive motions +and speech; (2) interference with the intellectual processes; (3) +affectlessness; (4) negativism. + +_Inactivity:_ There is a complete cessation or more or less marked +diminution of all spontaneous or reactive movements. This includes such +voluntary muscle reflexes as contain a psychic component. For instance, +there is, often, an interference with swallowing (letting saliva collect +and drooling), winking, and even with the inhibitory processes used in +holding urine and feces (soiling and wetting). Often there is no +reaction to pin pricks or feinting motions. The inactivity also often +interferes with the taking of food so that spoon-feeding or tube-feeding +has to be resorted to. The patient may keep his eyes covered or stare +vacantly, the face often presenting a remarkably immobile wooden, or +stolid, expression. Complete mutism is the rule. When activity is not +totally interfered with, those movements which are present may be slow. +The patient may have to be pushed around and be able to take a few +steps, but soon relapses. More often they are of normal rapidity. Speech +then may also be slow and low, but usually shows no change except for +the fact that it is diminished in amount. Sometimes awkward positions +are assumed and retained, and there may be catalepsy. + +_Negativism:_ A common symptom is perverse resistiveness. It may consist +in a marked stiffening of the body which is assumed spontaneously or +appears only when attempts at interference are made, or there may be a +more active turning away or even a direct warding off, sometimes with +scowling or anger or even swearing and striking. Retention of urine, +which is seen at times, should, perhaps, be mentioned here. Now and then +we find that a patient is put on the toilet and cannot be induced to +urinate or defecate, while soiling and wetting occur at once on +returning to bed. + +_The intellectual processes:_ Little is known about the intellectual +processes from direct observation in these more pronounced cases, except +for the fact that in Case 5 questions or obtrusive occurrences sometimes +produced a somewhat puzzled facial expression. Moreover, the patient +retrospectively stated that she was unable to understand the questions, +which points to marked difficulty in apprehension. We also find that +occasionally there is evidence of an interference with the intellectual +processes which showed itself in what may be called "paragraphic" +writing when the patient could be induced to write. Above all, we see +that retrospectively very little is remembered of what took place during +the stupor, even of such obtrusive events as the moving from one ward to +another, tube-feeding, physical examination, the presentation at a staff +meeting, and the like. + +_Affect:_ Complete affectlessness is an integral part of the stupor +reaction. Modification of the statement will later be mentioned. The +patient is indifferent so far as his basic condition is concerned, and +it is only by certain stimuli that at times emotional reactions can be +elicitated, some tears at a visit of a relative, an appropriate smile at +a joke or a comical situation when the stupor is not too deep or an +angry reaction called forth by interference. + +_Catalepsy:_ Waxy flexibility or merely a tendency to maintain +artificial positions is a frequent but not an essential symptom. + +_Physical Condition:_ Not infrequently we find in the beginning or in +the course of the stupor an elevation of temperature to 101 deg., 102 +deg. or even 103 deg. In one case we found a marked cyanosis in the +extremities. Case 2 showed marked loss of hair. Gain in weight is never +observed and marked emaciation is the rule. This we may attribute to the +refusal of food. + +A perusal of these cases, then, shows that the dominant (and well-nigh +exclusive) symptoms of the stupor are inactivity, apathy, negativism and +disturbance of the intellectual functions. Benign stupor can be defined +as a recoverable psychosis characterized by these four symptoms. The +meaning of such vague physical manifestations as the low fever is not +clear. + + +FOOTNOTES: + +[1] MacCurdy has discussed the psychological phenomenon of a dramatist +depicting a psychosis correctly in "Concerning Hamlet and Orestes." +_Journal of Abnormal Psychology_, Vol. XIII, No. 5. + +[2] Many of these states seem to be hysterical rather than +manic-depressive stupors, but so far as the unconsciousness goes, there +is probably as much psychological as symptomatic resemblance between the +two types of reaction. + +[3] Kraepelin recognizes, of course, the occurrence of stupor symptoms +or states in the course of manic-depressive psychoses. It is stupor as a +clinical entity, as a separate psychosis, that he regards as one form of +the catatonic, and therefore of the dementia praecox, reaction. + +[4] Kirby, George H.: "The Catatonic Syndrome and Its Relation to +Manic-Depressive Insanity." _Jour. of Nervous and Mental Disease_, Vol. +40, No. 11, 1913. + + + + +CHAPTER II + +THE PARTIAL STUPOR REACTIONS + + +The cases thus far considered, namely, those of marked stupor, are +fairly well known and have been studied by others. Less well known and +formulated, but even more important from a practical as well as from a +theoretical point of view, are what may be called partial stupors. + +The reader has noted that the states of deep stupor described in the +last chapter, did not end abruptly with a sudden return to health or a +sudden change to another type of psychosis. They all gradually passed +away, not by the disappearance of one symptom after another, but by the +attenuation of all. Sometimes a more or less stable condition persisted +for months, in which there was no stupor in a literal, clinical sense +but when apathy, inactivity, interference with the intellectual +functions and negativism all existed. Had these been the only states +observed in these patients, there might have been some ground for doubt +as to the diagnosis. As it was, it was clear that we were dealing with +mild stages of stupor. When a psychiatrist meets with an undeveloped +manic state, he calls it a hypomania and does not hesitate to make this +diagnosis in the absence of complete development into a florid +excitement. This procedure is not questioned, because the manic +_reaction_ as distinguished from a _mania_ is well recognized. We +believe that there is just as distinctive a _stupor reaction_ which may +be exhibited either in deep stupors or what we may term partial stupors. +Theoretically, complete apathy, inactivity, etc., make up the clinical +picture of a deep stupor. When these symptoms appear rather as +tendencies than as perfect states, a partial stupor is the product. That +partial stupors occur as well-defined psychoses, developing and +disappearing without the appearance of deep stupor, we shall attempt to +show in the following three typical cases: + + + CASE 6.--_Rose Sch._ Age: 30. Admitted to the Psychiatric + Institute August 22, 1907. + + _F. H._ Both parents were living (father 74, mother 68), as + were two brothers and two sisters. All were said to be + normal. + + _P. H._ Nothing was known of the patient's early + characteristics, except that she herself said she was slow + at learning in school and did not have much of an + education. But when well she made by no means the + impression of a weak-minded person. The husband had known + her for ten years. He married her eight years before + admission, by civil process, keeping this from his own + family because he was a Jew and she a Christian. He said + that this undoubtedly worried the patient at times and that + she often asked him when he would take her to his family. + The patient herself later also said that this used to worry + her. Finally, one and a half years before admission she + agreed, on account of the children, to accept the Hebrew + faith, and they were then married in the synagogue. But he + still did not take her to his family. + + There were four pregnancies: the first child died; of the + survivors one was 8, a second 5 years old. Finally, a year + before admission, she became again pregnant. During the + pregnancy one of the children had whooping cough and she + herself was thought to have caught it. The baby was born + three months before admission. It was a blue baby which + died two days after birth. The patient flowed heavily for + three weeks and was taken to a hospital, where she + continued to flow intermittently for some weeks more. + + Finally, three weeks before admission, a hysterectomy was + performed. Several days after this, when the sister-in-law + visited her, the patient begged her to take her home, said + the doctor wished to shoot her and to give her poison. + Later the patient confirmed this, saying that she thought + they wanted to give her saltpeter, and that she heard them + say they wanted to shoot her. + + When taken home she refused food; gazed about, was + absorbed, seemed obstinate, and several times tried to jump + out of the window. Retrospectively the patient stated that + she heard children on the street call "Katie." She thought + they meant her child, heard that it was to be taken away + from her, and a similar idea again came out later in her + psychosis, namely, that somebody was going to harm her + children. + + At the _Observation Pavilion_ she appeared stupid, rather + immobile, her attention difficult to attract. + + _Under Observation:_ On admission the patient appeared + sober, impassive, moved very little, was markedly + cataleptic, though not resistive. On the other hand, her + eyes were wide open and she looked about freely, following + the movements of those around her not unnaturally. When + questioned, she looked at the questioner rather intently, + and was apt to breathe a little more rapidly, and made some + ineffectual lip motions but no reply. To simple commands + she made slow and inadequate responses. She flinched when + pricked with a pin, but made no attempt at protecting + herself. She had to be spoon-fed. The catalepsy persisted + only for two days. + + After this she continued to show a marked reduction of + activity, moved very little, said nothing spontaneously, + had at first to be spoon-fed (later ate naturally enough). + But she never soiled herself and went to the closet of her + own accord. + + Emotionally she seemed dormant for the most part, though + for the first few days she appeared somewhat puzzled, and + one night when a patient screamed she seemed afraid and + did not sleep, whereas other nights she slept well. She + answered only after repeated questions and in a low tone. + Very often, though her attention was attracted easily + enough, her answers were remarkably shallow and also showed + a striking off-hand profession of incapacity or lack of + knowledge. This was often without any admission of + depression or concern about her incapacity. She would + usually say "What?" or "Hm?" or repeat the question, but + most often would say, "I don't know," this even to very + simple questions. For instance, when asked, "What is your + name?" she answered, "My name? I don't know myself" (but + she did give her husband's name), or when asked to write + her name, she said, "I don't know how to write," or "Call + Annie, she will write my name." When requested to read or + write (even when asked for single letters), she would make + such statements as "I can't read." However, she finally + named some objects in pictures. This condition was + characteristic of her for two weeks. + + Then her condition changed a little. She spoke a little + more freely but was similarly vague. The following + interview of September 9, is characteristic: When asked how + she was, she said, "Belle." (Are you sick?) "No." (Is your + head all right?) "Yes." (Is your memory all right?) "Yes." + (Do you know everything?) "Yes." (Understand everything?) + "Yes." (Are you mixed up?) "No." (Do you feel sick?) "No." + But when asked where she was, how long she had been here, + what the name of the place was, what was the occupation of + those about her, she said, "I don't know." (How did you + come here?) "I couldn't tell how I came up here." (What are + you here for?) "I am walking around and sitting on + benches," but finally, when again asked what she was here + for, she said, "To get cured." She now gave and wrote her + name and address correctly when requested, also gave the + names of her children. Yet when asked about the age of the + girl, said, "I don't know, my head is upside down." When an + attempt was made to make her repeat the name of the + hospital, or the date, or the name of the examiner, she did + so all right, but even if this was done repeatedly and she + was asked a few minutes later, she would say "I couldn't + say," or "I forget things," or "I have a short memory," or + she would give it very imperfectly, as "Manhattan Island," + or "Rhode Island" for "Manhattan State Hospital, Ward's + Island." (How is your memory?) "All right." But when at + this point the difficulty was pointed out, she cried. + (Why?) "Because I forget so easily." All this was while her + general activity was much reduced, and she seemed to take + very little interest in her surroundings. + + Then she improved somewhat, asked the husband some + questions about home, and on one occasion cried much and + clung to him and did not want to let him go without taking + her. She also began to work quite well, but still said very + little spontaneously. During this period when asked + questions, she spoke freely enough, but seemed somewhat + embarrassed. What was still quite marked were striking + discrepancies in giving dates, and her utter inability to + straighten them out when attention was called to them, as + well as to her inability to supply such simple data as the + ages of her children. Her capacity was later not gone into + fully but it was certainly less defective on recovery than + at this time. She was rather shallow in giving a + retrospective account during this period. Even later, when + she had developed a clear insight and made, in respect to + her activity and behavior, a natural impression, she was + not able to give much information about her psychosis, + although she apparently tried to do so. + + She was discharged recovered four months after admission, + her weight having risen from 93 lbs. on admission to 133 + lbs. on discharge. For the first two weeks of her stay in + the hospital, her temperature varied between 99 deg. and + 100 deg. + + _Retrospectively:_ She said in answer to questions about + her inactivity and difficulty in answering that she did not + feel like talking, felt mixed up, could not remember well, + did not want to write. + + Before she was quite well she knew of her entrance to the + Observation Pavilion and her transfer to Ward's Island, of + which she could give some details, but thought she had been + in the Observation Pavilion two weeks instead of three days + and in the admission ward one month instead of a few hours. + As to the precipitating cause of the attack, she spoke of + her flowing so much after childbirth and of her operation. + + She was seen again in March, 1913, when she seemed quite + normal mentally and claimed that she had been well ever + since leaving the hospital. + +With the exception of negativism, which appears only in the anamnesis, +all the cardinal stupor symptoms are found in this history. Particularly +noteworthy is her intellectual deficiency which seemed to be made up of +a real incapacity plus a remarkable disinclination for any mental effort +whatever. It is important to note that her attitude towards this +disability was usually one of indifference and that, in general, there +was no show of affect whatever. Freedom of speech was the last thing for +her to regain. + + + CASE 7.--_Mary C._ Age 26. Single. Admitted to the + Psychiatric Institute April 7, 1907. + + _F. H._ The father had repeated attacks of insanity, from + which he recovered, but he died in an attack at the age of + 60. A sister also had a psychosis, from which she + recovered. + + _P. H._ The patient was rather quiet and easily worried. + When 14 she had some dizzy spells, with momentary loss of + consciousness. After that time she had no such attacks, + except after a tooth extraction when about 24. + + The patient came to the United States six months before + admission. She went to live with a cousin who died a week + after she arrived at his house. She worried and said that + she brought bad luck. Then she took a position, where she + was well liked, but she was not particularly efficient. In + this situation she often felt homesick and lonely. + + Two weeks before admission an uncle died, which affected + her considerably. She spoke of his leaving three children, + and would not go to the funeral. Then she thought she was + going to die. She felt dizzy, weak, walked with a stooped + position, was sleepless. In the midst of this she suddenly + felt frightened and walked into her mistress' room, to + whom she complained that some one was talking outside but + could not tell what was said. She heard shooting. + Retrospectively, after recovery the patient said that at + that time she suddenly got "mixed up," and that her "memory + got bad." + + She was taken to a general hospital, where she thought + there was a fire, and screamed "Fire!" She was soon + transferred to the _Observation Pavilion_, where she + appeared dazed, moving slowly, yet showing a certain + restlessness. She spoke of "the boat" being shut up so that + no one could go out. Again, she said "The boat went down + and all the people keep turning up." Retrospectively the + patient stated about this condition that she remembered + going to the general hospital but not her stay at the + Observation Pavilion. (The trip to the Manhattan State + Hospital was again clearer to her.) About the ideas she had + at the time, she remembered only that the room seemed to go + around, and that after she had come to the Manhattan State + Hospital and was clearer, she thought she was in Belfast, + was on a ship, and that people were drowning. + + _Under Observation:_ On admission she had a temperature of + 100 deg., a coated tongue, suffused conjunctivae. There + were herpes of the lower lip, a general appearance of + weariness and exhaustion, a flushed face, trace of albumen + in the urine, which was absent on the third day, no + leucocytosis, but 41 per cent. lymphocytes. + + Then and henceforth she was inactive and very slow in all + her movements; she never stirred spontaneously, and had to + be pushed to the toilet and to the table; she ate slowly. + She did not speak spontaneously, and her replies were very + slow in coming. She had to be urged considerably before she + would speak and, as a rule, she did not answer. On one + occasion she was for a day totally inactive and looked + duller. That day and on a few other occasions she wet the + bed. There was at times an appearance of dull bewilderment. + When, soon after admission, asked whether she felt cheerful + or downhearted, she said "downhearted," but this was the + only time. Often she answered "I don't know," when asked + whether she was worried, and she could never say what she + was worried about. Again she directly denied worry. + Sometimes she smiled appropriately, and repeatedly, when + asked how she felt, said, "I feel better." In answer to + questions as to how her head was, she replied several + times, "My memory is gone," also "I can't take in my + surroundings," or "I don't know where I am," or "I cannot + realize where I am." Again, she spoke of being dizzy and + once said it was as though the room went round. Sometimes + she knew where she was or knew names, again said "I + forget," but she always was approximately oriented as to + time. There were no special ideas expressed and no + hallucinations, except in the very beginning when she still + thought at night, when she heard the boats on the East + River, that people were being drowned. She later, as stated + above, said she thought she was on a boat and people were + being drowned. + + By June, i.e., two months after admission, she began + rhythmical swaying of the body, twisting of the fingers, or + pulling out some of her hair. She ascribed this behavior + simply to "nervousness." + + On July 16, after a visit from her cousin, who said to her + that if she worked she would soon get better, she began + spontaneously to occupy herself somewhat. She became more + active, said she felt stronger and brighter, and that her + memory was better. By the beginning of August she was + fairly free, but still spoke in a rather low voice, + although answering well. Her capacity to calculate also + remained poor. When asked about the more inactive state, + she said she had been afraid to stir. (What afraid of?) "I + didn't know where to go or what to do." Further, she + recalled that she had had a numb feeling in her tongue, + could not speak quickly, and that her mind had felt + confused and "she could not take in things." Further review + with her of the earlier period of her psychosis showed that + there was a blank for external events and most of the + internal events during this time. + + She made a perfect recovery and was discharged August 7, + 1907, four months after admission. + +This case, although very like the last, differs from it in two +particulars. For one day her symptoms were sufficiently marked to +suggest a deep stupor. Secondly, her intellectual incapacity was not so +marked (always approximately oriented for time) and with this there was +some subjective appreciation of her defect. Apparently, however, this +insight did not cause her any worry. The affectlessness was equally +prominent in both of the foregoing cases, the fact that Mary C. (Case 7) +once admitted feeling downhearted in response to leading questions, +having little significance in the face of her expression, actions and +usual denial of worry. It is interesting to note that, during the bulk +of her psychosis, her only complaints were of mental hebetude and +dizziness. Possibly the latter was merely an expression of her +subjective confusion. + + + CASE 8.--_Henrietta H._ Age: 22. Admitted to the + Psychiatric Institute March 6, 1903. + + _F. H._ The father stated that both parents were living and + well, also eight brothers and sisters. + + _P. H._ The patient came to this country when she was a + baby. She was bright at school and industrious. From the + age of 17 on, she worked in a drygoods store and gave + satisfaction. About her mental make-up no data were + available, except for the statement that she always made a + natural impression. + + When 21 (February, 1902), without known cause, she broke + down and was sent to the Manhattan State Hospital, but was + not observed in the Institute ward. She remained in the + hospital for three months. It was claimed that the attack + came on suddenly two days before she was sent away. She + suddenly appeared anxious, said something had happened and + became excited. This lasted for about a week, and then she + was, as the description says, "depressed and cataleptic." + She remained in this condition for about a month, during + which time there was a slight rise of temperature. Then she + improved gradually and was discharged three months after + admission. After recovery from the present attack the + patient stated that during the first sickness she had + visions of dead friends. + + She was perfectly well in the interval. + + Six days before admission she suddenly became excited, + refused to eat, and began to talk, repeating phrases over + and over. Then she became elated and excited. + + After recovery the patient described the onset of her + psychosis as follows: Six days before admission, after + having been perfectly well and without any known cause, she + was feverish and vomited, but slept well. Next day she felt + nervous, and her thoughts were clear. She constantly + thought of dead friends, heard them talking, when she tried + to do anything the voices said, "Don't do that." She also + thought somebody wanted to harm her people. Soon she + started singing and felt happy. + + Then she was sent to the _Observation Pavilion_, where she + appeared to be in the same condition which was observed in + the Institute. + + _Under Observation:_ 1. On admission she was in good + physical condition, except for her skin seeming greasy. She + presented for nine days the following picture: She was + essentially elated, laughing, singing, jumping out of bed, + good-natured and tractable, and very talkative. Her + productions showed a good deal of sameness and a certain + lack of progression. She spoke at times in a rather + monotonous voice, but again often in very theatrical tones, + with much, rather slow, gesturing. The following are very + representative samples: + + "I have been suffering from my own blood, my own blood sent + all away from home. I just came from Bellevue. I left here + last May (correct) a healthy girl. A sister is a sister--I + wonder why shorthand is shorthand, a stenographer is a + stenographer (seeing stenographer write)--a kind brother, + Bill H.--why H. his wife is a sister-in-law to us, she has + four children--four beautiful children--sister-in-laws and + brother-in-laws--telephone ringing (telephone did + ring)--dear Lord, such a remembrance--remembrance was + remembrance, truth was truth--honesty is honesty--policy is + policy--if she married him, she is my sister-in-law and he + is my brother-in-law--Max knows me--she changed her name to + Mrs. R.--two children who are Rosie and Maud, if names were + given, names should not be mistaken--they are Julia, + Lillian--Rosie and Maud--why should wonders wonder and + wonders cease to wonder, why should blunders blunder and + blunders still blunder; sleep is one dream and dream means + sleep--if move is moving, why not move?" When she + accidentally heard the word wine, she said "Guilty wine is + not in our house--wine is red and women are women, and + women and wine and wine and women and wine and song." + Again, "You are not Mr. Kratzberger, Mr. Steinberger, Mr. + Einberger--you are not Mr. Horrid or Mr. Storrid--perhaps + you are Mr. Johnson or Mr. Thompson--no, you are Dr. C." + (correct). + + She was quite clear about her environment. + + Although the mood was throughout one of elation, on the + ninth day in the forenoon she cried at times, wanted to see + her mother, and spoke in a depressed strain (content not + known). A few hours after that she suddenly became quiet. + + 2. Then for four days (March 14-17) she was markedly + inactive, though at times got out of bed. She looked about + in a bewildered manner, did not speak spontaneously, but + could with urging be induced to make some replies. She did + this now fairly promptly, now quite slowly. Questions were + apt to bring on the bewilderment. Thus, when asked where + she was, she merely looked more bewildered, finally said + "Bellevue--I don't know," and questioned who the doctor was + whom she had called by name in her manic state, she said, + with some bewilderment, "Your face looks familiar." (Where + have you seen me?) "In New York." She claimed to feel all + right. There was no real affect. She made the statement + that at home she heard voices saying "You will be killed." + + 3. Henceforth this bewilderment ceased, and for 16 or 17 + days she was essentially inactive for the most part, for a + short time with a tendency to catalepsy and some + resistiveness, and at that time lying with eyes partly + closed. As a rule she said nothing spontaneously, but + replied to some questions, usually with marked retardation, + again more promptly. She constantly denied feeling sad or + worried, repeatedly said she felt "better," only on one + occasion did she cry a little. When asked to calculate she + sometimes did it very slowly, again fairly promptly. The + simple calculations were usually done without error, the + others with some mistakes. As to her orientation the few + answers obtained showed that at times she knew the name of + the place and the day, again she gave wrong answers + (Bellevue). Once asked on March 23 for the day, she said + April. She wrote her name promptly on one occasion, again + a sentence slowly but without mistakes. Once during the + period she sang at night. Once she suddenly ran down the + hall but quickly lapsed into the dull condition. + + On April 4, at the end of this period, she suddenly + laughed, again ran down the hall, said she had done nothing + to be kept on Ward's Island. But she quickly lapsed again + into the dull state. Later, on the same day, when the + doctor was near, she said, in a natural tone, "Thank God, + the truth is coming out." (What do you mean?) "That I have + been trusting in a false name and that Miss S. (the nurse) + should not nurse me." Then she got suddenly duller, + calculated slowly and with some mistakes, 3x17=41, 4x19=56, + and when asked to write Manhattan State Hospital she wrote + (not very slowly) "Mannahaton Hotspalne." + + 4. Next day it was noted that she was more stuporous, and + she remained so for two weeks, now showing a decided + tendency to catalepsy and more resistance than before, + though not marked, except in the jaw. She lay often with + head raised, sometimes with eyes partly open, or staring in + a dull, dreamy way, neither soiling nor drooling, however; + a few times she looked up when spoken to sharply. There was + no spontaneous speech. Usually she did not answer at all, + but a few times a short low response was obtained. Once she + wrote slowly a simple addition, put down on paper. When, on + one occasion, asked how she felt, she, as before, said, "I + feel better." + + 5. Then, with the exception of a day at the end of the + month, when the more stuporous state was again in evidence, + she returned to her former condition without catalepsy or + resistiveness and without staring, but essentially with + inactivity or slowness. She now even dressed herself, + answered slowly though not consistently, but she again + denied feeling troubled or sad, "I feel better." + + On July 7 she got brighter but was still rather slow. She + then even began to do some work. She again denied feeling + sad. + + In a few weeks, while having a temperature of 102 deg. with + vomiting and diarrhea, she suddenly got freer. She then + said, in answer to questions, that she did not speak + because she was not sure whether it would be right, again + because she seemed to lose her speech. She did not move + because she was tired, had a numb feeling. She said she + had not been sad, "but I had different thoughts," "saw + shadows on the walls of animals, living people and dead + people." She was not frightened, "I just looked at them." + People moved so quickly that she thought everything was + moved by electricity. She thought her head had been all + right. + + After a few days she relapsed into a duller state again, + but then got quite free and natural in her behavior. On + August 28 she gave a _retrospective_ account of her + psychosis, a part of which has been embodied in the + history. She had insight in so far as she knew she had been + mentally ill. She claimed to remember the Observation + Pavilion and her coming to the hospital, also the incidents + during the manic state, when she heard cannon and thought a + war was on, and voices she could not recognize nor + understand. Then she became stupid, although neither sad + nor happy. + + Then, she claimed, she got stupid, but neither sad nor + happy. She claimed to have known all along where she was, + but felt mixed up at times, her thoughts wandered and she + felt confused about the people. She thought she was in + everybody's way, thought others wanted to get ahead of her, + did not speak because she did not know if it were right or + wrong, felt she might cause disturbance if she answered. + (It is not clear whether she had complete insight into the + morbid nature of these statements.) She also claimed again + that all along she "saw shadows on the wall," "scenes from + Heaven and Earth," "shadows of dead friends laid out for + burial." She had insight into the hallucinatory nature of + these visions. Sometimes she thought she was dead also. She + claimed that she began to feel better when these shadows + stopped appearing in June (the actual time of her + improvement). + + She was discharged recovered a month later, after having + been sent to another ward. + +In this case, then, we find that the two months of stupor were ushered +in by a brief state in which, in addition to the usual inactivity, there +was a certain bewilderment, increased by questions, while the +orientation which in the preceding manic state had been good became +seriously interfered with. The psychosis bordered on deep stupor for +brief periods when the inactivity seemed to be complete or she lay in +bed with her head raised from the pillow. On the other hand, there were +occasional sudden spells of free activity even with a certain elation. +She could often be persuaded to answer questions or to write, the +slowness of this spoken or written speech varying considerably. Her +replies revealed the fact that she was essentially affectless and that +her intellectual processes were interfered with, even to the extent of +paragraphic writing. We have, therefore, here again features similar to +those of the preceding cases. In addition we must add as important that +this patient said retrospectively that she thought she was dead, that +she saw "shadows from Heaven and Earth," "shadows of dead friends laid +out for burial," all this without any fear. We shall see later that this +is a typical stupor content. + +We will here include state 3 of Anna G. (See Chapter I, Case 1) who +after the pronounced stupor was for two months merely dull, somewhat +slowed and markedly apathetic. Although her orientation was not +seriously affected, there was considerable interference with her +intellectual processes, as shown in her wrong answers or her lack of +answers when more difficult questions were asked. + +A similar picture was presented in state 2 of Mary D. (See Chapter I, +Case 4.) Here, to be sure, there were more marked stupor features in +that the patient wet and soiled, in addition to occasional spells when +she lay with her head raised. But she spoke and acted fairly freely +(even while soiling). By her replies she showed a considerable +intellectual inefficiency, although, like Anna G., her orientation was +not seriously disturbed. Here again there was complete affectlessness. + +This gives us, therefore, five states which may be analyzed for the +symptoms of partial stupor. The pictures of all five are unusually +consistent. There is inactivity, marked but not complete; poverty of +affect without perfect apathy; and a marked interference with the +intellectual processes. The last can be studied better than in the deep +stupors because these partial cases are more or less accessible to +examination. There is a tendency for the patient to think much of death +either in the onset or during the psychosis. Negativism seems much less +prominent than in the deep stupors. + +A natural criticism is that these cases merely had retarded depressions. +Although this topic will be discussed fully in a later chapter, two +differential characteristics should be mentioned now. First, depression +is a highly emotional state in which the sadness of the patient is as +evident from his facial and vocal expression as from what he says, while +these stupor reactions are by observation and confession states of +indifference. Secondly, there is no such disturbance of the intellectual +processes in depression as is here chronicled. Let the retardation once +be overcome so that the will is exercised and no real defect is +demonstrable. In our experience the cases of apparent depression with +intellectual incapacity are found on closer study to be really stupors +as other symptoms show. + + + + +CHAPTER III + +SUICIDAL CASES + + +An important "catatonic" symptom is a tendency to sudden, impulsive, +unexplainable acts. Such actions occur occasionally in benign stupors +and, since we attempt an understanding of the reaction as a whole, an +effort should be made to study these phenomena as well. The cases chosen +showed persistent, quite affectless, yet very impulsive attempts at +self-injury. They characterized the first of the three cases throughout, +were present in one stage (the second) of the second patient, while in +the last for one day there was behavior which can be similarly +interpreted. + +Mention has been made of the prominence, approaching universality, of +the death idea in stupor. This is a subject to be discussed in length +presently, but for the present we may say that there may be a delusion +of death with dramatization of that state or a mere abandonment of the +mental activities of life. It is but a step from corpse-like behavior to +suicidal attempts, psychologically speaking, yet this transition +necessarily modifies the clinical picture, since one necessitates +inactivity and the other activity. Secondarily, other atypical clinical +features appear, as will be seen. + + + CASE 9.--_Pearl F._ Age: 24. Admitted to the Psychiatric + Institute July 26, 1913. + + _F. H._ A paternal aunt was insane. Both parents died long + ago; the mother when the patient was a baby; the father + when she was a girl. She came to this country when 17. In + this country she had generally been a domestic. An older + brother and sister were also in America. + + _P. H._ She was described as sociable, good-natured, bright + enough, not inclined to be depressed. She had little + education. There was no former attack. + + Four months before admission, the patient did not + menstruate but was said not to have worried about this. A + month later she began to show symptoms. She said she did + not want to live, had done something wrong but could not or + would not say what it was. Again she said a young man was + going to sue her, a young Jewish fellow whom she had seen + only a few times. She talked of turning on the gas. She + also complained that people were looking at her and that + the food was poisoned. + + The patient after recovery gave the following version of + the onset: She had a position on 99th St. for 2-1/2 years. + She liked the people there and often went to see them + later. Her next position was in the Bronx. She was there + for nine months. In the same house lived "Harry." After the + work she used to talk to him in the yard and, after she + left, she used to think of him and long for him. But she + denied, with a very natural attitude, that she worried + about him at the beginning of her psychosis. After the + position in the Bronx she went to one on 96th St., where + she was for four months. In the same house was a girl whom + she liked and who was lively. When she left, the patient + left too. This was a month before the psychosis began. When + she left there, she got word that her employer on 99th St. + had developed consumption and had to go out West, but did + not worry over this news, she claimed. She looked for + another position and had one for two weeks, but felt + lonely, did not care to live. Then her sister took her to + her home. She thought people were looking at her and were + making remarks because she was not working. During this + time she had a dream one night in which her dead mother + appeared to her (in ordinary street clothes) and said to + her that she (the patient) "was going away." She woke up + frightened. She was worried, thought she had not prayed + enough for her mother, and asked her sister to pray also + and to give money to the poor. She did not recall, or at + any rate denied, speaking of the young man suing her. + + She was then taken to a _private sanatorium_, where she was + for two months preceding her admission to this hospital. + There she was described as quiet, mute, tube-fed, + resistive. + + When well, the patient said that in this sanatorium she was + first spoon-fed, cup-fed, later tube-fed, "I used to be + scared of them, they used to put a spoon way down my throat + and I had no appetite--I did not like them around me, they + were mean to me. They used to let me stand without clothes, + used to spite me." "If I did not want to dress myself, they + used to hit me." "I used to feel lonesome for home and I + imagined my people were there and that my sister passed the + place without stopping." She was afraid of the nurses, + thinking they wanted to kill her. + + At the _Observation Pavilion_ the patient was described as + dull, but brightening up under examination. She made few + spontaneous remarks, but in answer to questions said she + was melancholy, tired of life, because she was in love with + a Gentile fellow who refused to marry her. She also said "I + get peculiar thoughts that I am going to die." + + _Under Observation:_ The patient's condition lasted for + about two years. Much of the time she lay in bed, often + with the covers pulled over her, sometimes with her legs + drawn up, again in a more natural, comfortable position, or + she sat up with her head bowed. She obeyed almost no + commands. For months she soiled and wet herself, but never + drooled. For a time she refused food consistently, lost + flesh and had to be tube-fed. For the most part she said + very little and, when one accosted her, she was apt to turn + away. A few times, when further urged, she swore at the + examiner. There was also persistent marked resistance + towards any interference, sometimes merely passive or quite + often, especially at first, with wriggling or severe + scratching of her own body. There was often with this + evidence of irritation or she moaned. Again she was + described as quite affectless. One of the most striking + features throughout a large part of the course were her + suicidal attempts. She would try to strike her head against + the iron bedpost, throw herself out of bed, throw herself + about generally, try to strangle herself with the sheets, + try to pull out her tongue, all of which seemed to be done + with great impulsiveness. Almost her only utterances had to + do with death. She said she wanted to die, wanted to drop + dead, did not want to live, wanted to kill herself, that + she did not eat because she wanted to die. When once she + was found tossing about and was asked whether she worried, + she said "I know I am going to die." (You mean you will be + killed?) "I don't care." + + There were a few episodes which still have to be mentioned. + Quite early in the course of the stupor, when she was + restless, scratching herself and moaning, she once spoke + quite freely. She said "Give me that fellow (Harry), I + don't care, I can't help it. I must have him, even if it + costs me my life." "I would feel happy if I could get him. + O God, I love him--I will never get him even if I drop + dead, I know I won't get him, the darling" (cries). (What + if you did get him?) "I know I would lose him again." Then + with shame she claimed she had had sexual relations with + him (when well, denied). At the same interview, when the + doctor sneezed, she said "Gesundheit." In June, 1914, she + was seen smiling at times. But the first was the only + episode when she spoke more freely, and the two occasions + the only ones when she showed a frank affect. + + The improvement commenced in April, 1915. Although still + very inactive, she sometimes began to laugh and sing and + talk a little to other patients. She also answered a few + questions on April 22, 1915. Thus, when asked whether she + wanted to go home, she said "No, I want to stay here." (Do + you like it here?) "Yes" (smiles), "I can't get no other + place; I have got to like it here." She smiled freely. To + orientation questions, she knew the place, month, but not + the year. + + She continued inactive and above all diffident, but + improved steadily and, when examined by the writer on + November 15, she made a very natural impression and gave + the retrospective account of the onset embodied in the + history. She was quite frank, thanked the doctor for the + interest he took in her case, and said for example, "You + know I never thought I would get well. I quite gave up--I + am very glad I am well now." + + When questioned about her stay here, the patient evidently + remembered much. She was able to say which wards she had + been in and approximately how long she had been in each + one. She claimed that at first it "seemed strange." "I did + not eat, I did not want to eat, I used to tell them to + poison me and that I wanted to die, I was _disgusted_, I + thought I would never go home." She also says she felt + _angry_, wanted to kill herself. She bit and scratched + "because I was nervous." She remembered talking about + Harry, "I said I was in love with him, I thought I wanted + to die because I could not have him." She also talked of + having been _stubborn_. Sometimes she felt like running to + the river. She also claimed she imagined people were false + to her. + + In one of the wards she said she thought people were there + on her account, were waiting for her death. She did not + care for a time whether she died or not. She knew she tried + to choke herself occasionally. Asked how she behaved, she + first said she was quiet. (Were you not restless?) "I used + to get tired and have backache and roll around in bed." She + also felt like running away sometimes, wanted to get out of + bed and wanted to walk about. (What about going to the + river?) "I used to say that." She claimed not to have been + mixed up at any time and to remember everything. Remarkable + is the fact that she claimed she _did not worry at all_, + "_I felt I was lost and would not worry._ I used to worry + at home and at Dr. M.'s (the private sanatorium) but not + here. Here I never worried, I did not care where I went." + She said she did not talk because she was bashful in the + presence of doctors, sometimes she felt afraid of them, + afraid they would kill her, put poison in her food when + they fed her. "When my people came, I said I did not want + to live, wanted to kill myself. I used to cry." Again asked + why she did not talk, she admitted she really did not know. + Once she said she was bashful because she soiled her bed. + She did not want to go to the closet because she was afraid + of the nurse. She denied hearing voices. + +In addition to the activity incidental to her attempts at self-injury, +this patient showed an unusual degree of resistiveness and with this +some affect, for she appeared to be irritated and at times moaned. Still +more unusual were the appearances of delusions not associated with +death but with a vivid form of life, namely, a love affair. Occasionally +she spoke of her imaginary lover "Harry." Another atypical feature was a +fair memory for the period when she was in stupor. She claimed to +remember much of her movements and this claim was substantiated by her +answers to questions after recovery. + + + CASE 10.--_Margaret C._ Age: 23. Single. Admitted to the + Psychiatric Institute November 13, 1913. + + _F. H._ Heredity was absolutely denied. The mother is + living and made a natural impression. The father died at + 65, nine months before patient's admission, of cardio-renal + disease. Two brothers and one sister died of acute + diseases. One sister died in childbirth. Three brothers and + one sister were said to be well. + + _P. H._ The patient was bright and passed successfully + through high school. For seven years prior to the psychosis + she worked for the same company as clerk. She was described + as efficient, conscientious, systematic, though sometimes + upset by her work; as lively, talkative, cheerful, with + somewhat of a temper and easily hurt, also as quite + religious. She was more attached to her mother than to her + father, but still more to her older sister, whose death + precipitated her psychosis. She never had any love affair + and was said not to have cared for men. Two months before + admission, when her favorite sister was confined, the + patient was quite worried about her, but relieved when she + heard good news. A few hours later, however, the sister + died suddenly. When the patient learned of the sister's + death, she screamed, and screamed several times at the + funeral. She did not cry, said she could not. After this + she slept poorly, seemed nervous, went to church more, but + there was no other change. She continued to work and, + according to the employer, worked well. + + Nine days before admission she would not get out of bed in + the morning, said little and refused food. A few days later + she was induced to take a walk, but she seemed to have no + interest in anything. When she talked at all it was about + her sister and of wanting to go to a convent. When asked + to do anything she said she would if it were God's will. + She did not menstruate after her sister's death. When + practically recovered, the patient attributed her breakdown + to this tragedy. She added to the description above given + that, soon after losing her sister, she had a fright at + home. "It was the house in which my father died and one day + when I was in bed I thought somebody came in." But she + denied a vision and could not further explain. + + At the _Observation Pavilion_ she was very inactive, so + that she had to be fed and cared for in every way, mute, + often covering her head with a sheet, turning away when + questioned and resistive when the physical examination was + attempted. But at times she smiled or laughed. + + _Under Observation:_ 1. For two months the patient was + generally inactive, sometimes lying in bed with her eyes + tightly closed, or with her face covered by the sheets or + buried in the pillow; or she sat inactive, staring, or with + eyes closed, or her head buried in her arms. On one visit + she had to be brought into the examining room in a wheel + chair and lifted into another seat. A few times she was + observed holding herself very tense with her head pressed + against the end of the bed. But this inactivity was often + interrupted by her going quickly into various rooms to + kneel down, though she was never heard praying. Or she ran + down the hall for no obvious reason. Or, again, she was + found lying on the floor face down. She ate very poorly and + had to be tube-fed a considerable part of the time. When + this was done, she sometimes resisted severely, as she did + in fact most nursing attentions. Thus she soon began to + struggle when her hair was combed. She also resisted being + taken to the toilet or being brought back. She did not soil + or drool, however, but sometimes seemed to be in + considerable distress before she finally literally ran to + the closet. This resistance just spoken of consisted + chiefly in making herself stiff and tense. Sometimes at the + feeding she pulled up the cover when preparations were made + and held to it tightly. Quite striking was the fact that + with such resistance she sometimes, though by no means + always, laughed loudly, as she did occasionally when she + was talked to, or even without any external stimulation. + This laughter always was one of genuine merriment and quite + contagious, and by no means shallow or silly. + + Usually the patient was totally mute. The exceptions + occurred mostly when her resistance was called forth. Thus + one day when fed she said, "I wish you people would have + more to do," or on another occasion, when she had resisted + being brought into the examining room, she said, "I will + get out of here if I break a leg." But once when the nurse + accidentally tickled her, she said, "Since I am ticklish, I + must be jealous--I should worry." She also answered very + few questions and such responses as she made were chiefly + expressions of resentment. Thus, when one kept urging her, + she finally would say "stop," or after much urging "I am + going to hurt you pretty quick." Sometimes she said "Go + away," or "Let me alone." She was just as silent with the + mother and the priest as with the physicians. On one + occasion she told the nurse that the priest had told her to + talk to the doctors, but that she had nothing to say. + Sometimes she did not even look at the visitors, but turned + away from them, as she did from the physicians, but at one + visit from a priest, though she scarcely said anything, she + held on to him when he was about to depart and would not + let him go. Throughout this period, since scarcely any + answers were given, nothing was known about her + orientation, except when on admission she gave a few + answers. She then thought she was at the Observation + Pavilion, seemed unable to tell even that the physician was + a doctor, but knew the date. When asked how she came to + Ward's Island, she said "By ambulance." The physical + condition presented nothing of note, except for a certain + sluggishness of the skin with marked comedones. + + 2. By _January_, 1914, the picture changed somewhat and she + then presented the following state for an entire year: The + mutism persisted and indeed became even more absolute, and + she began to wet and soil constantly. This commenced as + what seemed to be an act of spite as a part of her + resistiveness, for the first time she soiled she seemed to + do it deliberately when the nurses insisted that she allow + them to put on a dress. Later this explanation no longer + held. Tube-feeding too was for the most part necessary, the + resistiveness continuing as before. But the inactivity was + broken into much more than before by constant impulsive + attempts to hurt herself in every conceivable way--by + bumping her head against the wall, putting her head under + the hot water faucet, trying to pound the leg of the + bedstead on her foot, striking herself, pinching her + eyelids, pulling out her hair, trying to pick her radial + artery, throwing herself out of bed, knocking her head + against the bed rail, etc. This was done in silence but + with what appeared a great determination that occasionally + showed itself in her face. She also sometimes scowled and + frowned. With the difficulty in feeding her and the + constant impulsive excitement in which bruises could not + always be avoided (once an extensive cellulitis developed + in the arm which had to be lanced), the patient got weak, + emaciated and exhausted; much of her hair fell out, + although some she pulled out. It should be stated that + during this entire impulsive state she could not be taken + care of in the Institute ward, but was sent to a special + ward in the Manhattan State Hospital, where suicidal + patients are under constant watch. These impulsive attempts + at self-injury lessened only towards the end of the period. + Her laughter, which had been such a prominent trait, + disappeared almost entirely during this entire phase. With + all this, the general resistiveness, as has been stated, + remained towards feeding or any other interference. It was + only in the beginning associated with laughter as in the + previous stage. + + Although there were, as a rule, no spontaneous remarks and + no replies, she on one occasion said spontaneously, + probably referring to her unsuccessful attempts to kill + herself: "I can't do it, I have no will." During the same + period she once said: "I don't want to eat, I don't want to + get well, I want to do penance and die." + + By _January_, 1915 (i.e., a year after the second phase had + commenced), she began to dress herself and eat, and also + became clean. But she remained for the most part very + inactive, sitting stolidly about all day and still without + interest in her environment. The impulsive attempts at + killing herself disappeared. Although she remained for + months to come still inactive, she gradually began to talk + a little, began to play a little on the piano, but said + little to any one. + + By _August_, 1915, she still was inactive, shy, standing + about, or sitting picking her fingers, occasionally going + to the piano, but evidently unable to finish anything. She + had to be coaxed to come to the examining room and talked + in a low tone. Often she commenced vaguely to speak and + then stopped and could not be made to repeat what she had + been saying. Affectively she was remarkably frank, + sometimes a little surly, or she showed a slight empty + uneasiness. She could, however, be made to laugh heartily + at times, or did so spontaneously on very slight + provocation. + + Some of her utterances were in harmony with her apparent + indifference. It was difficult to get her to say how she + felt even when thorough inquiries were made. Once she said, + when asked about worrying, "I don't worry," or again "I get + angry sometimes," or "I used to worry about my health, I + don't now," or, when asked what her plans were, she said + directly: "I don't care what happens." Again she said "I + guess I am disagreeable," or "I guess I am a crank." + Another interesting indication of her state was expressed + in her repeated statement, "I don't know what I want." But + she was oriented in a way, though not sure of her data. She + would give most of her answers with a questioning + inflection, "This is the Manhattan State Hospital, isn't + it?" or she would say, "I don't know exactly where I am, + it's Ward's Island, isn't it?" and in the same way she gave + the day, date and year correctly. But she did not know the + names of the physicians. At that time she could give many + data about her family correctly, but was slow, even if + correct, in calculation, and, though she got the gist of a + test story, she left out some important details. + + A retrospective account at that time showed she was + uncertain about the Observation Pavilion, that she was not + certain how she came to Ward's Island, "On a boat, I + believe." It was clear that she did not remember the + admission ward, about the Institute ward (in which she had + been for the first two and a half months and in which she + was again examined); she said it was familiar to her, but + she was not certain that she had been in it. About the + physician who saw most of her in these first two and a half + months, she said that his voice seemed familiar, and she + asked him whether he had tube-fed her (she had been + tube-fed by him many times), but she again said, "No, you + are not the one," and described as the man who had fed her + the one who did it on the second ward where she was for a + year. But she knew that she had been sent to the second + ward, because she constantly tried to injure herself. These + injuries she recalled but was unable to say why she + attempted them, "I suppose I didn't know what I was doing." + She claimed she heard voices and had "all sorts" of + imaginations, but could not be gotten to tell about them. + When it was difficult for her to give an answer, she was + apt to keep silent and then could be prodded without much + success. + + In _October_, 1915, there was further improvement, inasmuch + as she began to converse some with other patients, played + the piano and seemed able to carry a piece through. She was + put in the occupation class and did quite well. At the + interview with the physician she was still apt to laugh + boisterously at slight provocation. Even now she had great + difficulty in describing her condition and at the + examination was often still quite vague. Thus, when asked + how she felt, she said, "I do know I feel + ridiculous--sometimes I feel kind of angry--I don't + know--they say I am crazy but I am not, but I am hungry--I + don't know whether I am or not, I don't know what I can do + well," etc. This is quite characteristic. When asked + whether she was worried, she said: "I don't know, am I + worried?--yes, a little sometimes, I am to-day--I am so + untidy--don't know what is the matter with me." Again: + "Sometimes I lose my speech--I can't say what I feel, I + don't know what it was." Later, half to herself: "I don't + know what is the matter with me--I don't care anyway." + + In _December_, 1915, there was still further improvement, + and on the ward and in superficial conversation she made, + towards the end of the month, in many ways a natural + impression, though the laughter before described was still + somewhat in evidence. It usually came not without occasion, + but was, as a rule, quite out of proportion to the + stimulus. She again said she could not explain why she + tried to injure herself, claimed she did not feel it, and + even claimed she did not remember doing it in the Institute + but only in the second ward. + + The defect in thinking which still remained is very + difficult to formulate. She was now entirely oriented, no + longer with any hesitation about the correctness of her + information. She subtracted 7 from 100 very quickly and + could from memory write a long poem, but there was a + certain vagueness about her which partly may have been due + to a still existing indifference. This vagueness consisted + chiefly in a difficulty of attention or in her capacity to + grasp fully what was wanted. It is best illustrated by a + few examples: After she had been asked about the _onset_ of + her sickness and she had said that what was on her mind + then were prayers for the salvation of her relatives, she + was asked exactly when it was that she thought of this; she + answered "Now?" (What period were we talking of, the + present or past?) "The present." (What did I ask you?) + "About this period of my sickness." (Which one?) "What + sickness?" She said herself at this point, "I am rather + stupid" (quite placidly). Or again she said she did not + know why she pounded her head, but finally said, "To get + better and go home." (Do you think if you pounded your head + against the wall you would go home sooner?) "I don't + know--maybe." (How would it help you?) "You mean to go to + the city?" (Yes.) "I don't know." Again when asked how her + mind worked, she said, "Pretty quickly sometimes--I don't + know." (As good as it used to?) "No, I don't think so." + (What is the difference?) This had to be repeated several + times, at which she said, "There is no difference." (What + did I ask you?) "The difference." (The difference between + what?) "You did not say." Equally striking was the fact + that when she was jokingly told "If it snows to-night, we + shall have a black Christmas," she did not grasp the + absurdity at once, but in a rather puzzled way asked, + "Why?" + + She was then discharged on parole, two years and one month + after admission. Soon after discharge her menstruation, + which had been absent throughout her psychosis, returned. + On her discharge she had regained her normal weight, and + during the two subsequent months gained fifteen pounds. + + She then recovered completely, so that three months after + discharge she made a very natural impression. She said, on + looking back over her state with impulsive excitement, that + she constantly had the idea that she wanted to punish + herself, but that _she did not know why_, and did not think + she was sad or worried. + +Considering only the second phase of the psychosis, this deep stupor +showed many interruptions, due not merely to her suicidal efforts but +also to her resistiveness. The condition, too, was not so completely +affectless as one expects a deep stupor to be. In the first stage there +was much sudden laughter, reminding one of dementia praecox (except for +its never being shallow or silly) and this persisted into the first part +of the second phase. The actual attempts at self-injury brought out +emotion, for with them she scowled and frowned as well as showing +considerable energy. + +To these may be added the following case. It is not unlike the ordinary +stupor in the fact that there was intense inactivity and mutism with +great tenseness. The remarkable trait was, however, that for a whole day +she forcibly held her breath until she got blue in the face. The case in +detail is as follows: + + + CASE 11.--_Rosie K._ Age: 18. Admitted to the Psychiatric + Institute January 24, 1907. + + _F. H._ Both parents were living. The father was a loafer. + Nine brothers and sisters were said to be well, with the + exceptions of one brother who had an irritable temper, and + of a markedly inferior sister. + + _P. H._ The patient was a Galician Hebrew, a shirtwaist + operator. Not much was known about her make-up, but it is + certain that she was a bright girl. The patient herself + said after recovery that her father was nagging her + constantly with complaints that she was not making enough + money, although he himself did not work and she contributed + much to the support of her family. She disliked him very + much and claimed that all her relatives worried her, except + her mother. + + Nine weeks before admission a messenger came into the shop + where she worked and said, "Rosie, your father is dead" + (the message was intended for a fellow worker). In spite of + the fact that the matter was explained, she was upset and + nervous enough to be taken home. Though she continued to + work for over two weeks, she worried over many trivial + matters and talked much about this. She also said that + everything looked queer at her home and complained of + having difficulty in concentrating her mind. Finally she + became elated and talkative. Nothing is known of any + special ideas. + + At the _Observation Pavilion_ she appeared to be typically + manic. + + Then she was sent to an institution where she remained for + six weeks. The report from there stated that she was for + ten days "elated, excited, talkative, with flight of + ideas." Then her condition suddenly changed to a marked + reduction of activity, in which she neither spoke + spontaneously nor answered questions. She "appeared to + sleep," but was said to have talked to her people. When + interfered with, she was resistive and sometimes let + herself fall out of bed. On the other hand, she + occasionally wandered about at night. It should be added + that during the stupor an alveolar abscess developed which + discharged pus. It was washed out and healed. + + Then she was sent to the Manhattan State Hospital and + admitted to the service of the Psychiatric Institute. + + _Under Observation:_ 1. On the first day she lay in bed + with cyanotic extremities, weak pulse, grunting, moaning + and not responding in any way when examined. After this the + moaning and grunting ceased and she was essentially + indifferent, and for the most part kept her eyes closed. + Often she wet and soiled herself. She was resistive to any + care or examination. She would not eat, as a rule, but + again gulped down milk offered her. For a considerable time + she had to be tube-fed. During the early part of this + stupor she once took a paper from the doctor, examined it, + and then gave it back without saying anything, or again she + peered around silently, or asked to go home, or again, on a + few occasions, answered a question or two or spoke some + unintelligible words. Orientation could not be established. + + 2. After a few weeks she became more rigid, a condition + which continued for six months. She let saliva collect in + her mouth, and drooled. She had to be tube-fed. She lay + very rigid, with very pronounced general tension, with her + lips puckered, hands clenched, sometimes holding her eyes + tightly closed, and often with marked perspiration. For one + day she held her breath until she was blue in the face. On + the same day she was extremely rigid, so that she could be + raised by her head with only her heels resting on the bed. + Her eyes were tightly shut and she was in profuse + perspiration. Sometimes she interrupted this by a deep + breath, only again to resume the forcible holding of her + breath. On another day towards the end of the period, while + quite stiff, she kept grunting and screaming "murder." The + soiling continued. She never spoke. + + _Physical condition during the stupor:_ At first she had a + coated tongue, foul breath and a fetid diarrhea. The latter + was treated with high colonic flushing and mild diet. Urine + normal--gynecologically normal. General neurological and + physical examination not possible. At the same time she had + for two weeks a temperature which often reached 100 deg. or + a little above, a weak, irregular but not rapid pulse, a + leucocytosis of 17,500 and 80% hemoglobin. When she began + to refuse food and before she was tube-fed regularly, she + twice had syncopal attacks and lost considerable flesh + which was gradually regained under tube-feeding. After the + diarrhea she was habitually constipated. Cyanosis of the + extremities seemed to have been present only at first. + + 3. Six months after admission she began to make very free + facial movements--winking, raising the eyebrows--and soon + developed an excitement with marked elation. She had to be + kept in the continuous bath, talked continuously, whistled, + sang, was markedly erotic towards the physician, careless + in exposing herself and often obscene in her talk. Most of + her productions were determined by the environment. She was + therefore quite distractible, very alert; sometimes she was + meddlesome, again irritable, irascible. The following + illustrates her productions: "Send for my husband, S.--He + had one sister as big as that. She likes candy.... My + father is underneath and my mother is on top because she is + fat and he is skinny.... Wait till the sun shines, + Nellie--we will be happy, Nellie--don't you sigh, + sweetheart, you and I--wait till the sun shines by and + by.... Come in (as noise is heard)--I bet that is my + husband--my name is Regina K. (mother's name)--my mother's + name is the same--I got a little sister named Regina--she + is my husband." When she heard the word pain, she said, + "Who says paint, Pauline used paint, I used paint," etc. + + Towards the end of August she had pneumonia, which did not + change her condition. + + By October she was well, having gradually settled down. She + had good insight. + + _Retrospectively:_ She laid very little stress on the false + report of the father's death. She claimed to remember being + at the Observation Pavilion, but to recall very little of + the other hospital. Unfortunately an inquiry was not made + regarding her memory during the stupor period under + observation with the exception of the fact that she said + she wanted to die and therefore refused food. + + She was seen in March, 1913, appeared perfectly well, and + stated she had been well during the entire interval. + +If this forced holding of the breath had been the only anomaly, one +would, perhaps, not be justified in drawing any conclusions as to its +significance. But the deep stupor was interrupted again for a day by +grunting and screaming of "murder." This is certainly indicative of a +compulsive death idea and retrospectively she spoke of having refused +food in order to die. The latter seems to indicate some connection +between her negativism and death. Consequently, even if we regard the +breath holding as resistiveness, it would still be related to her idea +of dissolution. Her negativism went beyond ordinary limits in that it +affected the expression of the face. + +When we consider these three cases together, we see that what would +otherwise have been deep stupors with profound inactivity, were modified +by activity in two directions: suicidal and resistive. Presuming that +the symptoms of stupor are all interrelated, we can see a reason why the +affect should also have been altered. When one is modified, this should +influence the other. When the activity is increased, the emotional +concomitants of impulsive acts tend to break through as well. Hence the +changes observed in these cases in facial expression and tone of voice. +It is noteworthy, too, that all three showed a tendency for laughter to +appear, as if, the emotions once stirred, it was possible for them to be +exhibited in other than unpleasant forms. So, too, it was possible for +ideas unrelated to the stupor picture, such as those of lovers, to occur +sporadically. Finally, since activity must imply some contact with +environment, the first of these cases at least showed less interference +with the intelligence than is usual. In general, one may conclude that +any aberration from the pure type of stupor tends to allow other +impurities to appear. + + + + +CHAPTER IV + +THE INTERFERENCES WITH THE INTELLECTUAL PROCESSES + + +This is one of the most interesting and important of the stupor +symptoms. We are accustomed to think of the functional psychoses having +symptoms to do with emotions and ideas in the main, and, conversely, +that disorientation, etc., observed in such cases is merely the result +of distraction, poor attention or cooperation. But in stupor the deficit +in understanding, incapacity to solve simple problems and failure of +memory seem deep-rooted and fundamental symptoms. So far is this true +that Bleuler[5] looks on "schizophrenic" cases with this symptom of +"Benommenheit" as organic in etiology. It may be said at the outset that +we do not share this view for many reasons. One at least may now be +stated as it seems to be final. In benign stupor purely mental stimuli +may change the whole clinical picture abruptly and with this produce a +change in the intellectual functioning such as we never see in organic +dementias or clouded states. We find it more satisfactory to attempt a +correlation of this with the other symptoms on a purely functional +basis, as will be explained later. + +For the study of the interferences with the intellectual processes +during stupor reaction, we have two sources of information: The first is +derived from the account which the patient is able to give in regard to +what he remembers as having taken place around him or in his mind during +the stupor period; the second is the direct observation of partial +stupor reactions. + + +1. Information Derived from the Patient's Retrospective Account + +We will start with the cases of marked stupor mentioned in Chapter I. +Anna G.'s (Case 1) psychosis commenced at home, and under observation +lasted with great intensity for five months. She remembered only vaguely +the carriage going to the Observation Pavilion, had no recollection of +the latter, nor of her transfer to the Manhattan State Hospital and of +most of the stay at the Institute ward, including the tube- or +spoon-feeding which had to be carried on for four months. She also +claimed that she did not know where she was until four or five months +after admission. She was amnesic for her delusions and hallucinations. +Of Caroline DeS. (Case 2) we have no information. Of Mary F. (Case 3), +whose stupor began at home and under observation lasted two years, we +find that she had no recollection of coming to the hospital, what ward +she came to, who the doctor and nurses were (with whom she became +acquainted later), in fact she claimed that for about a year she did +not know where she was. But she remembered having been tube-fed (this +took place over a long period). Mary D.'s (Case 4) stupor also commenced +at home, and under observation lasted for three months. She had no +recollection of going to the Observation Pavilion, of the transfer to +Manhattan State Hospital, and of a considerable part of her stay here, +including such obtrusive facts as a presentation before a staff meeting, +an extensive physical and a blood examination, and she claimed not to +have known for a long time where she was. Annie K.'s (Case 5) stupor +commenced at home. Although she recalled the last days there and some +ideas and events at the Observation Pavilion, the memory of the journey +to Ward's Island was vague, as was that of entrance to the ward, and she +claimed not to have known where she was for quite a while. Specific +occurrences, such as the taking of her picture (with open eyes two +months after admission), an examination in a special room, her own +mixed-up writing (end of second week) were not remembered. But it is +quite interesting that an angry outburst of another patient within this +same period, which was evidently not recorded, is clearly remembered. + +We shall later show that when the patient comes out of a stupor the +condition may be such that, for a time at least, retrospective accounts +are difficult to obtain. It must also be remembered that not +infrequently the more marked stupors may be followed by milder states, +and it is important, if we wish to determine how much is remembered, +not to confuse the two states or not to let the patient confuse them. +For example, Mary D. (Case 4), who showed two separate phases, while she +claimed not to know of many external facts, also added that she could +not understand the questions which were asked. From observation in other +cases it seems that in marked stupor any such recollection about the +patient's own mental processes would be quite inconsistent. We have to +assume, therefore, that this remark referred in reality to the second +milder phase, for which, as we shall see, it is indeed quite +characteristic. It is not necessary to burden the reader with other +cases, all of which consistently gave such accounts. + +We see, then, that in the marked stupor the intellectual processes are +regularly interfered with, as evidenced by almost complete amnesia for +external events and internal thoughts. In other words, this would +indicate that the minds of these patients were blank. Inasmuch as direct +observation during the stupor adduces little proof of mentation, we may +assume that such mental processes as may exist in deepest stupor are of +a primitive, larval order. + +Before we examine more carefully the milder grades of stupor, it will be +necessary to say a few words about the retrospective account which the +patient gives of intellectual difficulties during the incubation period +of the psychosis. As a matter of fact, we find that these accounts are +remarkably uniform. While some patients, to be sure, speak of a more or +less sudden lack of interest or ambition which came over them, others of +them speak plainly of a sudden mental loss. Mary. C. (Case 7) claimed +she suddenly got mixed up and lost her memory. Laura A. spoke at any +rate of suddenly having felt dazed and stunned. Mary D. (Case 4) said +she felt she was losing her mind and that she could not understand what +she was reading. Maggie H. (Case 14) began to say that her head was +getting queer. We see from this that the interferences with the +intellectual processes may in the beginning be quite sudden. + +In some instances a more detailed retrospective account was taken, which +may throw some light upon the interferences with the intellectual +processes with which we are now concerned. Emma K., whose case need not +be taken up in detail, had a typical marked stupor which lasted for nine +months, preceded by a bewildered, restless, resistive state for five +days. She was in the Institute ward for the first four months, including +the five days above mentioned; later in another ward. When asked what +was the first ward which she remembered, she mentioned the one after the +Institute ward, and when asked who the first physician was, she +mentioned the one in charge of the second ward. However, when taken to +the Institute ward, she said it looked familiar, and was able to point +to the bed in which she lay, though somewhat tentatively. The same +rousing of memory occurred when the first physician, who saw her daily, +was pointed out to her. She remembered having seen him, and then even +recalled the fact that he had thrown a light into her eyes, but +remembered nothing else. This observation would seem to show that with +some often repeated or very marked mental stimuli (throwing electric +light into her eyes) a vague impression may be left, so that it may at +least be possible to bring about a recollection with assistance, whereas +spontaneous memory is impossible. In another instance, the patient was +confronted with a physician who had seen a good deal of her. She said +that he looked familiar to her, but she was unable to say where she had +seen him. Here then again evidence that a certain vague impression was +made by a repeated stimulus. + +Another feature should here be mentioned, namely, that isolated facts +may be remembered when the rest is blank. We have seen above that Annie +K. (Case 5), while very vague about most occurrences, recalled a sudden +angry outburst in detail. Another patient, though the period of the +stupor was a blank, recalled some visits of her mother. At these times, +as she claimed, she thought she was to be electrocuted and told her +mother so, "Then it would drop out of my mind again." These facts are +very interesting. We can scarcely account for such phenomena in any +other way than by assuming that certain influences may temporarily lift +the patient out of the deepest stupor. In spite of the fact that stupors +often last for one or two years almost without change, a fact which +would argue that the stupor reaction is a remarkably set, stable state, +we see in sudden episodes of elation that this is not the case, and +other experiences point in the same direction. A similar observation was +made on a case of typical stupor with marked reduction of activity and +dullness. A rather cumbersome electrical apparatus (for the purpose of +getting a good light for pupil examination) was brought to her bedside. +Whereas before, she had been totally unresponsive, she suddenly wakened +up, asked whether "those things" would blow up the place, and whether +she was to be electrocuted. During this anxious state she responded +promptly to commands, but after a short time relapsed into her totally +inactive condition. We have, of course, similar experiences when we try +to get stuporous patients to eat, who, after much coaxing may, for a +short time, be made to feed themselves, only to relapse into the state +of inactivity. + +Such variations are paralleled, as we shall later show, by a suddenly +pronounced deepening of the thinking disorder. We have already seen that +the onset may be quite sudden. All this indicates that, in spite of a +certain stability, sudden changes are not uncommon. Finally, we know +that, in spite of the fact that stupor is an essentially affectless +reaction, certain influences may produce smiles or tears, or, above all, +angry outbursts, which again can hardly be interpreted otherwise than by +assuming that those influences have temporarily produced a change in the +clinical picture, in the sense of lifting the patient out of the depth +of the stupor. All these facts suggest that inconsistencies in +recollection are correlated with changes in the clinical picture. + +As is to be expected, the cases with partial stupors remember much more +of what externally and internally happened during their psychoses. Rose +Sch. (Case 6), who had a partial stupor during which she answered +questions but showed a great difficulty in thinking, said +retrospectively that she felt mixed up and could not remember. Although +she recalled with details the Observation Pavilion and her transfer, she +was not clear about their time relations (how long in the Observation +Pavilion, how long in the first ward). Mary C. (Case 7), whose activity +was not entirely interfered with and who showed some thinking disorder, +said retrospectively that she could not take in things. Henrietta H. +(Case 8), who had a partial stupor, claimed to have known all along +where she was, but that she felt mixed up, that her thoughts wandered +and that she felt confused about people. In the cases where a partial +stupor was preceded by a marked one, such as in phase 2 of Anna G. (Case +1) and phase 2 of Mary D. (Case 4), we have no retrospective account +regarding the partial stupor, because emphasis in the analysis was +naturally laid on the period comprising the most marked disorder. +However, we can gather from the few cases at our disposal that the +patients retrospectively lay stress chiefly on their inability to +understand the situation. + +We finally have to consider the group of suicidal cases. We have +information only in regard to two cases, namely, Margaret C. (Case 10) +and Pearl F. (Case 9). In both of these, we find that a good many things +that happened during the period under consideration were remembered, as +were also the patients' own actions. In Rosie K. (Case 11) we have at +least the evidence that she remembered her own impulses, namely, that +she refused food because she wanted to die. In other words, in these +partial stupors with impulsive suicidal tendencies the interference with +the intellectual processes seems to be moderate, and memory for external +events not markedly affected. + + +2. Information Derived from Direct Observation + +The evidence can best be presented by considering the details of some +cases. + +Rose Sch. (Case 6) was remarkable, in connection with the present +problem, in her unusually poor answers. She either merely repeated the +questions, or made irrelevant superficial replies, or said she did not +know, this even with very simple questions. When better, too, though not +quite well, she showed striking discrepancies in time relations and +incapacity to correct them. It would seem that in this case there was +something more than an acute interference with the intellectual +processes, such as we are here discussing. As a matter of fact, we have +the statement in the history that the patient herself said she was slow +at learning in school and had not much of an education. A congenital +intellectual defect and the attitude which it creates may, however, as +my experience has repeatedly shown me, very greatly exaggerate an acute +thinking disorder. The case, therefore, while it shows us an +unquestionably acute interference with the intellectual processes, does +not give us useful information about its nature. More information can be +gathered from Mary D. (Case 4). Even toward the end of her marked stupor +some replies were obtained chiefly by making her write. When asked to +write Manhattan State Hospital, she wrote Manhatt Hhospshosh, and for +Ward's Island, Ww. Iland. Again, instead of writing 90th Street, she +wrote 90theath Street. These are plainly reactions of the path of least +resistance or, in these instances, of perseveration. Of the same nature +are some of her other replies in writing or speaking. After she had been +asked to write her name, she was requested to add her address, or the +name of the hospital; she merely repeated the name. Similarly, when +asked whether she knew the examiner, she said "Yes," but when urged to +give his name, she gave her own. In the partial stupor at a time when +she knew where she was, knew the names of some people about her, the +year and approximately the date, she made mistakes in calculation and +could not get the point of a test story. Moreover, she failed in +retention tests without there being any evidence of anything like a +marked fundamental retention disorder, such as we find in Korsakoff +psychosis. It seems that these results are best termed defects in +attention, which chiefly interfere with the apprehension of more +difficult tasks. As we shall see later, this seems to be rather +characteristic of these cases. Another point which should be mentioned +is the fact that her reaction to questions which she was unable to +answer (such as matters which referred to her amnesic periods) was +peculiar, inasmuch as she did not only not try to think them out, but +seemed indifferent to her incapacity, simply leaving the question +unanswered. This too, as we shall see later, is characteristic. Laura +A., at a time when she could be made to reply, merely repeated the +question, again a reaction of least resistance. The same patient +sometimes asked, "Where am I?" Mary C. (Case 7) made similar queries. +Although she was at times approximately oriented, she would say, "I +don't know where I am," or "I can't realize where I am," or more +pointedly, "I can't take in my surroundings." She often did not answer +and sometimes seemed bewildered by the questions. Henrietta H. (Case 8) +again showed some defect of orientation and mistakes in calculation, and +above all, marked mistakes in writing (for Manhattan State +Hospital--Manhaton Hotspal). A special feature here is that this +occurred immediately after she had been quite talkative, but suddenly +had relapsed into a dull state. Anna G. (Case 1), during the third phase +of her psychosis, showed the following: Although she was approximately +oriented and answered promptly simple questions; e.g., about orientation +or simple calculation, she, like these other patients, simply remained +silent when more difficult intellectual tasks were required of her +(more difficult calculations); or when she was asked how long she had +been here (which involved data that could not be available to her, owing +to her amnesia); or when questions were put to her regarding her +feelings or the condition she had passed through. On the other hand, she +sometimes gave appropriate replies in the words "yes" or "no," but it +was difficult to say whether these answers did not also represent the +path of least resistance. + +We will finally take up the last phase of Margaret C. (Case 10). +Although she was entirely oriented, there was a certain vagueness about +her answers which is difficult to formulate. She was telling about the +onset of her sickness and said that at that time her mind was taken up +with prayers about the salvation of her relatives. She was asked exactly +when it was that she thought of this and she answered "Now?" (What +period are we talking about?) "The present." (What did I ask you?) +"About this period of my sickness." (Which one?) "What sickness?" She +said herself at this point, "I am rather stupid." Again when asked how +her mind worked, she said, "Pretty quickly sometimes--I don't know." (As +good as it used to?) "No, I don't think so." (What is the difference?) +"There is no difference." (What did I ask you?) "The difference." (The +difference between what?) "You did not say." In this the shallowness of +her comprehension and thinking is well shown, and it seems here again +perhaps justifiable to formulate the main defect as one of attention, +which prevents completion of a complicated process of comprehension. A +feature of further interest in this case is that automatic intellectual +processes, such as those necessary for the writing of a long poem from +memory, were not interfered with. + + +Summary + +In the most pronounced stupor we have evidently a more or less complete +standstill in thinking processes. Practically no impressions are +registered and consequently nothing is remembered except events that +occurred in some short periods when some affective stimulus, or a brief +burst of elation, lifts the patient temporarily out of the deep stupor. +It is impossible to say whether the statement of a complete standstill +has to be qualified. In some stupors repeated environmental stimuli +sometimes make at least a vague impression, so that while spontaneous +recollection is impossible a feeling of familiarity is present when the +patient is again confronted with this environment. This might be an +exception to the dictum of complete mental vacuity, or it may be that +there are somewhat less pronounced stupor reactions. When more is +perceived, there is often a retrospective statement of having felt mixed +up, being unable to take in things, or, directly under observation, the +patient may say, "I cannot realize where I am," "I cannot take in my +surroundings." In harmony with this is the fact that questions often +produce a certain bewilderment. In quite pronounced states in which +some replies can still be obtained, we find that the intellectual +processes may be interfered with to the extent of a paragraphia, i.e., a +remarkably mixed-up writing in which perseveration (one form of +following the path of least resistance) plays a prominent part. This +same principle is also seen in such reactions as the repetition of the +question or the senseless repetition of a former answer. These phenomena +remind us of what we see in epileptic confusions, in epileptic +deterioration and in arteriosclerotic dementia. + +In milder cases difficulties in orientation may be more or less marked; +or there may be incapacity to think out problems, although the +orientation is perfect. The more automatic mental processes may run +smoothly (memory and calculation may be excellent) and there may yet be +a certain shallowness in thinking, a defect of attention (a purely +descriptive term) which is most obvious in the patient's inability to +grasp clearly the drift of what is going on or the meaning of +complicated questions. I am inclined to think that poor results in +retention tests are entirely due to this attention disorder, for we have +no evidence of any fundamental retention defect such as we find in the +totally different organic stupors. From a practical point of view it is +important at this place to call attention to the fact that such mild +changes are particularly seen in end stages. Even when pronounced +negativistic tendencies do not play a prominent role, the patient is +then apt to be silent chiefly as a result of the residual disorder in +the intellectual processes. Still more striking are the conditions which +are on a somewhat higher level and in which the shallowness of the +responses, due to the residual disorder of attention, together with the +last traces of the affectlessness, are apt to create the impression of a +dementia. In such cases the opinion is often held that the patient has +reached a defect stage from which recovery is impossible, whereas a +thorough knowledge of these end stages teaches us that they are not only +recoverable but quite typical for the terminal phases of stupor. + +Considering these data, especially those gathered in the end stages, it +would appear that there is no tendency in this intellectual disorder +associated with the stupor reaction for any special side of mental +activity to be most prominently affected. It looks rather as if it were +a question of a general diminution of the capacity to make a mental +effort which in its different intensities accounts for the symptoms. + + +FOOTNOTES: + +[5] See Chapter XV. + + + + +CHAPTER V + +THE IDEATIONAL CONTENT OF THE STUPOR + + +_Brief survey of the ideas associated with stupor:_ Having thus +described the formal manifestations of the various stupor reactions, it +will now be interesting to see what ideas seem to be associated with +these reactions. It is, of course, impossible to obtain during a +considerable part of the stupor any statement of the patients' thoughts. +We therefore have to depend on their utterances during periods when the +inactivity temporarily ceases, or on the retrospective account which the +patient gives after the stupor has completely disappeared; and as we +shall see, we also may obtain considerable information by studying the +ideas which occur in the period preceding the stupor. These last may be +autogenous delusions or thoughts about actual events which precipitated +the psychosis. + +It is not likely that many observers have a very clear conception about +what sort of ideas to expect. We have, as a rule, not been in the habit +of paying much attention to the content of delusions, hallucinations, +and the like. So far as we could judge, therefore, the ideas expressed +might be expected to be fairly multiform, and it was distinctly +interesting to us when we found a marked tendency for the trends of +ideas to remain within a certain small compass.[6] It was possible, to +state this at once, to show that in by far the majority of cases the +same set of ideas returned, and that these ideas had among themselves a +definite inner relationship, being concerned with thoughts of "death." +In isolated instances other ideas were found as well, and they will have +to be discussed later. For the present we shall take up more habitual +content. + +In addition to the eleven cases already described, it may be well to +cite four others which present material now of interest to us. + + + CASE 12.--_Charlotte W._ Age: 30. Admitted to the + Psychiatric Institute October 21, 1905. + + _F. H._ The father was alcoholic and quick-tempered; he + died when the patient was a child. The mother was alcoholic + and was insane at 40 (a state of excitement from which she + recovered). A brother had an attack of insanity in 1915. A + maternal uncle died insane. + + _P. H._ The patient was described as jolly, having many + friends. She got on well in school and was efficient at her + work. + + She was married at 23 and got on well with her husband. The + latter stated, however, that she masturbated during the + first year of her married life. The first child was born + without trouble. + + _First Attack at 25:_ Two or three days after giving birth + to a second child, her mother burst into the room + intoxicated. The patient immediately became much + frightened, nervous, and developed a depressive condition + with crying, slowness and inability to do things. During + this state she spoke of being bad and told her husband + that a man had tried to have intercourse with her before + marriage. This attack lasted six months and ended with + recovery. + + When 29, a year before her admission, she had an abortion + performed, and four months later another. Her husband was + against this, but she persisted in her intention. Seven + months before admission she went to the priest, confessed + and was reproved. It is not clear how she took this + reproof, but at any rate no symptoms appeared until three + weeks later, after burglars had broken into a nearby + church. Then she became unduly frightened, would not stay + at home, said she was afraid the burglars would come again + and kill "some one in the house." The patient herself + stated later, during a faultfinding period, that at that + time she was afraid somebody would take her honor away, and + that she thought burglars had taken her "wedding dress." + "Then," she added, "I thought I would run away and lead a + bad life, but I did not want to bring disgrace to the + family." + + The general condition which she presented at this time is + described as one of apprehensiveness when at home. For this + reason she was for five weeks (it is not clear exactly at + what period) sent to her sister, where she was better. + About a month before the patient was admitted, the husband + moved, whereupon she got depressed, complained of inability + to apply herself to work, became slow and inactive, and + blamed herself for having had the abortion performed. She + began to speak of suicide and was committed because she + bought carbolic acid. She later said that while in the + _Observation Pavilion_ she imagined her children were cut + up. + + _Under Observation_ the condition was as follows: + + 1. For the first three days the patient, though for the + most part not showing any marked mood reaction, was + inclined at times to cry, and at such times complained + essentially that this was a terrible place for a person who + was not insane. + + 2. On the fourth day the condition changed, and it will be + advisable to describe her state in the form of abstracts of + each day. + + On _October 24_ the patient began to be preoccupied and to + answer slowly. A few days later she became distinctly dull, + walked about in an indifferent way or lay in bed immobile. + Twice on _October 27_ she said in a low tone and with + slight distress, "Give me one more chance, let me go to + him." But she would not answer questions. At times she + lapsed into complete immobility, lying on her back and + staring at the ceiling. When the husband came in the + afternoon, she clung to him and said: "Say good-by forever, + O my God, save me." Again, very slowly with long pauses and + with moaning, she said: "You are going to put me in a big + hole where I will stay for the rest of my life." _On + October 28_ she was found with depressed expression and + spoke in a rather low tone, but not with decided slowness + as had been the case on the day before. She pleaded about + having her soul saved; "Don't kill me"; "Make me true to my + husband"; once, "I have confessed to the wrong man the + shame of my life." Later she said she did not tell the + truth about her life before marriage. Again she wanted to + be saved from the electric chair. At times she showed a + tendency to stare into space and to leave questions + unanswered. + + 3. From now on a more definite stupor occurred, which is + also best described in summaries of the individual notes. + + _Oct. 29._ Lies in bed with fixed gaze, pointing upward + with her finger and is very resistive towards any + interference. She has to be catheterized. + + _Oct. 30._ Can be spoon-fed but is still catheterized. + During the morning she knelt by the bed and would not + answer. At the visit she was found in a rather natural + position, smiling as the physician approached, saying "I + don't know how long I have been here." Then she looked out + of the window fixedly. At first she did not answer, but, + when the physician asked whether she knew his name, she + laughed and said, "I know your name--I know my name." Then + she would not answer any more questions but remained + immobile, with fixed gaze. When her going home was + mentioned, however, she flushed and tears ran down her + cheek, though no change in the fixedness of her attitude or + in her facial expression was seen. + + _Nov. 1._ Lies flat on her back with her hands elevated. + She is markedly resistive. + + _Nov. 2._ Free from muscular tension and more responsive. + When asked whether she felt like talking, she said in a + whining tone, "No, go away--I have to go through enough." + Then she spoke of not knowing how long the nights and days + were, of not having known which way she was going. When + asked who the physician was she whimpered and said, "You + came to tell me what was right." She called him "Christ" + and another physician "Jim" (husband's name), though, later + in the interview, she gave their correct names. When asked + about the name of another physician, she said: "He looks + like my cousin, he was here, they all came the first night. + I did not take notice who it was till I went through these + spirits, then I knew it was right."--She paused and added: + "My God--mother it was; she is here on Earth, somewhere in + a convent--Sister C. (who actually is in a convent) she was + here, too, I could hear her." She said they all came to try + to save her. When asked whether she had been asleep, she + said: "No, I wasn't asleep, I was mesmerized, but I am + awake now--sometimes I thought I was dead." (When?) "The + time I was going to Heaven." Again: "I went to Heaven in + spirit, I came back again--the wedding ring kept me on + Earth--I will have to be crucified now." (Tell me about + it.) "Jim will have to pick my eyes out--I think it is him. + Oh, it is my little girl." (Who told you?) "The spirits + told me." Again: "Little birds my children--I can't see + them any more--I must stay here till I die." (Why?) "The + spirits told me--till I pick every one of my eyes out and + my brains too." When asked what day it was, she said, "It + must be Good Friday." (Why?) "Because God told me I must + die on the cross as he did." When asked why she had not + spoken the day before, she said that "Jesus Christ in + Heaven" had told her she should not tell anything, "till + all of you had gone, then I could go home with him, because + that is the way we came in and it was Jim too all the + time." Finally she said crossly, "Go away now, you are all + trying to keep me from Jim" (crying). + + _Nov. 3._ Knelt by bed during the night. This morning lies + in bed staring, resistive, again she is markedly + cataleptic. She has to be spoon-fed, and is totally + unresponsive. In the afternoon she was found staring and + resistive. Presently she said with tears: "I am waiting to + be put on the cross." + + _Nov. 4._ Still has to be catheterized. She sits up, + staring, with expressionless face, but when asked how she + felt she responded and said feebly: "I don't know how I + feel or how I look or how long I have been here or + anything." (What is wrong?) "Oh, I only want to go to a + convent the rest of my days." (Why?) "Oh, I have only said + wrong things, I thought I would be better dead, I could not + do anything right." Later she again began to stare. + + _Nov. 5._ During the night she is said to have been + restless and wanted to go to church. To-day she is found + staring, but not resistive. When questioned she sometimes + does not answer. She said to the physician, "I should have + gone up to Heaven to you and not brought me down here." She + called the physician "Uncle James." Again she said, "I want + to go up to see Jim." Sometimes she looks indifferent, + again somewhat bewildered. + + _Nov. 6._ She eats better, catheterizing is no longer + necessary. She is found lying in bed, rigid, staring, + resistive, does not answer at first, later appears somewhat + distressed, says "I want to go and see Jim." (Where?) "In + Heaven." She gave the name of the place and of the + physician, also the date. + + _Nov. 8._ In the forenoon, after she had presented a rather + immobile expression and had answered a few orientation + questions correctly, she suddenly beckoned into space, then + shook her fist in a threatening manner. When later asked + about this, she said: "Jim was down there and I wanted to + get him in." (And?) "You was up here first." (And?) "I + thought we was going down down, up up--the boat-- --you + came in here for--to lock Jim out so we wouldn't let him + in." Later she said, when asked whether anything worried + her, "Yes, you are taking Jim's place." + + _Nov. 9._ During the night she is reported to have varied + between stiffness with mutism and a more relaxed state. + Once, the nurse found her with tears, saying "I want to go + down the hall to my sister--to the river," and a short time + later with fright: "Is that my mother?" Again she said: "Oh + dear, I wish this boat would stop--stop it--where are we + going?" In the forenoon she was quiet and unresponsive. In + the afternoon she said in a somewhat perplexed way, "We + were in a ship and we were 'most drowned." (When was that?) + "Day before yesterday it must have been"--Again she said in + the same manner: "It was like water. I was going down. I + could hear a lot of things." She claimed this happened + "to-day." "I saw all the people in here, it was all full + of water," "I have been lying here a long time--do you + remember the time I was under the ground and it seemed full + of water and every one got drowned and a sharp thing struck + me?" "I was out in a ship and I went down there in a + coffin." When asked whether she had been frightened at such + times, she said: "No, I didn't seem to be, I just lay + there." She also said: "the water rushed in," and when + asked why she put up her arms, she said, "I did it to save + the ship." + + _Nov. 10._ She is still fairly free. She said that when she + was on the ship things looked changed, "the picture over + there looked like a saint, the beds looked queer." (How do + things look now?) "All right." (The picture too?) "The same + as when I was going down into a dark hole." When asked + later in the day where she was, she said, "In the Pope's + house, Uncle Edward is it?" but after a short time she + added, "It is Ward's Island, isn't it?" + + _Nov. 11._ Inactive, inaccessible, but for the most part + not rigid. + + _Nov. 14._ Varies between mutism with resistance and more + relaxed inactivity. To-day lies in a position repeatedly + assumed by her, namely, on her stomach with head raised, + resistive towards any interference, immobile face, totally + inaccessible. + + _Nov. 15._ Freer. She said: "One day I was in a coffin, + that's the day I went to Heaven." She also said she used to + see "the crucifix hanging there" (on the ceiling)--"not now + but when I was going to Heaven." (When was that?) "Over in + that bed" (her former bed). Later she added, "The place + changed so ... things used to be coming up and down + (dreamily)--that was the day I was coming up on the ship or + going down." She is quite oriented. + + _Nov. 17._ Usually stands about with immobile face, + preoccupied, but she eats voluntarily. + + _Nov. 24._ When the husband and sister came a few days ago + she said she was glad to see them, embraced them, cried and + is said to have spoken quite freely. To-day she speaks more + freely than usually. When asked why she had answered so + little, she said she could not bring herself to say + anything, though she added spontaneously, "I knew what was + said to me." When shown a picture of her cataleptic + attitude with hands raised, she said dreamily, "I guess + that must have been the day I went to Heaven, everything + seemed strange, things seemed to be going up and down." + (Did you know where you were?) "I guess that was the day I + thought I was on the ship." When the sister spoke to her, + she seemed depressed and said, "If only I had not done + those things I might be saved, if I had only gone to church + more." + + _Dec. 3._ Seems depressed. She weeps some, says she is sad, + "There seems to be something over my heart, so I can't see + my little girls." Again: "I should have told you about it + first--I should not have bought it"--(refers to buying + carbolic acid). She wrote a natural letter but very slowly. + + 4. There followed then a state lasting for six months, + during which the patient was rather inactive, preoccupied, + even a little tense at times. Sometimes she did not answer, + again at the same interview spoke quite promptly. For the + most part the affect was reduced, at other times she + appeared a little uneasy, bewildered, or again depressed. + She said that sometimes a mist seemed to be over her. Now + and then spoke of things looking queer and she asked, when + the room was cleaned, "Why do they move things about?" and + she added irrelevantly: "I thought the robbers broke into + my house and stole my wedding dress and my children's + dresses" (refers to the condition during the onset of her + psychosis). In the beginning of this state, when asked + about the stupor, she spoke again of the "ship" and about + going "down, down," but also said that on one occasion she + heard beautiful music, was waiting for the last trumpet and + was afraid to move. Moreover, she had some ideas referring + to the actual situation which were akin to those in the + more marked stupor period. Although she admitted she was + better, she said on December 8 that she still had queer + ideas at times, "I sometimes think the doctor is Uncle Jim" + (long dead). She also spoke of other patients looking like + dead relatives, and added, "Are all the spirits that are + dead over here?" "We never die here, the spirits are here." + But after that date no such ideas recurred, in fact this + whole period seems to have been remarkably barren of + delusions. Exceptionally isolated ones were noted. Thus, on + January 28 it is mentioned that she stated she sometimes + felt so lonely, and as though people were against her; and + on February 13 she said she felt as though the chair knew + what she was talking about. It is also mentioned in January + that she wept at times, but this seems not to have been a + leading feature at all. In March, when asked why she was + not more active and cheerful, her lips began to quiver and + she said, "Oh, I thought my children would be cut up in + Bellevue." "I don't know why I feel that way about them." + She sometimes cried when her friends left her. + + 5. Then followed a week of a rather faultfinding, + self-assertive state, during which she demanded to be + allowed to go home, saying indignantly that she was not a + wicked woman, had done nothing to be kept a prisoner here; + she wanted justice because another patient had called her + crazy. But in this period also she said that after the + robbery (at home) she felt afraid that her honor would be + taken away. When told that her husband had been with her, + she said "Yes, but I was afraid they would get into a + fight." (You mean you were afraid the other man would kill + him?) "No, he is not dead." She further talked of a + disagreement she had at that time with her husband, and + that she felt then like running away and leading a bad + life, but thought of the children. With tears she added: "I + would not do anything that is wrong. I have my children to + live for." Quite remarkable was the fact that she then told + of various erotic experiences in her life, though with a + distinctly moral attitude and minimizing them. + + 6. On _June 16_ another state was initiated with peculiar + ideas, the setting of which is not known, as she told them + only to the nurses. She said that she was not Mrs. W. but + the Queen of England, again that she was an actress, or + again the wife of a wealthy Mr. B., and that she was going + to have a baby. But at night she is said to have been + agitated and afraid she was to be executed. She asked to be + allowed to go to bed again, then stopped talking, and + remained in this mute condition for about a week. She often + left her bed and went back again, remained much with a + perplexed expression. On one occasion she put tinsel in her + hair saying it was a golden crown. + + 7. At the end of that time she became freer and more + natural, and remained so for three weeks. She occupied + herself somewhat. When asked what had happened in the + condition preceding, said she thought she was a queen or + was to be a queen. + + 8. Towards the end of this period she had again three more + absorbed days, but when examined on the third of these days + got rather talkative and somewhat drifting in her talk on + superficial topics. + + 9. Two days later she began to sing at night, kissed + everybody, said it was the anniversary of her meeting her + husband, again cried a little, and on the following morning + began to sing love songs, with a rather ecstatic mood, and + at times stood in an attitude of adoration with her hands + raised. This passed over to a more elated state, during + which she smiled a good deal, often quite coquettishly; she + sang love songs softly; on one occasion put a mosquito + netting over her head like a bridal veil; or she held her + fingers in the shape of a ring over a flower pinned to her + breast. But even during this state she said little, only + once spoke of waiting for her wedding ring, and again, when + asked why she had been singing, said "I was singing to the + man I love." (Why are you so happy?) "Because I am with + you" (coquettishly). + + This, however, represented the end of the psychosis. She + improved rapidly. At first she smiled rather readily, but + soon began to occupy herself and made a perfect recovery. + + She gave a rather shallow retrospective account about the + last phase: at first she said it was natural for people to + feel happy at times, and that she did not talk more because + the inclination was not there. The only point she added + later was that she held her fingers in the shape of a ring + because she was thinking of her wedding ring. + + She was discharged on _October 11_. + + The patient was seen again in _September, 1915_. She then + stated that she had been perfectly well until 1912, when + she had a breakdown after childbirth. (A childbirth in 1910 + had led to no disorder.) The attack lasted six months. She + slept poorly, lost weight, and felt weak, depressed, "my + strength seemed all gone." In _July, 1915_, following again + a childbirth, she was for about six weeks "despondent, weak + and tired out." + + At the interview she made a very natural, frank impression, + and displayed excellent insight. + + + CASE 13.--_Johanna S._ Age: 47. Admitted to the Psychiatric + Institute January 23, 1904. + + _F. H._ It was claimed that there was no insanity in the + family. + + _P. H._ The patient was said to have been bright and rather + quick-tempered. She came to the United States from Ireland + at the age of 20, worked as a servant, was well liked, and + retained her position well. + + She was married at 24. After a second confinement, at the + age of 26, the patient had her first attack of manic + excitement, from which she recovered in four months. She + had, subsequently, at the ages of 28, 30, 32, 35, 43, and + 45, other attacks of the same nature, each one lasting + about four months. No precipitating cause was known for any + of them. Only one of the attacks, the fifth, (none were + well observed) seems to have shown features different from + an elated excitement with irritability. At the end of this + attack she was said to have been "dull" for a month. + + Her husband died four years before the present admission, + evidently soon after her sixth attack. + + The present attack: + + About two months before admission the patient began, + without appreciable cause, to be sleepless, complained of + headaches and appeared downhearted and sad. She sat about. + + After a week she would not get out of bed and remained in + bed until she was sent to the Observation Pavilion, getting + up only to go to the closet. She said very little and would + not eat much. About a month before admission she began to + say that she did not want to live, begged her daughter to + throw her out of the window. About two weeks before + admission she began to insist that she heard the voice of + her brother (living in Ireland) calling her. She got out of + bed to look for him. + + At the _Observation Pavilion_ she was described as slow, + looking about in an apprehensive manner, bewildered, dazed, + saying "I am dead--there is poison in it (not clear in + what)--I am dead, you are dead." + + _Under Observation:_ 1. On admission the patient had a + coated tongue, foul breath, constipation, lively knee-jerks + and a pulse of 110. She appeared dull, inactive, lay in bed + with her eyes closed. She would open them when urged but + appeared drowsy and her face was strikingly immobile. At + times she moaned a little. She could be made to respond in + various ways such as shaking her head, or making some + motions as though to indicate that she could not give any + explanations. All movements were slow. She also responded + to a few questions by "I don't know." + + Two days after admission the condition was not essentially + different except that she was a little uneasy when urged to + speak, corrugated her forehead, said "Everything is dark," + again "I am very sick," or she turned away her head. + + On the fourth day, i.e., January 26, the picture altered, + inasmuch as she was much more responsive. She was found + sitting up in bed and, at times, a little uneasy. She was + slow in her movements and answers, speaking in a whisper + and sometimes a little fretfully. The answers, though slow, + were, however, by no means given in the shortest possible + manner, but with variations, e.g., from "I don't know," to + "I could not tell you," or "I can't tell that either." She + said herself that everything had "been so dark--it is light + now, but it gets so dark sometimes." She denied knowing + where she was, even in what city, also denied knowing the + month, adding to the latter answer "the nurse can tell + you." She could not tell where she had been before coming + to the hospital, or how she came. Finally, she also claimed + not to know her age, her birthday or the date of her + marriage; but she gave the current year correctly, the + place where she went to school, the names of some of her + teachers, and the year of her arrival in the United States. + She also stated in answer to questions that she came to the + hospital "to get well." She repeatedly said "I am so sick," + or "I am so stupid," or "My mind is mixed up, twisted," or + "My mind is not so good," or "I am so tired." What could be + obtained of a content was as follows: When she spoke of + being "twisted," she said, "I got all kinds of medicine." + (How does it affect you?) "Through my head and it made me + hot inside." Again, when asked whether anybody had done + anything to her, she said "No, I have done wrong myself, by + speaking bad of my neighbors." She claimed to hear voices + "all over," but could not tell what they said. When, in the + evening of that day, the nurse asked her why she did not + talk more, she said, "God damn it, I am all twisted, my + brain is mixed up, my system is all upset, the doctor made + me stupid with questions, and the medicine I have taken + made me all stupid and I am inhaling gas now." Then she + again settled into a dull state and was found by the + physician with immobile expression, slow motions and mute. + + 2. For about ten days, i.e., from January 27 to February 8, + her condition was of a more pronounced character. For the + most part she lay in bed with often quite immobile face and + with eyes closed, or she looked about in a bewildered + manner. She was very inactive, presented a marked + resistance in her arms and jaw when passive motions were + attempted, or, again, exhibited decided catalepsy. She had + to be tube-fed. Once on the 27th of January, when the nurse + tried to feed her, she pushed her away and said, "I am + dead--I am not home." Sometimes she turned her hands about + with slow tremulous movements, looking at them in a + bewildered manner. + + She usually was mute, except on the few occasions to be + mentioned later, as well as on February 3, when she was + generally a little more responsive. At that time she could + be made to open her eyes, and then replied to a few + questions slowly and in a low tone; others were left + unanswered. (To the questions where she was and how long + she had been here, she replied with "I don't know," but to + questions about who the physician and the nurse were, by + saying "You are a doctor," and "she is a nurse.") + + In the general setting just described there occurred at + various times changes in behavior which were as follows: On + the evening of the 27th of January she got out of bed and + walked about with slow restlessness, saying: "They say I am + going to be cut up." On February 1, she was seen for a time + making peculiar slow swimming motions with her hands. Again + on the 3d of February she got out of bed, walked about + slowly, with peculiar steps, as though avoiding stepping on + something. Next day (the 4th) she sat up in bed--again made + at times her peculiar slow swimming motions. She presented + at the same time a peculiar dazed bewildered uneasiness + and, when questioned what was the matter, said: "I am--I + am--at the bottom of the deep--deep water--oh--oh--the + deep--deep--dark water." And when further urged she added + with the same manner, "I can't swim--I don't know--but the + place"--She did not finish but later again muttered "the + deep--deep--dark water." (Do you really think you are in + the water?) "I don't know--my head is so bad." + + For the following five days this behavior was repeated + from time to time, when she would sit up and with + bewildered uneasiness make slow swimming motions and mutter + when questioned, "I am in the deep, dark water." + + Some other emotional responses in reaction to external + events must still be mentioned. They were rare. On February + 1 the patient's daughter came while she was lying + motionless in bed. She slowly extended her hands, tried to + speak, and then her eyes filled with tears. Again, at the + end of the interview of February 3, after she had made a + few replies, she settled down to her usual inactivity and, + when further urged to answer, her eyes filled with tears. + + 3. From about February 9 to February 24 the condition again + presented a different aspect, inasmuch as while there was + still a marked reduction of activity, she showed this to a + decidedly lesser degree. Moreover, there was no + bewilderment at any time. No resistance, but cataleptic + tendencies were still seen occasionally. There was at no + time the peculiar dazed uneasiness and slow restlessness + associated with the idea of being in the deep, dark water. + + She now dressed herself very slowly, ate slowly but of her + own accord, and spoke, though her voice was consistently + slow, in a low tone and her words were few. + + At the beginning of this period on February 9, when asked + how she was, she said "I--I am sick." To the questions as + to where she was, how long she had been here and how she + had been taken sick, she replied by saying "I don't know." + But she knew she was in a hospital, had been here before + "many times." (Correct.) She was then again asked for the + name of the hospital, but replied "I don't know." So the + physician pointed out of the window and asked her what it + was that she could see there (the East River). She replied, + "It is the dark water. Sometimes I go there and don't come + back again--and--something throws me up and I come back." + (What has been the matter with you?) "I have been sick all + this time." Again, "I can't tell--I am not a good woman--I + am very sick." (Why do you say you are not a good woman?) + "Oh, I did not do things right." + + At a later interview, during the same period, she knew the + doctor's name, knew she had seen him at Ward's Island, + knew she was in a hospital, but somehow could not connect + the present place with Ward's Island. She said she didn't + know, when asked where she was, and when questioned about + the season, said, after a pause "Summer" (February 15). + + We have seen above that she once spoke of not having been a + good woman. She repeated this on February 10, said "I have + done lots of harm, I have been a bad woman all my life." + Again: "I had bad thoughts." (What kind?) "I have forgotten + all about them." It should be added that at this interview + she also said, "My mind is better now." + + On February 25 there was a sudden change. She laughed when + a funny remark was made on the ward. Later, when the + physician came to her, she still lay in bed inactive and + had to be urged considerably at first, but presently began + to laugh good-naturedly and quite freely commented on the + funny remark she had heard earlier in the morning, and on + peculiarities of some patients. She spoke quite freely and + without constraint. But it was striking how little account + of the condition she had gone through could be obtained + from her. She either turned the questions off by flippant + remarks, or said she did not know. The only information + obtained was that she had been sick since Christmas, felt + like a dummy, that she had lost track of time, and did not + know how she had felt during that period. When asked why + she had not spoken, she said, "I couldn't, I had a jumping + toothache," or she said, "Ask the nurse, she put it down in + the book." Or again she said, "Did you ever get drunk? That + is the way I felt. I felt like dead." + + She soon developed a lobar pneumonia and died. + +The following typical case of partial stupor is quoted as an example of +delusions appearing only during the onset. + + + CASE 14.--_Maggie H._ Age: 26. Admitted to the Psychiatric + Institute February 8, 1905. + + _F. H._ The father died when 33. The mother was living. + Psychopathic tendencies were denied. + + _P. H._ The husband and brother stated that the patient + was natural, capable, rather jolly. She married about a + year before admission and shortly became pregnant. During + the pregnancy she was rather nervous and had various + forebodings, among which were that the child might be born + deformed, or that she would die in childbirth. + + The baby was born three weeks before admission. The patient + seemed much worried immediately after the childbirth, + fretted about not having enough milk, was quite concerned + about her husband and did not want him to leave her side. + The brother stated that about this time the patient heard + that the husband was out of work. She worried about this + and told her sister so. She also began to say that her head + was getting queer. On the fifth day after childbirth, a + change came over the patient. She cried and said she was + going to die. She also spoke of poison in the food and + accused the husband of unfaithfulness. The next day she + became silent, "did not seem to want to have anything to do + with anybody," lay in bed, had a tendency to pull the + covers over her head and scarcely ever spoke. But during + this period she continued to look after the baby + faithfully. Sometimes she clung to her husband, saying she + was afraid he was going to die. + + After recovery the patient said that while she was at home + she thought she saw bodies lying about. + + At the _Observation Pavilion_ she was quiet and apathetic, + indifferent to environment and could not be induced to + speak. She soiled, refused food, and was resistive when + anything was done to her. + + _Under Observation:_ 1. On admission the patient was fairly + well nourished but looked rather anemic and weak. The + temperature was normal, the pulse a little irregular but of + normal frequency, the tongue coated. She lay inactive but + looked about, and the facial expression sometimes changed + as she did this. Any interference met with intense + resistance. There was no catalepsy. In contradistinction to + this inactivity and resistance, natural, free motions were + observed at times, as, for example, when she arranged her + pillows. She did not speak and could not be made to answer. + + For the rest of the first week she made no attempt to + speak, except once when she seemed to attempt to return a + "good morning," or on another occasion, when the nurse + tried to feed her, she said, in quite a natural tone, "I + can feed myself." The resistance to interference remained + in a variable degree, and was at times quite strong. It was + largely passive, though not infrequently associated with a + scowl, or she moved away when approached. She sometimes + looked dull and stared, again she looked determined, + "disdainful," or scowled; or she looked about watching + others, sometimes only out of the corners of her eyes. She + had to be spoon-fed at times, again she ate naturally when + the food was brought. Repeatedly, when taken out of bed, + though she resisted at first, she dressed with natural free + motions. She always retracted promptly from pin pricks. + + Towards the end of the week she even complied at times with + a request to do some work, but on the same day she would + remain passive, with a look of disdain, or resist intensely + when interfered with, e.g., when an attempt was made to + make her sit down. She never soiled and never showed any + catalepsy. + + 2. Then the condition changed, inasmuch as the marked + resistance ceased entirely, and the mutism gave way first + to slow and low answers, and later to much freer speech, + though the inactivity improved only gradually. Thus at the + examination on February 19, though she was quite inactive, + she answered some questions, albeit in whispers and + briefly. This was the case when questioned about the year, + month and date, which she gave correctly, but she merely + shook her head when asked how long she had been here, why + she was here, what was the matter with her. Once she smiled + appropriately. Later she became freer in speech, with a + more natural tone, although her answers continued to be + short. Not infrequently, when asked to calculate or to + write, she would not cooperate, saying "This has nothing to + do with my getting well," or (later) "What has that got to + do with my going home?" or she would simply say she did not + want to. Improvement in her listlessness and inactivity was + more gradual. + + The prevailing affective state was indefinite. She denied + repeatedly that she was depressed, though later she + admitted once being downhearted, yet it seems that even + then her mood was not so much one of sadness as of a slight + resentment. On one occasion, however, she showed some tears + when asked about the baby. She repeatedly expressed the + wish to go home, but not in a pleading, rather in a + resentful, way, saying she would never be better here, that + the questions which were asked had nothing to do with her + going home, that she would be all right if she went home. + She never admitted that she had ever been sick enough to be + taken to a hospital, though she quite appreciated that + there had been something the matter with her head at home + and in the hospital. She stated, in answer to questions, + that she had a peculiar feeling in the head which she could + not explain, that she could not remember so well as + formerly. Once she said, "I hear so much around here that + my head gets so full." + + When towards the end she was questioned about her + condition, i.e., the reason for her resistance, her mutism, + and her refusal of food, she said that then she "wanted to + be left alone"; that she did not eat "because she did not + want food," and she also spoke of not having had any + interest. + + She was discharged on April 29, i.e., about ten weeks after + admission before she had become entirely free. + +The last case is interesting in that a depressive onset to a deep stupor +was observed in the Institute. It was characterized by constant +repetitions of a request to be killed. + + + CASE 15.--_Meta S._ Age: 16. Admitted to the Psychiatric + Institute June 26, 1902. + + _F. H._ The father was dead, and the mother living abroad. + Not much could be learned about them and the immediate + family. + + _P. H._ An aunt who gave the anamnesis had known the + patient only since she came to the United States, a year + before admission. After her arrival the patient at once + went to work as a servant. It was claimed that her employer + liked her, but that she was rather slow about the work. The + only trouble known was that she sometimes complained of + indigestion. She went to see her aunt about once every two + weeks. + + Three weeks before admission, when the patient visited her + aunt, she seemed quieter than usual. Further, she spoke + about sending money home on the _Kaiser Wilhelm der + Grosse_, which was thought peculiar because she had no + money, and on a walk through a cemetery said "I would like + to be here too." At the time this did not impress the aunt + as very peculiar. The patient continued to work until nine + days before admission. The employer then sent for the aunt + and said the patient had been very quiet for about two + weeks, and that she now had become more abnormal. She + suddenly had begun to cry, said the police had come, + claimed, without foundation, that she had "stolen," and + kept repeating "I have done it, I will not do it again." + The aunt took her home with her. There she was quite + dejected, cried, spoke of killing herself (wanted to jump + out of the window, wanted to get a knife). On the whole, + she said very little, but when the aunt pressed her to say + why she was so worried, she said she had allowed men to + kiss her and had taken money from them. It is claimed that + she never menstruated. + + After recovery the patient herself described the onset as + follows: Ever since she came to this country she had been + homesick, and felt especially lonesome for some months + before admission. She knew, however, of no precipitating + cause, in spite of what she had said to the aunt and what + she said at first under observation. She consistently + denied that anything had happened with young men. A short + time before she left her place (she left it nine days + before admission) she could not work, began to accuse + herself of being a bad girl and of having stolen. Then she + was taken to the aunt's house. There she wanted to die. + + _Under Observation:_ 1. On admission the patient appeared + depressed, sat with downcast expression, looking up rarely. + She spoke in a low tone and slowly. But, in spite of delay, + she answered all questions, knew where she was and gave an + account of the place where she had worked. When questioned + about trouble with men, she claimed that a man who lived in + the same house where she worked had tried to make her "lie + on the bed," but that she refused; that later a man had + assaulted her and had after that repeatedly come to her + room when she was alone. Yet when asked whether she worried + about this, she denied it. + + 2. For eight days her condition was sometimes one of marked + reduction of activity, with preoccupation. She sat in a + dejected attitude, and had to be urged to do anything. + Sometimes she was very slow in greeting and slow in + answering, and said very little. But whenever spoken to she + was apt to cry and this might lead to such distress that + the reduction of activity was no longer to be seen. Thus on + June 28, when greeted, she began to cry and say, "Oh, what + have I done!--Oh, just cut my head off--Oh, please what + have I done--I have given my hand." (Tell me the whole + story.) Imploringly and with hands clasped: "No, I can't do + it--just cut my head off, please, please." (Why can you not + tell me?) "Oh, what have I done!" The imploring to cut her + head off was then several times repeated, and she could not + be made to answer orientation questions. On June 29 she + became agitated spontaneously and cried loudly, saying, + "Oh, let me go home and die with my father." She was then + put to bed, and when seen she could not be made to answer + orientation questions. But when asked whether she had seen + the physician before, she said, "I saw you yesterday." She + could not be made, however, to say how long she had been + here, "I think a"--not finishing the sentence. Although she + would not answer further, she presently began to say "Oh, + cut my head off--oh, where is my papa and mamma?" When told + that her people were in Germany and that she could go back + to them, she said "I haven't any money to pay it." Then she + wanted to know if she was to pay for her board and bed and + said she could not do it. + + Again, on July 1, although she had been quite preoccupied, + inactive and silent, she began to say when greeted, "Oh, + please cut my head off." But she then answered some + questions, said she had not worked enough. On questioning, + she explained it was not that the work had been too much, + but that she had been nervous, had tried to work as much as + the servant next door, but could do only half as much, "Oh, + I ought to have worked." + + Repeatedly on other occasions she begged, with distress, to + have her head cut off or to be killed. Frequently there + were statements of self-blame: she ought to have worked + more, was lazy or "I am not worthy"; or she said she had + lied and stolen; or again, "I have not paid for these beds + and I cannot," or "I am a bad girl." + + 3. For a month she presented a more marked reduction of + activity. She sat about with a dejected look, often gazed + in a preoccupied manner, or she stood or walked around + slowly. Sometimes she had to be spoon-fed. At other times + she ate slowly. Toward the latter part of this period, a + distinct tendency to catalepsy appeared. During this + period, too, as a rule (though not always), she would cry + when spoken to. A few times she would make some ineffectual + motions when questioned, but she scarcely ever spoke. + + 4. Then followed a period again lasting about one month in + which the picture was at times one of still greater + inactivity. She would retain uncomfortable positions, allow + flies to crawl over her face. She presented resistance in + the jaws, did not react to pin pricks. She sometimes sat + with eyes closed or, with an immobile face, the eyes stared + with little blinking. The catalepsy was more decided. She + often would not swallow solid food but swallowed fluid. + Again she held her saliva, sometimes drooled. Once she held + her urine and had to be catheterized. When spoken to she + once smiled at a joke, sometimes there was no response, but + as a rule there were tears or flushing of the face. On the + physical side, there were marked dermatographia and, for a + time, towards the end of the period, profuse sweating. + Throughout the stupor proper her temperature was between 99 + deg. and 100 deg. as a rule. + + 5. The period which followed and which lasted about two + months was characterized, like the one just described, by + marked stupor symptoms, associated, however, with more + resistance, while the crying practically disappeared. On + the other hand, a number of plainly angry reactions were + seen and, towards the end, smiling and laughing. She lay in + bed, on her back, staring, allowing the flies to crawl over + her face; retained uncomfortable positions without + correcting them, and her arms often showed a decided + tendency to catalepsy. Sometimes she soiled. She constantly + held saliva in her mouth, though she did not often drool. + She was totally mute, did not respond in any way except in + the manner to be presently indicated. She had to be + tube-fed a good part of the time, was quite resistive when + an attempt was made to open her mouth. When attended to by + the nurse, she was apt to make herself stiff. But as a + rule, she was not resistive to passive motions when tested. + On a few occasions she had, as was stated, marked angry + outbursts. Thus on one occasion when her temperature was + taken she angrily pushed the nurse away and then struggled + vigorously. On another occasion, when the bed-pan was put + under her, she threw it away angrily and struck the nurse; + once she did the same with the feeding tube. She struck a + patient, on another occasion, when the latter came to her + bed. On two occasions she suddenly threw herself headlong + on the floor. Towards the end of the period, when the + blood-pressure was taken, she smiled and then laughed out + loud. She could be made to smile again later. + + 6. The last period, before the more definite improvement, + lasted about a month. She was inactive and slow, ate slowly + (feeding no longer necessary), and was mute. But she did + not stare, was no longer resistive, no longer held saliva. + She appeared indifferent, but could be made to smile quite + readily when spoken to. On one occasion she laughed out + loud when a comical toy was shown her, again was amused at + a party. In the beginning of the period she was once seen + to cry a little when sitting by herself, and at the same + time wept a little when spoken to, but this was now + isolated. Towards the end of the period she spoke a little, + asked for paper and pencil and wrote: "Dear Mother.--I only + take up the pencil in order to write you a few lines. We + are all cheerful and in good health and hope that you are + the same and we congratulate you on your birthday 19th of + December that I have not written to you for a long time + were in the same ..." (Translated.) This was written very + slowly. + + On the day after this letter she was distinctly freer, + talked a little to the nurse and then improved rapidly. A + week after this, January 16, she is described as quite free + in her talk and activity, but when asked about the + psychosis she merely shrugged her shoulders. However, mere + extensive retrospective accounts were taken later. + + The retrospective accounts were obtained on January 24 and + March 13. As these two accounts do not seem to be + fundamentally different for the period of the psychosis, + they may here for the sake of brevity be combined. + + She remembered clearly going to the Observation Pavilion, + and feeling frightened, as she did not know where she was + going and what they were going to do with her. She knew + when she was in the Observation Pavilion and had a good + recollection of the place, also of the transfer to the + hospital, the ward she came to, who spoke to her, etc. She + did not know what the place was until the doctor told her a + day or two after admission. Unfortunately definite + incidents were inquired into only for the first part + (July). But she remembered those clearly. She also claimed + to remember all visits which were made to her by her + friends, but it was not specifically determined whether + there was a period of less clear recollection or not. + However, she remembered the tube-feeding, which occurred + only during the more marked stupor. Her desire to be + killed, to have her head cut off, she recalled but claimed + not to know why she wanted to be killed. However, she + remembered worrying about being bad, about the fact that + she could not "pay for the beds," etc. + + Her mutism and refusal of food she was unable to account + for. She could not talk, her "tongue would not move." As + regards ideas during the more stuporous period, she claimed + that (when quite inactive) she heard voices but did not + recall what they said. But she remembered having dreams at + that time "of fire," "of her dead father and of home." + +In a survey of thirty-six consecutive cases of definite stupor, literal +death ideas were found in all but one case. They seem to be commonest +during the period immediately preceding the stupor, as all but five of +these cases spoke of death while the psychosis was incubating. From this +we may deduce that the stupor reaction is consequent on ideas of death, +or, to put it more guardedly, that death ideas and stupor are +consecutive phenomena in the same fundamental process. Two-thirds of +these patients interrupted the stupor symptoms to speak of death or +attempt suicide, which would lead us to suppose that this intimate +relationship still continued. One-quarter gave a retrospective account +of delusions of being dead, being in Heaven, and so on. From this we may +suspect that in many cases there may be a thought content, although the +patient's mind may seem to be a complete blank. It is important to note +that when a retrospective account is gained, the delusions are +practically always of death or something akin to it, such as being in +prison, feeling paralyzed, stiff, and so on. + +In the one case of the thirty-six who presented no literal death ideas, +the psychosis was characterized essentially by apathy and mild +confusion, a larval stupor reaction. It began with a fear of fire, +smelling smoke and a conviction that her house would burn down. It is +surely not straining interpretation to suggest that this phobia was +analogous to a death fear. When one considers the incompleteness of +anamneses not taken _ad hoc_ (for these are largely old cases) and that +the rule in stupor is silence, the consistence with which this content +appears is striking. + +To exemplify the form in which these delusional thoughts occur we may +cite the following: Henrietta H. (Case 8) said, retrospectively, that +she thought she was dead, that she saw shadows of dead friends laid out +for burial, that she saw scenes from Heaven and earth. Annie K. (Case 5) +claimed to have had the belief that she was going to die, and to have +had visions of her dead father and dead aunt, who were calling her. She +also thought that all the family were dead and that she was in a +cemetery. Rosie K. (Case 11) said she had the idea that she wanted to +die and that she refused food for that purpose, and during the stupor +she sometimes held her breath until she was cyanotic. Mary F. (Case 3), +before her stupor became profound, spoke of the hereafter, of being in +Calvary and in Heaven. In this case, as well as in the above-mentioned +Henrietta H., we find, therefore, associated with "death" the closely +related idea of Heaven. Whether Calvary merely referred to the cemetery +(Mt. Calvary Cemetery) or leads over to the motif of crucifixion, cannot +be decided. It is, however, clear that this latter motif may be +associated with that of death, as is shown in Charlotte W. (Case 12), +who, during intervals when the inactivity lifted, spoke of having been +dead, of spirits having told her that she must die, of having gone to +Heaven, of God having told her that she must die on the cross like +Christ. But this patient also showed in a second subperiod of her stupor +another content. She said: "It was like water. I was going down." Or +again, she spoke of having gone "under the ground"; "I went down, down +in a coffin." She spoke of having gone down "into a dark hole," "down, +down, up, up"; again, of having been "on a ship." We shall see in the +further course of our study that this type of content occurs not at all +infrequently. + +_The internal relationship among the different ideas associated with +stupor:_ Before we go any further it may be advisable to examine the +meaning of such ideas when they arise in other settings than those of +the psychoses. If we consider these ideas of death, Heaven, of going +under ground, being in water, in a boat, etc., we are impressed with the +similarity which they bear to certain mythological motifs. This is, of +course, not the place to enter into this topic more than briefly. We are +here concerned with a clinical study, and therefore, among other tasks, +with the interrelationship of symptoms, but for that purpose it is +necessary to point out how these ideas seen in stupor can be shown to +have, not only a connection amongst each other, when viewed as +deep-seated human strivings, but also are closely related to, or +identical with, ideas found in mythology. + +To one's conscious mind death may be not only the dreaded enemy who ends +life, but also the friend who brings relief from all conflict, strife +and effort. Death may, therefore, well express a shrinking from +adaptation and reality, and as such may symbolize one of the most +deep-seated yearnings of the human soul. But from time immemorial man +has associated with this yearning another one, one which, without the +adaptation to reality being made, yet includes a certain attempt at +objectivation, the desire for rebirth. We need not enter further into +possible symbols for death _per se_, but it is quite necessary to speak +briefly of the symbolic forms in which the striving for rebirth has ever +found expression. The reader will find a large material collected in +various writings on mythology, for the psychological interpretation of +which reference may be made to Jung's "Wandlungen und Symbole der +Libido" and Rank's "Mythos von der Geburt des Helden." From them it +appears how old are the symbols for rebirth, and how they deal chiefly +with water and earth, and the idea of being surrounded by and enclosed +in a small space. Thus we find a sinking into the water of the sea, +enclosure in something which swims on or in the water, such as a casket, +or a basket, or a fish, or a boat; again, we find descent into the +earth. The striving for rebirth might be assumed to have adopted these +expressions or symbols on account of the concrete way in which the human +mind knows birth to take place. The tendency for concrete expression of +abstract notions causes the desire for another existence to appear, +first as a rebirth fantasy and then as a return to the mother's body. +One thinks of Job's cry, "Naked came I from my mother's womb and naked +shall I return thither," as an example of the literal comparison of +death with birth. We need only refer to the myths of Moses and the older +one of Osiris, and the many myths of the birth of the hero, to call to +the mind of the reader the examples which mythology furnishes. There is +probably not one of the ideas expressed by these patients which cannot +be duplicated in myths. We have, therefore, a right to speak of these +ideas as "primitive," and to see in them, not only deep-seated strivings +of the human soul, but to recognize in them an essential inner +relationship. It is especially this last fact to which at this point we +wish to call attention: that without any obvious connection the +fantasies of our forefathers recur in the delusions of our stupor cases. +We presume that in each case they represent a fulfillment of a primitive +human demand. In one of our cases a vision of Heaven and a conscious +longing to be there was followed by a stupor. On recovery the patient +compared her condition to that of a butterfly just hatched from a +cocoon. No clearer simile of mental rebirth could be given. + +_Brief survey of the ideas associated with the states preceding the +stupor:_ If we now return to the study of the further occurrence of such +ideas in the cases described, we find motifs, similar to those seen in +the stupor, in the period which immediately precedes the more definite +stupor reaction. Indeed we find the ideas there with greater regularity. +In Meta S. (Case 15) the stupor followed upon six days with reduced +activity and crying, with self-accusation, but also with entreaties to +be allowed to go home and die with her father. At the very onset of her +breakdown, the desire for death had also occurred. Anna G. (Case 1) +expressed a wish to be with her dead father, and, at the visit of a +cousin, she had a vision of the latter's dead mother. A second attack of +this same patient began with the idea that the dead father was calling +her. Maggie H. (Case 14) saw dead bodies, and during outbursts of +greater anxiousness, she thought her husband was going to die. In +Caroline De S. (Case 2) the psychosis began with a coarse excitement, +with statements about being killed, with entreaties to be shot, with the +idea of going to Heaven, again with frequent calling out that she loved +her father (who was dead since her ninth year), while immediately before +the stupor the condition passed into a muttering state in which she +spoke of being killed. Mary D. (Case 4) began by worrying over the +father's death (dead four years before), had visions of the latter +beckoning, and she heard voices saying, "You will be dead." Mary F. +(Case 3) had a vision of "a person in white," and thought she was going +to die. In Henrietta H. (Case 8) the stupor was preceded by nine days of +elation, with ideas of shooting and of war, but this had commenced with +hearing voices of dead friends, and with ideas that somebody wanted to +kill her family. In the case of Annie K. (Case 5) we find before the +stupor a state of worry, with reduction of activity, and then a vision +of the dead father coming for her. In Charlotte W. (Case 12) the stupor +was preceded by a state of preoccupation, with distress and entreaties +to be saved, partly from being put into a big hole, partly from the +electric chair. + +We see, therefore, in the introductory phase of the stupor in almost +every case ideas of death, and in one case an idea belonging to the +rebirth motif, namely, of being put into a dark hole. In well-observed +cases apparently we do not find the stupor reaction without either +coincident or preceding ideas of death. + +_Relation of death and rebirth ideas with affect:_ In order to +investigate the relation of these ideas to the affective condition +associated with them, it will be necessary to study not only the +abstract ideational content but the special formulation in which the +content appears. In looking over the enumeration of the ideas given +above, it is very clear that these formulations differed considerably +from each other. A priori we would say that it is, psychologically, a +very different matter whether a person expresses a desire to die, or has +the idea that he will die or is dead, or says he will be killed. We +associate the first with sadness, the last with fear, while our daily +experience does not give us so much information about the delusion of +being dead. A vivid expectation of death is usually accompanied by +either fear or resignation. + +In studying the ideas which we obtained from the patients by +retrospective account after the psychosis or from a retrospective +account during freer intervals, it is, of course, difficult, especially +in the former case, to say whether they have persisted for any length of +time. Probably in most instances this was not the case, and we must +remember in this connection that in a considerable number of cases the +patients recalled no ideas whatever. + +Of the five cases which we may consider as types, Henrietta H. (Case 8) +and Mary F. (Case 3) formulated their ideas simply as _accepted facts_ +during the stupor. The former thought she was dead, saw dead friends +laid out for burial, and scenes from Heaven and earth. The latter spoke, +during the stupor, of being in "Calvary," "the hereafter," or "Heaven." +We have seen that these stupors were essentially affectless reactions +and we can therefore say that, so far as these two cases are concerned, +the ideas thus formulated were not associated with any affect. + +Annie K. (Case 5) was a little different. During the stupor she made a +few utterances about priests and "all being dead," and retrospectively +she said that she had thought she was in the cemetery, was going to die, +that she had repeated visions of her dead father and once of a dead aunt +calling her; that she had thought her family were dead, again that the +baby (who was born just before the psychosis) was dead. The formulation +is therefore less one of fact than of something prospective, something +which is coming--the _going_ to die. Correlated, perhaps, with this +anticipation were slight modifications of the usual apathy. The patient +often had an expression of bewilderment. She was also more in contact +with her environment than many stuporous patients are, for, not +infrequently, she would look at what was going on about her. Her apathy +was also broken into in a marked degree by her active resistiveness, +which was sometimes accompanied by plain anger. It seems that a prospect +of death may occur in other instances in a totally affectless state. We +have recently seen it in a partial stupor during which the patient spoke +and had this persistent idea in a setting of complete apathy. We see +here also, as in one of the former cases, the idea of other members of +the family being dead. + +More difficult and deserving more discussion are the two remaining +cases, Rosie K. (Case 11) and Charlotte W. (Case 12). Rosie K. showed a +peculiar condition. She said, retrospectively, that during the stupor +she had the desire to die and that for this purpose she refused food. +Moreover, she was repeatedly seen to hold her breath with great +insistence, though without affect. This is worth noting. We are in the +habit in psychiatry to say in a case like this that "there is no +affect," and yet there is evidently a considerable "push" behind the +action. We shall later have to mention in detail a patient whom we +regard as belonging in the group of stupor reactions, and who for a time +made insistent, impulsive and most determined suicidal attempts, yet +with a peculiar blank affectless facial expression and with shouting +which was more like that of a huckster than one in despair. Here also, +then, there was a great deal of "push," yet not associated with that +which we call in psychiatry an affect. In both instances we see acts +which we are in the habit of calling for this very reason "impulsive." +Evidently this is an important psychological problem which leads +directly into the psychology of affects and deserves further study. For +the present it is enough to say that with a different formulation--that +of wishing to die--there is here not, as in other psychoses, a definite +affect, such as sadness or despair, but no affect, though there may be a +good deal of "push" or impulsiveness. + +The case of Charlotte W. (Case 12) is a complicated one, for she had +short stupor periods with inactivity, catalepsy, resistiveness, etc., +which were interrupted with freer spells. A careful analysis of her +history has been instructive and justifies a detailed and lengthy +discussion. For the purpose in hand it is necessary to separate the +ideas which she expressed only in the freer periods (during which some +affect was at times seen) into those which referred retrospectively to +the stupor phase and those which referred to the freer periods +themselves. + +We find that the time during which more marked stupor symptoms appeared +may be divided into two subperiods. This is not possible in regard to +the manifestations belonging to the general reaction, which seem to have +undergone no decided change, but only in regard to the form of the +delusions. In this we find there was a first phase in which ideas of +death and Heaven (and crucifixion) occurred, and a second phase in which +ideas were present which belonged essentially to the motif of rebirth +but which were also associated with ideas of Heaven. + +About the first subperiod she said: "I was mesmerized," or "I thought I +was dead," or "God told me I must die on the cross as He did," or "I +went to Heaven in spirit." About the second subperiod she said +retrospectively: "We were on a ship and we were 'most drowned." "It was +like water, I was going down, down." She said she saw the people of the +hospital and "it was all full of water"; or again, "I went under the +ground and it was full of water and every one got drowned and a sharp +thing struck me"; or "I was out on a ship and I went down in a coffin." +She claimed she put up her arms to save the ship. Again she spoke of +having gone into a dark hole. She also said: "One day I was in a +coffin--that was the day I went to Heaven." "They used to be coming up +and down, that was the day I was coming up in a ship or going down." And +when shown her picture in a cataleptic attitude, she said: "That must +have been when I went to Heaven--everything seemed strange, things +seemed to go up and down--I guess that was the day I thought I was on +the ship." Finally she also said: "Once I heard beautiful music--I was +waiting for the last trumpet--I was afraid to move." + +We see, therefore, that most of the ideas which she thus spoke of +retrospectively as having been in her mind during this stupor, and which +belonged both to the death and the rebirth motifs were formulated as +facts (as in the cases of Henrietta H. and Mary F. above mentioned). It +was, moreover, a condition which was accepted without protest. Here +again an affect was not associated with these ideas, and when the +patient was asked whether she had not been frightened, she said herself, +"No, I just lay there." The idea that God told her she would have to die +on the cross like Christ, is, in the religious form, like the beckoning +of the father with Henrietta H. The only exception to the claim that the +ideas were formulated as facts and accepted as inevitable seems to be +the statement that she held up her arms to save the ship. This would +seem to be, in contradistinction to the rest, a formulation as a more +dangerous situation. However, this was isolated and we can do no more +than to determine main tendencies. We must expect, especially in such +variable conditions as we see in this patient, to find occasional +inconsistencies. + +In summing up we may say, therefore, that so far as the stupor itself +is concerned, the ideas are formulated as a rule:-- + + 1. As accepted facts (being dead, being in a ship, etc.). + + 2. As accepted prospects (going to die). + + 3. As the wish to die. + +In the first two types the ideas are not associated with affect; in the +third, though not associated with affect, they are combined with +"impulsive" suicidal attempts. + +In order not to tear apart the analysis of Charlotte W. (Case 12) too +much, we may begin our study of the intervals and the conditions +preceding the stupors with the ideas which this patient produced when +the stupor lifted somewhat. We shall see that the ideas are closely +related to those mentioned above but formulated differently. + +It will be remembered that Charlotte W. had freer intervals when she +responded and was less constrained generally, and that it was in these +that the ideas above mentioned were gathered. Since they were spoken of +in the past tense, we regarded them as not belonging to the actual +situation but to the more stuporous period. It seems tempting now to see +whether the ideas which are expressed in the present tense are different +in character, the general aim being to discover whether any tendencies +can be found in regard to the types and formulations of delusions +associated with different clinical pictures. We see that on November 2 +the patient, when speaking much more freely than before, said she had +felt that she was mesmerized, was dead, and that she had gone to Heaven, +ideas which we have taken up above as belonging to the stupor period. In +addition to speaking much more freely in these intervals, she showed at +times some affect. Thus to the physician whom she called Christ, she +said, with tears, "You came to tell me what was right," or again with +tears, "I will have to be crucified," or she spoke in a depressed manner +about her children, "I can't see them any more," "I must stay here till +I die," and she spoke of having to stay here till she picked her eyes +and her brains out; or she claimed her husband or her children had to +pick them out. Once she exclaimed crossly and with tears, "You are +trying to keep me from Jim" (husband). Another idea was not plainly +associated with affect. She said she had come back from Heaven, "The +wedding ring kept me on Earth." What strikes one about these +formulations is that they are, on the one hand, sometimes associated +with an affect, and that, on the other hand, they refer much more to her +actual life, her marriage, her husband, her children. At least this +seems to be a definite tendency. A similar tendency may be seen later: +On November 4, while generally stuporous, this suddenly lifted for a +short time, and with feeble voice she uttered some depressive ideas. She +said she wanted to go to a convent, that it would be better if she were +dead, that she could not do anything right. On November 5 and 6 she +said she wanted to go to Jim in Heaven (in contradistinction to the +retrospective statements that she had gone to Heaven), and on the 8th, +when she had the idea of being in a boat, she said with some anger that +she had wanted to get her husband into the boat, but that the doctor +kept him out and took his place. + +Later there were at times ideas expressed which referred to the actual +situation or essentially depressive ideas in a depressive setting. Thus +on December 3 she appeared sad, retarded, and spoke of not being able to +see her children and that she had done wrong in buying carbolic acid +(her suicidal attempt). So far as this case is concerned, therefore, we +do find a distinct tendency for the ideas which refer to the more +stuporous condition to differ from those which refer to the actual +situation in the freer intervals, a difference which we may formulate by +saying that, though primitive ideas are expressed, the tendency seems to +be to connect them more with actual life, or that the primitive +character is lost and the ideas take on a more depressive character with +a depressive affect. A few words should be added in regard to the +peculiar ideas that she or her husband or her child had to pick out her +eyes (or her brain). It is probable that this idea belongs to the motif +of sacrifice (the _Opfer motiv_ of Jung) into which we need not enter +further, except to say that in this instance it was plainly connected, +like some of the other ideas just spoken of, with the real situation of +her life (husband, children). + +It will now be necessary to examine the earlier state of Charlotte W. +The condition preceding the stupor set in with pre-occupation, slow talk +and slight distress. During the time she asked to be given one more +chance, she said to the husband she would not see him again. Then +followed a day when she was very slow and with moaning said she was +going to be put into a dark hole. Again on the next, when speaking more +freely, she begged to be saved from the electric chair, and also said, +"Don't kill me, make me true to my husband," etc. [Again the connection +with real life!] We see here the idea of death and especially an idea +pertaining to the rebirth motif in a setting of distress and slowness, +as an introduction to the stupor which had in it both of these motifs. +We must leave it undecided whether it is accidental or not that the +distress was associated with more slowness (i.e., more marked stupor +traits) when she spoke of the dark hole than when she spoke of the +electric chair or death. But what interests us is that distress and +reduction of activity (not sadness and reduction of activity, which +seems as a rule to have a different content) are here associated with +ideas seen in stupor but formulated as prospective dangers. We know from +experience that we often find associated with the fear of dying +considerable freedom of action, and we see at times in involution states +conditions with freedom of motion and marked anxiety, whereas the ideas +seem to belong to the motif of rebirth; e.g., the fear of being boiled +in a tank.[A] + +In this connection, however, two other cases should be taken up which +show a condition which reminds one somewhat of that we have just +discussed, but in which the rebirth motif appeared, not as prospective, +but, as in the stupor, as an actual situation. At the same time this +situation was not passively accepted but conceived as a dangerous +situation. The significant phenomenon in both these conditions was that +there was not anxiety with freedom of action but a bewildered uneasiness +with marked reduction of activity. + +The first case is that of Johanna S., whose history has been given in +this chapter. It will be observed that in the fourth period the patient +presented two days of typical stupor with the idea that she was dead. We +are familiar with this. But this was followed by several days of +bewildered uneasiness and slow restlessness, with ideas that she was at +the bottom of the deep, dark water and for a time she made attempts at +stepping out of the water or swimming motions. All of this was in a +general setting of reduction of activity with bewildered uneasiness. In +the ideas about being at the bottom of the deep, dark water, we +recognize again the rebirth motif, yet the situation is not accepted +but attempts are made by the patient to save herself, i.e., the attitude +is one in which the situation is taken to be one of danger. It is +interesting in this connection that immediately following this state +there was one day of ordinary retardation with sadness and ideas of +being bad and sick. That is, when the element of anxiety, the +uneasiness, disappeared and sadness supervened, the rebirth ideas were +no longer present. + +In Mary C. (See Chapter II, Case 7) we have, unfortunately, not a direct +observation, but we have, at any rate, a description from the +Observation Pavilion which seems so plain that we should be justified in +using it here. The condition we refer to is described as a dazed +uneasiness, with ideas of being shut up in a ship, of the ship being +closed up so that no one could get out, of the boat having gone down, of +the people turning up. We should add here that the condition was not +followed by a typical stupor. Essentially it was a retardation, in which +only on one occasion was a definite akinesis observed. During this phase +she soiled her bed. Perhaps the persistent complaint of inability to +take in the environment belonged also more to the retardation of stupor +than to that of depression. We have again, therefore, in this initial +phase, a similar situation, namely, ideas belonging essentially to the +rebirth motif, formulated as of a threatening character if not as +actually dangerous. + +We can say, therefore, that what characterizes these three cases, and +brings them together, is the fact that all three had ideas belonging to +the rebirth motif, but formulated as dangerous situations. Associated +with this there was not a typical anxiety with the relative freedom of +activity belonging to this state, but an anxiety or distress or +uneasiness with traits of stupor reaction, namely, slow movements, lack +of contact with the environment, and a dazed facial expression. It would +seem that these facts could scarcely be accidental but that they must +have a deeper significance. As a discussion of this belongs, however, +more into the psychological part of this study, we shall defer it for +the present, and be satisfied with pointing out here the clinical facts +of observation. + +In brief, then, our findings as to the ideational content of the benign +stupor are as follows: From the utterances during the incubation period +of the psychosis, from the ideas expressed in interruptions of the deep +stupor, as well as from the memories of recovered patients, we find an +extraordinary paucity and uniformity of autistic thoughts. They are +concerned with death, often as a plain delusion of being no longer +alive, or with the closely related fancy of rebirth. The rule is a +setting of apathy for these ideas, but when they are formulated so as to +connect them with the real life and problems of the patient, or when +rebirth is represented as a dangerous situation, some affect, usually +one of distress, may appear. + + +FOOTNOTES: + +[6] Kirby, _loc. cit._, pointed out that stupor showed resemblance to +feigned death in animals, that the reaction suggested a shrinking from +life and that ideas of death were common. + +[A] We may mention that since this study was made we risked a prediction +of stupor, which events justified, in the case of a patient who showed +expectation of death without affect. Such opportunities are rare, +however, since we usually do not see these cases till the stupor +symptoms are manifest. It would be unsafe to dogmatize on the basis of +such meager material. + + + + +CHAPTER VI + +AFFECT + + +The most constant and significant symptom in the stupor reaction is the +change in affect. This extends from mere quietness in the mildest phases +of the disease through the stage of indifference where apathy replaces +the normal reactions of the personality, to the final condition of +complete inactivity in the vegetative stupor where all mental life seems +to have ceased. It seems as though there were, as a pathognomonic sign +of the morbid process, a lack of energy and loss of the normal _elan +vital_. + +We may say, in fact, that the establishment of a specific type of +emotional change is justification for classifying all milder stupor +reactions with the deep stupors. In other words, our reason for the +enlargement of the stupor group to include all apathetic reactions +(except those of dementia praecox) is the belief that this dulling of the +emotional response is as specific a type of emotional change as is +anxiety, depression or elation. Perhaps it would be more accurate to say +that this clinical group is founded on the symptom complex which is +built around apathy. There is never any resemblance between apathy and +the mood of elation or anxiety. A discrimination from depression is the +only differentiation worth discussion. + +The first point that should be made is that there is a difference +between marked depression and the mood of stupor. In the former we get a +retardation with a feeling of blocking, rather than of an absence of +energy. The expression of the patient is one of dejection, not of +vacancy, which bespeaks a mood of sadness, even when the patient is so +retarded as to be mute and therefore incapable of describing his +emotions. Running through all the stages of stupor, however, there is an +emptiness, an indifference that is in striking contrast to the positive +pain that is felt or expressed by the depressed patient. It may be +objected, of course, that this apathy really represents the final stage +in the emotional blocking of the depressed individual, but the +development of stupor and recovery from it shows an entirely different +type of process. A deep depression recovers by changing the point of +view from a feeling of unworthiness and self-blame to one of normality. +The stuporous case, on the other hand, evidences merely less and less +indifference, and more and more interest in his environment and in +himself as he gets well. + +The associated symptoms are no less dissimilar. The difficulty in +thinking which troubles the depressed patient is slight in proportion to +his emotional gloom, and he feels himself to be much more incompetent +intellectually than examination proves him to be. On the other hand, in +the stupor reaction we find that the thinking disorder runs hand in +hand with the apathy and that the intellectual capacity of the patient +is really markedly interfered with, as can be shown by more or less +objective tests. A mere slowing of thought processes accompanied by +subjective feeling of effort is the limit reached in true depression, +while it is merely the beginning of the intellectual disorder in stupor, +for one meets with retardation symptoms only in the partial stupors. The +slowing in these cases seems to represent an early stage of the +intellectual disturbance which reaches its acme in the mental vacuity +and complete incompetence of the deep stupor, just as slow movements in +the partial stupors seem to represent a diluted inactivity reaction. +This actual thinking disorder is not present in those forms of +manic-depressive insanity which are characterized by elation, anxiety or +depression but is seen only in stupors, occasionally in absorbed manic +states (manic stupor) and sometimes in perplexity states. The +psychological mechanisms of this last group are probably analogous to +those of stupor, but this is not the place for a discussion of this +topic. + +Another associated symptom whose manifestations differ in depression and +stupor is that of unreality. In the former there is frequently a feeling +of unreality that is purely subjective, whereas the stupor case does not +usually complain of this but does exhibit a difficulty in grasping the +nature of his environment, which the typical depressive case never has. + +The occurrence of other mood reactions than apathy in the same patient +is also characteristic. Manic states (usually hypomanic) frequently +occur during the phase of recovery from the stupor. This is an unusual, +although not unknown, phenomenon in recovery from severe retarded +depressions. The circular cases who swing from depression to elation +usually show the milder types of depressive reaction which would never +be confused with stupor. On the other hand, deep stupors very frequently +are terminated by manic reactions, and if not by such means, recovery +seems to occur merely in virtue of a gradual attenuation of the stupor +symptoms. Rarely do we see a change to depression or anxiety heralding +improvement. This tendency of the stupor reaction to remain pure or +change to hypomania is a peculiarity which seems to put stupor in a +class by itself among the manic-depressive reactions, as all the other +mood reactions frequently change from one to the other. + +Although apathy is the central pathognomonic symptom of stupor +conditions, there are other mood anomalies to be noted. One of these is +the tendency for inconsistency in, as well as reduction of, the +expression of emotion. For instance, in the states where one would +expect anxiety during the onset of stupor or in its interruptions, +manifestation of this anxiety is often reduced to an expression of dazed +bewilderment. In the anxiety states associated with stupor one does not +meet with the restlessness and expressions of fear which would be +expected. Quite similarly, when a manic tendency is present, it occurs +either in little bursts of isolated symptoms of elation (such as smiling +or episodic pranks), or some of the evidences of elation which we would +expect are missing. For instance, Johanna S. (Case 13) terminated her +stupor with a hypomanic state which was natural except for her always +wearing an expressionless face. Sometimes laughter occurs alone and +gives the impression of a shallow affect, raising a suspicion of +dementia praecox. In fact, such evidences of affect as do appear in the +course of the stupor are apt to be isolated, queer and "dissociated." It +does not seem as if the whole personality reacted in the emotion as it +does in the other forms of manic-depressive insanity. For example, we +may think of the resistiveness which is so frequently present when the +patient seems in other respects to be psychically dead. One may recall +the case of Meta S. (Case 15), who, otherwise inert, was occasionally +seen with tears or smiles. Anna G. (Case 1), too, was often seen smiling +or weeping. It was noted once of Charlotte W. (Case 12) that she ceased +answering questions and remained immobile with fixed gaze, but when some +mention was made of her going home she flushed and tears ran down her +cheeks, although no change in the fixedness of her attitude or facial +expression was seen. When Johanna S. was visited by her daughter and was +lying motionless in bed, she slowly extended her hands, apparently tried +to speak, and then her eyes filled with tears. Two days later, at the +end of an interview when she had made a few replies, she settled down +into her usual inactivity and, when further urged to answer, her eyes +filled with tears. Similarly, too, in fairly deep stupor pin pricking +may result in flushing, in tears or an increased pulse rate without the +patient giving any other evidence of the stimulus being felt. These +examples seem to show a larval effort at normal human response which, +failing of complete expression, appeared as single isolated features of +emotion suggesting true dissociation. We should also in this connection +bear in mind the impulsive suicidal acts which occur either as +unexpectedly as the impulsiveness in a true dementia praecox patient, or +in a setting of coarse animal-like excitement that seems quite unrelated +to the personality. One is reminded of the patient who made suicidal +attempts during the period when she shouted like a huckster, giving no +evidence whatever by her expression or the tone of her voice of feeling +anxiety, sorrow or any other normal emotion. + +All these queer and larval affective reactions remind one strongly of +dementia praecox. The resemblance of the benign stupor to certain +dementia praecox types is not merely a matter of identity with catatonic +features (catalepsy, negativism). In these anomalous mood reactions it +seems as if there were a definite dissociation of affect, and so there +is. How then can we differentiate these emotional symptoms from the +"dissociation of affect" which is regarded as a cardinal symptom of +dementia praecox? The answer is that this term is used too loosely as +applied to the latter psychosis. It is a particular type of dissociation +which is significant of the schizophrenic reaction, for in it there is +an acceptance of what should be painful ideas evidenced either by +incomplete manifestations of anxiety or depression or actually by +smiling. We never see in dementia praecox the reverse--a painful +interpretation of what would normally be pleasant. It is the pleasurable +interpretation of what is really unpleasant that gives the impression of +queerness in the mood of these deteriorating or chronic cases. In +stupor, on the other hand, although this dissociation takes place, the +mood is never inappropriate, merely incomplete in that all the +components or the full expression of the normal reaction are not seen. + +Our description of the mood reactions in stupor would be incomplete if +we omitted to mention the occasional appearance of an emotional attitude +not unlike that seen in many cases of involution melancholia, which +reminds one in turn of the reactions of a spoiled child. The commonest +of these manifestations is resistiveness that may occur when an +examination is attempted, feeding is suggested, or a sanitary routine +insisted upon. One also meets with resentfulness. One patient, who +frequently showed this reaction, explained it retrospectively by saying +that she wanted to be left alone. Quite analogous to this is sulkiness +that occasionally appears. Then we have, particularly as recovery +begins, other childish tricks, such as flippancy in answering questions +or the playing of pranks. Such tendencies naturally lead over to frank +hypomanic behavior. + +Finally, a peculiar characteristic of the stupor apathy must be +mentioned. This is its tendency to interruptions, when the patient may +return to life, as it were, for a few moments and then relapse. Such +episodes occur mainly in milder cases or towards the end of long, deep +stupors. It is interesting that the occasion for such reappearance of +affect is frequently obvious. We usually observe them in response to +some special stimulus, particularly something that seems to revive a +normal interest. Visits of relatives are particularly common as such +stimuli, in fact recovery can often be traced to the appearance of a +husband, mother or daughter. It is also important to recognize that with +this revived interest, other clinical changes may be manifest, that the +thinking disorder may, for instance, be temporarily lifted. Helen M., +for example, when visited by her mother was so far awakened as to take +note of her environment, and remembered these visits after recovery like +oases in the blank emptiness of her stupor. She further remembered that +definite ideas were at such a time in her mind that ordinarily was +vacant. She then had delusions of being electrocuted. + +In summary, then, we may say that the _sine qua non_ of the stupor +reaction is apathy in all gradations, and that this apathy is as +distinct a mood change as is elation, sorrow or anxiety. Incidental to +this loss of affect there is a dissociation of emotional response +whereby isolated expressions of mood appear without the harmonious +cooperation of the whole personality which seems to be dead. Thirdly, +there tends to be associated with the stupor reaction a tendency to +childish behavior. Finally, the apathy and accompanying stupor symptoms +may be suddenly and momentarily interrupted. An explanation of these +apparently anomalous phenomena will be attempted in the chapter on +Psychology of the Stupor Reaction. + + + + +CHAPTER VII + +INACTIVITY, NEGATIVISM AND CATALEPSY + + +1. INACTIVITY. We must now turn our attention to the other cardinal +symptoms of the stupor reaction, and quite the most important one of +these is the inactivity. It is convenient to include under this heading +both the reduction of bodily movement and the diminution or absence of +speech. This inactivity is, of course, related to the apathy which we +have just been discussing, in fact it is one of the evidences of the +loss of emotion. We presume that a patient is apathetic when there is no +expression in the face and when he does not respond to external stimuli, +whether these be physical or verbal, by movement or by word. + +Bodily inactivity is present in all degrees, and in some forty +consecutive cases was recognizable in every one. In its most extreme +form there is complete flaccidity of all the voluntary muscles, and +relaxation of some sphincters. As a result of the latter we see wetting, +soiling and drooling. Even those reflexes which are only partially under +voluntary control, like those of blinking and swallowing, may be in +abeyance; for instance, saliva may collect in the mouth because it is +not swallowed, and tube-feeding is frequently necessary on account of +the failure of the patient to swallow anything that is put into his +mouth. The eyes may remain open for such long periods of time that the +conjunctiva and sclera may become quite dry and ulcerate. In these +extreme cases there is, of course, no response to verbal commands. What +is more striking, no reaction appears to pin pricks, so that it seems as +if consciousness of pain were lost. + +This deep torpor does not usually persist indefinitely. The commonest +evidence of some form of consciousness persisting is probably to be seen +in blinking when the eye is threatened or the sclera or cornea actually +touched. A very large number of patients, when otherwise quite inactive, +showed considerable response in their muscular resistiveness, the +phenomena of which will be discussed shortly. The relaxation of the +sphincters is apt to persist even after control of the rest of the body +is exercised to the point of permitting the patient to stand or walk +about. + +The first phase of obvious conscious control is seen in those patients +who will retain a sitting posture in bed or in a chair. The next stage +is reached where the stuporous case can be stood upon his feet but +cannot be induced to walk. The next degree is that of walking only when +pushed or commanded. Finally spontaneous movement is observed in which +the inactivity is evidenced merely by a great slowness. + +No correlation can be established between restrictions of speech and +motion other than that present in the extremes. With complete inactivity +there is almost always consistent mutism, and perfect freedom of speech +does not, as a rule, appear until the movements are free. In between +these extremes all variations are possible, even the deepest stupors are +occasionally interrupted by one or two words; for instance, a patient +may remain comatose, as it were, and absolutely mute for six months, +then to every one's surprise say one or two words and relapse into a +year of silence. Again one sees cases where movements have become fairly +free and yet the patient says nothing. This is another example of that +inconsistency in reaction which we have already noted in connection with +the mood or affect. + +In so far as inactivity is merely an expression of apathy, its causation +will be considered in connection with the psychology of the stupor +reaction as a whole. In so far as there may be specific factors, +however, it may be of interest to consider what information the patients +themselves give us from time to time as to what determined their +inactivity. It is really surprising how frequently something can be +gained either from careful notes taken during the stupor or from the +retrospective accounts of the psychotic experiences. Of course when one +considers the degree of amnesia which is usually present and the extent +of the intellectual defect in general, it becomes obvious that one +cannot think of getting anything like a complete explanation of the +behavior of any given case. Nevertheless this material is quite +suggestive in the mass; it gives one some idea of the mental state as a +whole. + +Among 40 cases, 27 offered some explanation either during or following +the psychosis. Of these, 20 spoke of feeling dead, numb or drugged, or +feeling as if paralyzed or having lockjaw. This group, just half of all +the cases, apparently ascribed their disability to something which +seemed physical. One might call them somatopsychic cases. The other 7 +gave more allopsychic explanations: 3 attributed their inactivity to +outside influence; 3 more said they were afraid (one of these because +she imagined herself to be in prison), which is analogous to the outside +influence; the 7th case thought she would injure people if she moved. + +The following are some examples of the statements of the somatopsychic +group: Laura A.: "I can't move," and retrospectively, "My arms were +stiff." Bridget B. claimed retrospectively that she felt dead or +drugged, that her limbs were lifeless, she felt as if she had lockjaw. +Johanna B. remembered being pricked with a pin on several occasions but +claimed that she did not feel the pain at any time. This suggests a +definitely hysterical mechanism. Anna L. (Case 16) said retrospectively +that she felt as if she were dead, although walking around, and also +that she thought she was a ghost and not supposed to speak. Anna M. said +she had tried to speak but everything stuck in her throat. Alice R. said +that she had no energy, did not want to talk. Meta S. (Case 15) claimed +that while stuporous her tongue would not move. Isabella M. in +intervals claimed that during the stuporous periods she felt as if dead +and said retrospectively when the whole psychosis was over that it was +"an effort to speak." Johanna S. (Case 13), while stuporous when pressed +with questions would say: "I can't think," "I don't know," "I am +twisted." When food was offered her she protested, "I am dead." +Charlotte W. (Case 12), in reviewing her case, said: "I was mesmerized," +"I thought I was dead." Anna G. (Case 1), in retrospect said: "I don't +think I could speak," again "I made no effort," or "I did not care to +speak." Henrietta H. (Case 8) said, "I lost speech." She claimed that +she did not move because she was tired and had a numb feeling. Mary C. +(Case 7) said that her tongue had been thick and that she felt dull. +Rose Sch. (Case 6) said during the psychosis that her head was upside +down and retrospectively that she had been mixed up, could not remember +well, did not feel like talking. Mary D. (Case 4) said that she had been +dazed, that she had not felt like talking, and that her limbs "were +stiff like." We should probably also include here as a delusion of death +the statement of Annie K. (Case 5) who wanted to die and thought she +would do so if she kept still enough. + +It is rather striking that among all the forty cases only one spoke of +being sick--"I am so sick." Only one evaded questions with "that was my +illness." One would expect a priori that these patients would offer some +vague explanations or make complaints of weakness. If these stupors +were purely physical in origin, one would expect such explanations as +weakness or illness to be offered in accounting for the inactivity. That +there is a rather definite type of explanation offered is, we think, +distinctly suggestive. If one tries to correlate and group the death +ideas, one sees that they are all delusions of death or of loss of +energy or complaints of hysterical symptoms that look like sham death. +If the lack of energy complained of be looked upon as lifelessness, one +can conceive of these explanations being variations of one theme, +namely, that of death. In the last chapter it has been shown that a +delusion of dying, being dead, or having been dead is extremely frequent +in the stupor group. It would seem only natural then to regard the +inactivity, in so far as it may be specifically determined, as an +expression of some such delusion. + +Psychiatrists are more or less aware of there being typical ideational +contents in the different manic-depressive psychoses. For instance, +every one is familiar with ideas of wickedness and inadequacy in +depression, ideas of violence in anxiety, or expansive and erotic +fancies in manic states. Quite similarly we have seen that death is a +dominant topic in a stupor. Now in addition to these typical ideas we +often hear expressed what we might term non-specific delusions, ideas +that seem to have nothing to do with a peculiar type of reaction which +the patient presents. It is therefore not surprising to find that +inactivity is not consistently ascribed to death or a related delusion. + +For instance, Henrietta B. had much talk of higher powers that were +controlling her, also said that it was fear which kept her quiet. +Josephine G. said retrospectively that she had thought she would injure +people if she moved and that if she opened her eyes she would murder the +people around her. Johanna B. was afraid to talk because she fancied she +was in prison. Laura A.: During her stupor was more vague, saying, "I +can't move, they won't let me be," without betraying any suggestion of +whom "they" might be. Finally Mary C. (Case 7) was still more +indefinite, ascribing her immobility merely to fear. When one considers, +however, that these five were the only ones who gave any atypical +explanation of their inactivity among the thirty-seven cases, the +preponderance of the death idea becomes striking. + +2. NEGATIVISM. The next of the cardinal symptoms to be considered is +negativism. This term, which is often loosely used, we would define as +perversity of behavior which seems to express antagonism to the +environment or to the wishes of those about the patient. Naturally it is +only in the minor stupors that we see it in well-developed form as +active opposition and cantankerousness. For example, Harriett C., who +stood about until her feet became edematous, would spit out food when it +was placed in her mouth but would eat if she were left alone with the +food. Josephine G., in a milder state, would turn her back on people. +When more inactive once rolled out of bed and lay on the floor. At this +time also she tried to keep people out of her room. Rarely, patients may +have angry outbursts, as did Annie K. (Case 5) who would strike at the +nurses. + +Very often the failure to swallow and anomalous habits of excretion seem +to be negativistic in their nature. One thinks at once of the necessity +for tube-feeding, which is so common even when patients seem otherwise +fairly active. Naturally this form of treatment is necessary only when +the patient refuses to swallow. Quite frequently a refusal to urinate is +met with so that catheterization is necessary, or a patient may never +use the toilet when led to it, but will defecate or urinate so soon as +he leaves it. These latter, like some other perversities, suggest +reactions of a petulant, spoiled child. + +By far the commonest manifestation is muscular resistiveness, often +spoken of as "resistiveness." It was present in thirty-two out of +thirty-seven of our cases. Usually it takes the form of a contraction of +the whole system of voluntary muscles when the patient is touched or the +bed approached. Often it appears only when any passive movement of the +limb is attempted. All muscles of the limb then stiffen, making the +member rigid. Sometimes the negativism is expressed by quite isolated +symptoms, such as stiffness in the jaw muscles alone. One patient showed +no opposition except by holding her urine for two days. Another kept her +eyes constantly directed to the floor. The reaction of another showed +no irregularity except for stiffness in the neck and arms and wetting +herself once after she had been taken to the toilet. One displayed +merely a slight stiffness in her arms. An interesting case was that of +Annie G. (Case 1) who kept one leg sticking out of bed. If this were +pushed in, she would protrude the other. Mary F. (Case 3) sometimes +expressed her antagonism to the environment by slapping other patients. +She spoke only twice in a year and a half, and each time it was when +interfered with. By far the commonest cause of muscular movement in +these inactive cases is resistiveness, and as a rule the inactivity is +interrupted only by negativistic symptoms. + +If we look for some explanation or correlation of these symptoms, we +find that chance references to conduct seem to point in the same +direction, namely, to the desire to be left alone. This resentment +against interference again reminds us of the reactions of a spoiled +child. For instance, Laura A., in manic spells during which she was +still constrained and drooled, said, "I don't want to have my face +washed." In the intervals she showed an intense muscular resistiveness. +Mary G. used to say, "Leave me alone," and covered her head or buried it +in the pillows. Maggie H. (Case 14) said in retrospect that she had +wanted to be left alone. Similarly Alice R. thought she did not want to +talk. Emma K. thought that she was in prison and apparently resented +this. Henrietta B. combined in her behavior tendencies both to +compliance and opposition. When her arms were raised they retained the +new position for a minute. Then she dropped them and said, "Stop +mesmerizing me." But then she put them up again of her own accord, and +when she had done this presented intense resistiveness to any movement. +Later she extended her arms in front of her and said, "I am all right," +in a theatrical manner, and then added, "Why don't you go away?" + +There seems to be some correlation between inaccessibility and muscular +resistiveness. For example, Charlotte W. (Case 12), whose condition +varied a great deal, always lost the resistiveness when she became +accessible, during which periods she also showed some facial expression. +The resistiveness would invariably return when the inaccessibility +reappeared. Caroline DeS. (Case 2) lost her resistiveness as she became +more accessible, although the inactivity and apathy persisted. This +tendency, which is quite common, suggests that muscular resistiveness +represents a lower level of expression of opposition which patients put +into words or purposeful actions when there is other evidence of some +contact with the environment. Sometimes one observes both general +resistiveness and specific acts. For instance, Mary G., who said, "Leave +me alone," and covered her head or buried it in the pillows, accompanied +her muscular resistiveness with laughter. This shows the affective +nature of the apparently purposeless muscular tension. The case of Annie +K. (Case 5) is more instructive. In the stage of deeper stupor she had +the automatic type of resistiveness but also outbursts of anger, +particularly toward the nurses, striking one of them she said, "You are +the cause of it all." When food was offered her, she said, "I wonder +people would not leave me alone sometimes." Again, when her bed was +approached, she would clutch and hold the bed clothes in an apparently +aimless way as if the impulse to resist never reached its goal. +Retrospectively she could not account for her muscular rigidity on the +basis of definite ideas, and could recall only that she felt stubborn. +In a later period when more accessible, she felt cross and did not want +to be bothered. This emotional attitude was quite conscious with her, +whereas the acts and speech of the earlier period, when her stupor was +more profound, seemed more automatic and impulsive. In other words, the +resistiveness looks like a larval attempt to express an idea which is +probably not fully conscious and therefore gives the appearance of being +aimless. As another example of this we may cite the case of Pearl F. +(Case 9), who said when she recovered, "I was stubborn." In addition to +the muscular resistiveness she had shown, she would often bite the bed +clothes or scratch herself when she was approached. Mary F. (Case 3), +while in a stupor, slapped at nearby patients quite aimlessly. When +somewhat better, this conduct appeared in a more conscious form, as +sullenness, indifference and smearing of feces (again the behavior of a +naughty child). Here one might quote Laura A. once more, whose +resistiveness when stuporous was intense but who in her manic spells +expressed her negativism in a definite idea, "I don't want my face +washed." + +To summarize, then, we may say that negativism is apparently the result +of a desire to be left alone, and that muscular resistiveness is a +larval exhibition of the same tendency. But the appearance of this +attitude in such aimless, impulsive acts or habits reminds us strongly +of the dissociation of affect, which was commented on in the previous +chapter. It would seem to be another example of this rather fundamental +tendency of the stupor reaction, not merely to diminish conative +reactions in general, but to reduce their appearance to that of +isolated, partial and therefore rather meaningless expression. + +3. CATALEPSY. The last of the cardinal symptoms to be considered is +catalepsy. It occurred in thirteen of thirty-seven cases, although it +was present only as a tendency in three of these. If we define it as the +maintenance of position in which a part of the body is placed regardless +of comfort, we can see that sometimes it is difficult to differentiate +from the phenomenon of resistiveness with its rigidity. It is most +frequently observed in the hands and arms, perhaps because it is, as a +rule, most convenient to demonstrate the retention of awkward positions +in the upward extremities. But any part or even the whole body may be +involved; for example, Charles O. retained standing positions even where +balance was difficult. This phenomenon is often accompanied by "waxy +flexibility," where the joints move stiffly but retain whatever bend is +given them, like a doll with stiff joints. + +The significance of catalepsy is best studied by considering its +relationship to other symptoms and by noting remarks made by the +patients in reference to it. The most important observations which we +have made seem to indicate that it never occurs with that degree of deep +inactivity which suggests a complete lack of mentation on the part of +the patient. One is therefore forced to conclude that back of this +phenomenon there must be some purpose, some kind of an ideational +content, although this may be of a primitive order. This is demonstrably +true in some cases, at least such as that of Isabella M., who left her +arm sticking up in the air but took it down to scratch herself and then +put it back. Somewhat similarly, Charlotte W. (Case 12), when she was +shown during convalescence a photograph of herself in a cataleptic +state, said that that was when she was waiting to go to Heaven and was +afraid to move. Again she remarked, "I was mesmerized." Josephine G., +who showed only a tendency to catalepsy, said that she feared the devil +would get control of those about her if she moved. Sometimes there is a +development of this symptom from others which seem to be ideational in +their origin. For instance, Charles O. began making flail-like +movements. These passed over into slow circular motions which finally +subsided into the maintenance of fixed position. + +References to hypnotism are not infrequent, and in many cases there is +evidence of a delusion that the posture is desired by those in charge of +the patient. Annie G. (Case 1) said so directly. In retrospect she +explained the holding of her arms in the air by saying, "I thought you +wanted me to have them up." Henrietta B. at one examination kept her +arms raised in the position in which they had been put for a minute and +then dropped them, saying, "Stop mesmerizing me." But she then put them +up again of her own accord and now presented intense resistance to any +motion. Later she extended her arms in front of her and said, "I am all +right," in a theatrical manner. Some patients give evidence in other +symptoms of larval efforts at cooperation with the actual or supposed +wishes of the physician and in such cases it is not impossible that +passive movements are interpreted as orders. One must remember in this +connection that the more primitive are the mental operations of any +individual, the more important do signs, rather than speech, come to be +a medium of communication with other people. As an example of this type +we might mention Rose Sch. (Case 6), who flinched from pin pricks +(showing that she felt them) but made no effort to get away. When +somewhat clearer she said that she was "here to be cured." Similarly +Mary D. (Case 4), who showed no catalepsy from ordinary tests, kept her +head off the pillow for a long time after it was raised to have her hair +dressed. She showed such perseveration in many constrained positions. +She too flinched from pin pricks but not only made no effort to prevent +them but would even stick out her tongue to have a pin stuck in it. + +The relationship of catalepsy to resistiveness is interesting but +unfortunately complicated and unclear. In only one of our cases was +catalepsy definitely present without resistiveness, and in one other a +"tendency to catalepsy" was noted without muscular rigidity being +observed. In this latter case, when the catalepsy became unquestionable, +resistiveness also appeared. It is one thing to note this coexistence +and another to explain it adequately. All that we can offer are mere +speculations as to the real meaning of the association of these +phenomena. It may be that the tension of muscles that occurs when +resistiveness is present gives the idea to the patient of holding the +position. There would be two possible explanations for this. We might +think there is a dissociation of consciousness, like that of hysteria, +where the feeling of tenseness in the muscles that comes from the +resistance to gravity is not discriminated from the resistance to the +movements made by the examiner. On the other hand, there might be a +similar dissociation where the perception of contraction in the +antagonistic muscles is interpreted as the action of the examiner in +placing the limb in a given position. This latter view would seem, on +the face of it, ridiculous, inasmuch as its presumes the existence of +two directly opposed tendencies, namely, those of opposition to the will +of the physician and compliance with it. But ambivalent tendencies are +frequently present in psychopathic states, and moreover we find +occasionally some evidence in the behavior of the patient to +substantiate this view. For example, at one stage of the stupor of Annie +G. (Case 1), her arm could be moved without resistance. Then the elbow +would catch and at this moment the position would be maintained. Such +observation is highly suggestive of the resistance being signal for the +catalepsy. In Isabella M. the catalepsy appeared when resistance to +passive movements also developed. On the other hand, when the resistance +became extreme, the catalepsy was reduced, and vice versa. This makes +one think of two tendencies: suggestibility on the one hand, and +opposition on the other. We might presume that when both are present and +equally strong, stiffness with passive movements results as a kind of +compromise, but when there is a greater development of one, the other is +inhibited. + +Such speculations remind one strongly of the psychology of conversion +hysteria and of hypnotism. In some cases of stupor hysterical symptoms +are quite definitely present. For instance, Celia G. began her psychosis +with hysterical convulsions which would terminate with short periods of +stupor. Later the stupor became persistent and during this stage she had +catalepsy (and restiveness as well) in her left arm only. On recovery +from her stupor she complained of stiffness in her hands, which +examination proved to be a purely hysterical difficulty. + +This whole subject is without question obscure and many more and very +careful observations are needed before really satisfactory explanations +can be given for these phenomena. That it is a reaction which is related +to the primitiveness of the mental content and the intellectual deficit +in stupor would seem to be a reasonable view, inasmuch as quite similar +phenomena have been observed in a large number of animals, even among +crustaceans. As a result of our own observations the only thing we feel +at liberty to state with real confidence is that catalepsy is presumably +a phenomenon mental in origin rather than somatic, because it always +occurs in conditions which show other evidence of mentation. + +Whatever may be the origin of the idea of the posture assumed, there can +be little doubt that its indefinite maintenance is a phenomenon of +perseveration. The conception of the position being in the patient's +mind, it is easier to hold it than elaborate another idea. This, of +course, is part of the intellectual disorder in stupor. In fact, it is +difficult to imagine any one whose critical faculty was functioning +cooperating in a test for catalepsy. + + + + +CHAPTER VIII + +SPECIAL CASES: RELATIONSHIP OF STUPOR TO OTHER REACTIONS + + +We have described typical cases of benign stupor and isolated certain +interrelated symptoms which, when they dominate the clinical picture, we +believe establish the diagnosis of stupor, regardless of the severity of +the reaction. These symptoms are apathy, inactivity, a thinking disorder +and, quite as important as these, an absorbing interest in death. It is +typical that the patient contemplates his dissolution with indifference +or, at most, with mild or sporadic anxiety. There seems little reason to +doubt that when these four symptoms occur alone, we are justified in +making a diagnosis of stupor. The next problem is to consider the +meaning and classification of cases where these symptoms occur in +conjunction with others. This naturally introduces the subject of +relationship of stupor to other manic-depressive reactions. + +It is probably best to begin with presentation of three such cases. + + + CASE 16.--_Anna L._ Age: 24. Admitted to the Psychiatric + Institute August 21, 1916. + + _F. H._ Maternal grandmother temporarily insane during + illegitimate pregnancy, thereafter a little odd. Mother + high strung and emotional. Father high strung, impulsive + and irritable. + + _P. H._ As a child she was quick tempered, quite a spitfire + and given to tantrums. At the age of 14 she became a + vaudeville actress in Cleveland, which was the home of her + childhood. When 17 she married a Jew, although she was + herself a Catholic. Her husband noted that she was fretful, + sensitive, resentful and quick tempered, although apt to + recover quickly from her rages. Previously healthy, + neurotic symptoms began with marriage, taking the form of + stomach trouble and a tendency to fatigue. Shortly after + marriage an abortion was induced. After being married for + two years she had a quarrel and separated from her husband. + They were reconciled later, but in the meantime she had + been having relations with another man. When 20 an + abdominal operation was performed in the hope of relieving + her gastric symptoms, but no improvement occurred. The + patient after recovery stated that she continued to be + nervous, shaky and dizzy, at times trembling when going to + bed at night. Two years later, however, she took up + Christian Science and showed objectively some improvement + in her health, although according to her later accounts she + continued to feel somewhat nervous and fatigable. Her + husband stated that at this time she also began to ponder + much about such questions as the difference between life + and death, what "matter" was, and also studied "grammar" + and "etiquette." According to the patient some five or six + months before admission she began to have peculiar + sensations following intercourse--a feeling of bulging in + the arms, legs and back of the neck. One evening after an + automobile ride there were peculiar sensations on her right + side like "electricity" or as if she were inhaling an + anesthetic. She gasped and thought she was dying. Two + months before her admission she went with her husband and + his family to a summer resort where she felt increasingly + what had always been a trouble to her, namely, the nagging + of this family. + + Just before her breakdown, because she went daily to the + Christian Science rooms in order to avoid the family, they + suspected her of immorality and accused her of going to + meet other men. Even her husband began to question her + motive. Retrospectively the patient herself said that she + now felt she was losing her mind and did not wish to talk + to any one. At the time she told her husband that she felt + confused and as if she were guilty of something and being + condemned. Repeatedly she said she knew she was going to + get the family into a lot of trouble. Once she spoke of + suicide, and for a while felt as if she were dying. Finally + she became excited and shouted so much that she was taken + to the _Observation Pavilion_, where she was described as + being restless and noisy, thinking that she was to be + burned up and that she had been in a fire and was afraid to + go back. + + _On admission_ she looked weary and seemed drowsy. + Questions had to be repeated impressively before replies + could be obtained, when she would rouse herself out of this + drowsy state. She seemed placid and apathetic. She said + that nothing was the matter, but soon admitted that she had + not been well, first saying that her trouble was physical + and then agreeing that it had been mental. When asked + whether she was happy or sad, she said "happy," but gave + objectively no evidence of elation. Her orientation was + defective. She spoke of being in New York and on + Blackwell's Island, but could not describe what sort of + place she was in, saying merely that it was "a good place," + or "a nice country place," again "a good city." Once when + immediately after her name L. had been spoken and she was + asked what the place was, she said "The L." She knew that + she had arrived in the hospital that day but said that she + had come from Cleveland, and to further questions, that she + had come by train, but she could not tell how she reached + the Island. She claimed not to know what the month was and + guessed that the season was either spring or autumn + (August). She gave the year as 1917, called the doctor "a + mentalist," and the stenographer "a tapper," or "a mental + tapper." She twice said she was single. When asked directly + who took care of her, said "Mr. Marconi," who she claimed + at another time had brought her to the hospital. To the + question, who is he? she replied, "Wireless," and could not + be made to explain further. That night she urinated in her + bed, and later lay quite limp, again held her legs very + tense. + + For five days she remained lying quietly in bed for the + most part, although once she called out "Come in, I am + here," "Jimmie, Jimmie" (husband's name). Several times she + threw her bed clothes off. Otherwise she made no attempt to + speak and took insufficient food unless spoon-fed. At one + examination she looked up rather dreamily but did not + answer. When shaken she breathed more quickly and seemed + about to cry but made no effort to speak. When left to + herself she closed her eyes and did not stir when told she + could go back to the ward. She was then lifted out of her + chair and took a step or two and stopped. Such urging had + to be repeated, as she would continue to remain standing, + looking about dreamily, although finally when taken hold of + she whimpered. When she got to the dining-table she put her + hand in the soup and then looked at it. So far there is + nothing in this case atypical of what we would call a + partial stupor. The cardinal symptoms of apathy, + inactivity, with a thinking disorder, are all present and + dominate the clinical picture. There is, further, the + history of a delusion of death during the onset of the + psychosis. Had her condition remained like this, there + would be no difficulty in classifying the case, but other + symptoms appeared. + + Five days after admission she was restless, somewhat + distressed, and announced that she wanted to talk to the + physician. When examined, the distress, with some + whimpering, continued. She asked the doctor not to be harsh + to her, frequently said there was something wrong and began + to cry. A normal interest appeared only once, when she + spontaneously said she wanted to see her relatives. A most + interesting feature, however, was a certain perplexity that + now appeared. She spoke of this directly: "I do not know + what it is all about. I know you are a doctor, that is all. + I don't know whether I passed out and came back again or + what--I don't know what to make of it." She also felt + confused about her marriage--"There is where all the mixup + is. I was married when I was 16." She was reminded that she + had said she was single, and replied "I am single." Then + where is your husband? she was asked. "He must be dead." + She recalled the examination on admission and remembered + some of the questions that she was asked then, also knew + that she had been at the Observation Pavilion and that she + had reached this hospital by boat. On the other hand she + still claimed that the year was 1917, and in connection + with the delusion of having died was quite unclear as to + the time. She said that it seemed as if she had died many + years ago and that she had come to the hospital years ago. + She also spoke of having died at a summer resort the year + before. When asked for her age, she said that she must be + very old, but on the other hand claimed that she was + supposed to die and to come to the hospital when she was 26 + (two years more than her actual age). + + Her psychosis continued from then on for about ten weeks. + She soon began to feed herself, but otherwise for most of + this period remained quietly in bed, looking about a good + deal, although showing no particular mood reaction until + questioned, when she was apt to make repeated statements + about her perplexity--that she did not know what it was all + about, every one had mixed her up, everything was so + strange, "my head is mixed up, I am trying to straighten + things up." She frequently when interviewed became + lachrymose and often with her subjective confusion there + was considerable anxiety. Another unusual phenomenon for a + stupor patient was that she was frightened at a thunder + storm. On the whole, however, her apathy and indifference + were quite marked. For instance, during the latest phase of + her psychosis, when the nurses would sometimes make her + dance with them, she did so but without showing any + interest and not until immediately before her recovery did + she begin to speak spontaneously to any extent whatever. A + marked difference from the ordinary stupor was that this + apathy was invariably broken into when she was questioned + and ideas came to her mind, the nature of which seemed to + be essentially connected with her perplexity. + + Not only did ideas appear more frequently than one meets + them in stupor cases, but they were present in greater + variety. The dominant stupor death idea was, it is true, + almost constantly present, but it did not come to the + direct and unequivocal expression which we are accustomed + to see in typical stupor. She did not say "I am dead," or + "I was dead," but it was always "It seems as if I were + dead," or "I think I must have died," or some such dubious + statement. Other ideas were that her mother was dead and + had been put into a box. She frequently gave her maiden + name and said that she lived in Cleveland with her mother + and that this was Cleveland. At times she thought she was + engaged and was going to be married to her husband shortly. + Again there were notions that her husband had married + somebody else or that some harm was going to come to him. + Sometimes she thought that her mother's name was her own, + that is, Mrs. L. The hospital once seemed like a convent to + her. + + Her subjective and objective confusion seemed quite + definitely to be connected with the insecurity and + changeability of these ideas. It appeared as if insight and + delusion were struggling for mastery in her mind, so that + reality and fancy were alternately, even simultaneously, + possessing her, and that this gave her the feeling of + perplexity from which she suffered. Once when she remarked + "It seems as if I had been dead all the time," she was + questioned more about this and replied, "Well, sometimes I + thought I was dead, at other times it seemed as if I + wasn't." In answer to a direct question about her feeling + of confusion she said "I don't know. I know I have lots of + good friends, they all want to help me and it seems as if + everything got mixed up between the L.'s (her married name) + and the G.'s (her maiden name)." This was apparently an + elaboration of the wavering ideas she had about her + singleness or her married state. Once after referring to + her husband as her sweetheart whom she was to marry, and + immediately thinking that perhaps he had married somebody + else, she added, with a sigh, "The more this goes on, the + more mixup." In short, any question, even on some + apparently neutral topic, seemed to start up conflicting + ideas in her mind, the inconsistency of which she + recognized without being able to control their appearance. + Hence, whenever she was spoken to, she became perplexed and + distressed. + + Her orientation gradually improved so that, although it + remained vague, it was no longer glaringly inaccurate. Then + quite suddenly she one day came to a nurse and asked how + long she had been in the hospital. When told, she remarked + that it seemed as if she had spent the whole winter there. + She was examined at once and found to be quite clear and at + first in good control of her faculties. She remembered a + good many of her ideas, in fact was able to elaborate a + little from memory on what had already been reported from + her utterances during the psychosis. The recovery was not + immediately complete, however, for at this examination, + when told that she had constantly given her maiden name, + she became distressed and said the physician was trying to + mix her up and was reluctant for this reason to discuss her + ideas. This soon passed, however, and within a few days + she was quite normal and had remained so for some months + after her discharge from the hospital, when last seen. In + fact, according to the husband, she was in better mental + and physical health following the psychosis than she had + been for years. + +Essentially, then, this case shows what was at first a typical partial +stupor, but soon became complicated by a tendency for questioning to +provoke rather a free flow of ideas and a distressed perplexity. This +symptom of perplexity soon grew to dominate the clinical picture, so +that the psychosis was really a perplexity ushered in by a brief stupor +reaction with a background of stupor symptoms running through it. The +second case shows similar tendencies but different from the one whose +history has just been cited in that the perplexity was never complained +of by the patient herself and that her emotional reactions were more +marked and varied. + + + CASE 17.--_Celia C._ Age: 18. Admitted to the Psychiatric + Institute May 2, 1914. + + _F. H._ Four years after this attack her mother was a + patient in the hospital with an atypical manic-depressive + psychosis from which she apparently recovered. + + _P. H._ The patient herself was described by superficial + observers as being bright, sociable, well-informed and very + ambitious. + + When 18 years of age she was working very hard preparing + for some examinations, and worried lest she should fail in + them. Some years later the patient accounted for her + psychosis by saying she had a quarrel with her sister, + immediately after which she began to feel depressed. The + anamnesis states that she was slow, complained of not being + able to think and feeling as if she had no brain. She was + sent to a general hospital, where she was apprehensive, + wanted her mother to stay with her and one night called out + "Mother." + + The case being recognized after a few days as a psychosis, + she was sent to the _Observation Pavilion_, where she was + described as jumping about in bed in a jerky, purposeless + manner, resistive when anything was done for her, and mute. + Her sister reported that when she visited her the patient + said "Go away, I am dead." + + _On admission_ she looked dazed, stared vacantly and had a + tendency to draw the sheet over her. When put on her feet + she let herself fall limply. At times she became agitated, + sobbed and cried loudly, especially when attempts were made + to examine her physically, or, when she was asked + questions, she scarcely spoke. + + Her psychosis lasted but a little more than three months + under observation and was characterized by the following + symptoms: She was usually in bed, staring blankly or + appearing otherwise quite indifferent and apathetic, but + not infrequently, especially during the first few weeks, + she was quite restless, resistive, whined and suddenly + appeared startled or distressed with no occasion for this + reaction in the environment. Rarely she was suddenly + assaultive. When attempts were made to examine her, she was + frequently mute or would repeat the question with a rising + inflection, not getting anywhere, or would say, "What shall + I say," or "I, I----" never finishing her sentence. After + orientation questions she might say "This is--this is--this + is----" all this, together with a rather perplexed + appearance, gave the impression of considerable + bewilderment, but at no time did she complain of + autopsychic perplexity. It was difficult to judge of her + orientation on account of her failure to answer questions, + but it soon appeared that she knew the names of the nurses, + for she sometimes called them spontaneously by name. She + always ate reluctantly. + + During these examinations, however, other symptoms often + appeared. When she was talked to, she was apt to indulge in + depressive statements and show considerable distress. Such + remarks were: "I must confess my guilt," "I am a bad girl + and I have to face my guilt," or "I have sinned," or, + standing up with a dramatic air, "I must stand up and tell + the truth." Once she said, "It is too late to live now." + She spoke of having lied and usually would not say what + about, but once on questioning replied "I said I would not + tell what happened here." She was asked, What do you mean? + and answered "I took my oath not to tell anything." Pressed + further she said that the nurses poisoned her. Another time + she said she was in prison. To her aunt who visited her she + said, "I am a prostitute," and once she remarked to the + doctor, "I have killed my honor," and on another occasion + in the middle of the night she called out, "Chinatown + Charlie, come here." She thought the doctor was her + brother. + + Most of these statements were associated with painful + emotion, but there were a few occasions when an element of + elation cropped out. Thus on one occasion she laughed, + another time gripped the doctor's pad and tried to read it. + When the nurse laughed, she made a funny grimace at her and + said "Why do you laugh?" Again she once sang two songs, but + after the first verse got stuck and kept repeating one + word. + + At the end of three months she improved rather rapidly and + was in a condition for discharge as "recovered" a month + later. Retrospectively she said that she recalled feeling + guilty, thinking that her mother was dead, having been + killed by the patient as a result of worrying over the + latter's failure in her examinations and refusal to eat. + She remembered, too, that at times she thought the building + was burning. Some things like "Chinatown Charlie" she + denied remembering, although she had a good recollection + for the external facts throughout the psychosis. Her + insight was superficially good, but she was reluctant to + discuss her psychosis, in fact claimed that she had been + made more of a lunatic by coming to the hospital than she + was on admission. + + Some five years later she had another somewhat similar + attack, again following a quarrel, this time with a fellow + employee. In this second psychosis, however, manic elements + were much more prominent. + +Here again, then, we have the symptoms of apparent apathy, inactivity, +and similar ideas of death, but the thinking disorder was possibly not +very profound, inasmuch as she had a good memory for external events. +Her ideas, too, are much more florid than those which we customarily +meet with in stupor cases, but the most marked peculiarity was that +this "stupor" was liable to constant interruption, either spontaneously +or as a result of questioning, which always produced a mood reaction. +She was apathetic only so long as she was left alone. In other words, +whenever an effort was made to test what seemed to be apathy, the +evidences of it disappeared. + +The third case to be considered is somewhat like that of the first, Anna +L. (Case 16), in that with the inactivity and apathy there was a +coincident subjective perplexity. The apathy, however, was less marked +than in the case of Annie L. + + + CASE 18.--_Catherine M._ Age: 24. Admitted to the + Psychiatric Institute November 10, 1913. + + _F. H._ Information as to the family is confined to the two + parents. The mother, who was frequently seen, seemed to be + a natural, sensible woman. The father, on the other hand, + had been alcoholic all his life, had had two convulsions + while drinking, and had little respect from any member of + the family, including the patient. + + _P. H._ The patient was said always to have been healthy, + from a physical standpoint, although never robust. She got + on well at school, and then worked first as a stock girl + and later as clerk in a department store, where her work + was efficient and she advanced steadily. As a child she + played freely with other girls but little with boys. As she + grew older she moved about socially a little more, made the + acquaintance of men as well as of girls, but never cared + much for the former and had no love affairs until she met + her husband. She was never demonstrative but always rather + quiet and modest. Occasionally she spoke of thinking that + people talked about her, but the informant doubted if she + brooded over this, because she was not of a worrying + disposition. Considering the ideas which appeared in her + psychosis, it is striking that in her normal life she was + rather antagonistic towards her father on account of his + alcoholism and the crudity of his speech and manners. + + When she met her husband she liked him from the first, + although she at no time became really demonstrative. They + were engaged for a year, during which time she agreed to a + postponement of three months for the marriage, which was + suggested by her mother. For some time before this event + she was working harder than usual and seemed a bit worn + out. She ceased working a month before marriage and + improved physically, although she became rather nervous, + that is, she was more easily startled, an accentuation of + what had been a characteristic for some years. Her husband + stated that at this time she became fearful of the + approaching marriage relations and asked him to be kind to + her in this respect. She was married a year before + admission. For two and a half months she refused + intercourse and visited her mother's home a great deal. She + finally submitted. She was quite frigid but became pregnant + at once. Her abnormality then became apparent. She kept the + fact of her pregnancy to herself for several months and + then when she told her mother wanted to have an abortion + performed. Neurotic symptoms appeared. She became sensitive + with her husband, correcting his grammar, and cried easily. + She also began to be anxious about the approaching + childbirth, and with this became more religious. + + For the first few days after the delivery, she was fussy + with the nurse so that two in succession had to be + discharged. On the fifth day she woke up and seeing a nurse + lying on the couch beside her bed thought the latter was + colored. On the seventh day she had a dream in which she + thought she "nearly died in childbirth." Then she began to + talk of dying for her baby or of having two babies, of + dying herself and rising again after Easter Sunday. She + became antagonistic to her husband and with this excited + and confused so that she was taken to the Observation + Pavilion. + + On _admission_ she looked pale and exhausted, had a slight + temporary fever and a coated tongue. Her orientation was + usually vague but sometimes she gave fair answers. Her + verbal productions were rather fragmentary and with the + exception of some repetitions there did not seem to be any + special topics which dominated her train of thought. + + For some days the great weakness and the slight fever + continued, and then, as it gradually cleared up, there came + a change in her mental condition that settled into the + state which characterized the rest of her psychosis. She + talked less and was often quite inactive, frequently lying + with her eyes closed for long periods, or sat or stood + about. Such movements as she made were slow and languid. + Her expression was either blank, absorbed, or gave the + appearance of peculiar appealing perplexity. This last was + not infrequently associated with a rather sheepish smile. + She was never resistive and always ate and slept well. With + the exception of a few times she did not soil herself. The + most interesting feature of her mood reaction was that in a + general setting of a slight perplexity there appeared at + times and evidently associated with definite ideas, changes + in her emotional state. Sometimes this was a matter of + distress or of mild ecstasy, sometimes she became markedly + blocked. There was at no time any frank elation, but often + an appropriate smile, that is, appropriate to the situation + and to the thought to which she was giving expression at + the time. Then, rarely, there were sudden bursts of + peculiar conduct, such as throwing herself on the floor or + running down the hall. When questioned as to her motive for + these acts, she would flush, look perplexed and apparently + be unable to explain them. + + Her verbal productions dealt with a rather limited range of + topics which can be briefly summarized. As in the other + cases, the reader will notice that the bulk of these ideas + are of a kind not usually prominent in the typical stupor + cases. Many of her thoughts seemed centered around her + husband. She always knew him when he visited her, but in + her thoughts there was a constant change as to his + personality. She persistently confused him with the + physicians, with her father, and with God, and one remark + is typical, "I thought he was God, priest, doctor, + lawyer--well, I wanted to go to Heaven; I thought he would + still be my husband; I always hoped that I would be home in + Heaven." Not unnaturally with this confusion there were + doubts about her marriage. People said her marriage was + wrong and her husband bad. Frequently she thought he was + dead, or voices informed her that she was not married to + him, or that he was the devil in Hell. In this connection + she also said that people called her a whore, or it seemed + as if she were accused of not being married. + + As prominently as appeared the ideas of the invalidity or + impossibility of her marriage, to the same extent did her + father assume an important role for her. As a rule he + appeared in religious guise as God, but often he was the + doctor--"I knew my father at home and my father in Heaven; + which God do you mean? did you say God or father?" At times + she spoke of being in Heaven and that God seemed to be God, + doctor or priest. In this connection there were ideas of + being under the power of some one, God, devil or father. + + As is usually the case where strong interest is expressed + in the father, ideas of the mother being dead occurred, + although in the frankest form she reported them as dreams; + for instance, one night she woke up screaming, said that + she had dreamed that her mother was dead and her sister + dying. That, in the psychoanalytic sense, this represented + a removal of a rival, making union with her father easy, + appeared in the statement that her father was dead but that + she had dreamed he had come to life again for some one + else. When asked what she meant, the question had to be + repeated several times, then she said "My mother died, my + father and mother had a quarrel." There is more than a + suggestion here of a difference in the significance of + death, in so far as it concerned the two parents. The + mother dies and remains dead, that is, she is gotten rid + of. The father dies but takes on a spiritual existence and + comes to life again, a frequent method in psychoses for + legitimizing the idea of union with the parent by + elimination of the grossly physical. + + There were strikingly few allusions to the plainly sexual. + She spoke of being married to the doctor, and even went so + far as to say that they belonged together in bed. On + another occasion she called him "darling." Once she + reported that it was said that she was going to have babies + and babies and babies. These references were, however, + quite isolated, so that the erotic formed a very small part + of her productions. + + Delusions of death, we have seen, are the most constant + content of true stupors. In this case they were present but + distinctly in the background. She spoke quite frequently of + being in Heaven. She also talked of being crucified. Once + she said "I died but I came back again." This last + utterance was rather significant in that frankly accepted + ideas of death were unusual; for instance, she would say + sometimes, "I think I am in Heaven, again not. It confuses + me, but I know I am in Heaven." + + In general, then, her ideas were, on the whole, not at all + typical of stupor but much more like those met with in + other manic-depressive conditions. Correlated with this was + an unusual mood picture. Quietness and apparent apathy of + the patient were interrupted by little bursts of emotion, + and throughout the psychosis there was a coloring of + perplexity. Not only was this last objectively noticeable, + but she spoke very frequently of it and always in + connection with the inconsistency of the ideas in her mind + which puzzled her. For instance, in speaking to the doctor + she said "I think of you as Bill (her husband's name) + sometimes--I get confused thinking of Bill as God, doctor, + lawyer, priest." Again, referring to her husband, she made + these curious statements: "They seemed to speak of him as + being in the wrong--the right--it seems that the right + devil is the wrong one for me--they say he is not the right + one for me; they say he went wrong from the time we were + married." Again, she said that she did not know who her + father was, and went on: "It puzzles me, this father + business, I knew my father at home and my father in + Heaven." Again, "Which God do you mean? Did you say God or + father?" A hint as to how this subjective confusion made + the environment seem uncertain comes from the statement, + "You looked like the devil and yet you were God." + + Distress and anxiety appeared not infrequently and always + appropriately. The distress was usually occasioned by an + idea of injury to others, as when she cried over the + fancied accusation of drowning her husband and mother; or + in connection with accusations of herself, such as when she + reported "They called me a whore." As has been stated, + there was never any frank elation, but an element of + pleasurable expansive emotion was frequently present in + connection with her religious utterances. This came + particularly when she spoke of union with her father as + God. She seemed to swell with ecstatic emotion. It was + especially well marked once when she threw herself on the + floor and when asked what she was trying to do replied, "I + want to do what God wants me to do, drop dead or anything + at all." Perhaps the most unusual affective reaction was a + blocking which occurred when certain topics appeared. This + is a phenomenon quite unusual for stupor, where speech + seems to stimulate and arouse the patient as a rule. One + got the impression that ideas tended to come into this + patient's mind which were painful enough to disturb her + capacity for connected thought. A good example of this + reaction was when she was speaking of her father having + died and coming to life again. On being asked what she + meant, she became quite blocked and the question had to be + repeated several times, when finally the apparently + unrelated statements appeared: "I dreamed my mother + died--they had a quarrel." Who had a quarrel? she was + asked, and replied "My mother and father." Apparently her + thinking about her father coming to life for some one not + her mother stimulated deeply unconscious ideas concerning + the separation of her mother and father, and her taking the + mother's place, and these ideas were sufficiently + revolutionary to upset her capacity of speech for the time + being. + + She recovered completely about six and a half months after + her admission. + +If we consider together the common features of these three cases, we see +that they resemble stupors only in the presence of inactivity and +apparent apathy. It is true that death appears in the ideational content +but not with that prominence, bordering on exclusiveness, which +characterizes such delusions in the true stupors. These three patients +give one the impression of being absorbed in thoughts that have many +variations. It seems as if they had difficulty in grasping the facts of +the environment, while feeling at the same time the vividness of the +changing internal thoughts, hence a confusion develops which is either +subjective, objective, or both. It is probably the introversion of +attention which gives rise to the apparent apathy, because normal +emotions emerge as part of our contact with reality around us. This lack +of contact with the environment leads also to inactivity. If one's +attention and interest is turned inwards, there can be no evidence of +mental energy exhibited until the patient is roused to contact with the +people or things about him. It is noteworthy that in these cases +emotional expression emerged when the patients were stimulated to some +productiveness in speech. + +These conditions really constitute a different psychosis in the +manic-depressive group, essentially they are perplexity states such as +have recently been described by Hoch and Kirby.[7] Not infrequently we +see exhibitions of this tendency in what are otherwise typical stupors. +For example, Mary F. (Case 3) (the third case to be described in the +first chapter), showed for a few days after admission a condition when +she was essentially somewhat restless in a deliberate aimless way. At +the same time she looked dazed or dreamy. With this restlessness she +appeared at times "a little apprehensive." Although she spoke slowly, +with initial difficulty she answered quite a number of questions. Her +larval perplexity was evidenced by the doubt expressed in a good many of +her utterances, such as, "Have I done something?" "Do people want +something?" "I have done damage to the city, didn't I?" When asked what +she had done, she said, "I don't know." She asked the physician, "Are +you my brother?" and when questioned for her orientation said, "Is not +this a hospital?" The atmosphere of perplexity also colored the +information which she did recall correctly; for instance, when asked her +address, she said, "Didn't I live at ----?" then giving the address +correctly. + +As stated in Chapter V dealing with the ideational content of stupor, +one has to look on the delusions of patients as symptoms subject to +analysis and classification just as truly as the variations in mood or +intellectual processes, in fact they should be subject to the same +correlation as are the mental anomalies which are usually studied, +particularly if we are to understand these psychoses as a whole. Let us, +therefore, consider the death ideas in the three cases studied in this +chapter. We find that, as in the ordinary stupors, there are delusions +of death, also of mutual death (with the father), but there is a +tendency to elaboration so that the death is only part of a larger +OEdipus drama, the rest of which is usually lacking in stupors. Here +it is present. So we have thoughts of the death of the mother or +husband, another rival, considerable preoccupation with Heaven, and also +erotic fancies. + +We find in manic-depressive insanity a tendency for more or less +specific ideational contents with different types of the psychoses.[8] +For example, there are religious and erotic fancies or ambitious schemes +dominating the thoughts of manic patients, fears of aggression and +injury met with in anxiety cases, and so on. In stupors, death seems to +be a state of non-existence with other meanings lacking or only hinted +at occasionally. When it tends to be elaborated, it leads over to +formulations suggesting personal attachments and emotional outlet, and +then we are apt to find interruptions of the pure stupor picture. For +example, Charlotte W. (Case 12), whose case has been described, thought +much about being in Heaven and ended with a hypomanic state. Atypical +symptoms appear just as constantly in these cases, as do the atypical +ideas. In other words, the thought content is definitely correlated with +the clinical picture. + +As the clinical pictures show the relationship of stupor to other +psychoses, so there is also a correlation with varying formulations of +the death fancy. We are now in a position to define more narrowly what +death means in stupor. It is an accepted fact, a Nirvana state. When +death means union with God or appears in other religious guise, manic +symptoms tend to develop. When it is unwelcome and appears as "being +killed," we find anxiety symptoms. A patient can conceive of death +variously and have various clinical pictures. A knowledge of the +metamorphoses of ideas and their relationship to other symptoms enables +us to understand such cases, that, without this key, seem confused and +lawless jumbles of symptoms. Such theories tend to justify the view of +essential unity of the manic-depressive group. + +It would be instructive at this point to consider another case which +illustrates beautifully how a stupor reaction may crystallize out of +other manic-depressive states when attention has become focused on +personal death. This patient went through four phases while under +observation. First, while showing a perplexed expression but with fair +orientation, she gave utterance to erotic and expansive fancies. She was +restless, somewhat intractable and gave the impression of brooding over +her imaginations rather than luxuriating in them. In other words, her +condition seemed to be more that of absorbed than active mania. Second, +these same ideas, somewhat reduced, continued in an apathetic state +while impulsive symptoms developed: She began to shout like a huckster +to be taken to Heaven and made numerous affectless, suicidal attempts. +Third, came a true stupor and, fourth, a period of recovery when the +stupor symptoms all disappeared but insight into the falsity of her +ideas was lacking. + + + CASE 19.--_Celia H._ Age: 19. Admitted to the Psychiatric + Institute October 22, 1913. + + _F. H._ The father was living; he always drank, and + especially in later years contributed little to the support + of the family. The mother was living and said to be + normal, while a brother was coincidentally insane, with a + recoverable psychosis. + + _P. H._ The mother stated that the patient was bright at + school, enjoyed company and going out, had a droll wit, was + not at all seclusive, no dreamer, helped to support the + family and was efficient. She was very much attached to her + brother and once said that if anything should ever happen + to him she thought she would die. She also cared much for + her older sister, with whom she worked, and for her mother. + + Three months before the patient's admission her brother + became depressed, mute, seemed worried, cried at times. He + was sent to the country. Two months before admission, when + the mother and the patient went to bring the brother to + town, and while they were at the station, he suddenly tried + to throw himself under a train but was restrained just in + time. The patient appeared intensely frightened, but did + not talk. In fact, she seemed somewhat bewildered and at + once became dull. "Her movement and manner were much as at + present." + + When the patient was able later to give a retrospective + account of the onset, she claimed that for some months + before this incident she saw that her brother was losing + his mind. She worried about this as well as about her work, + and felt worn out. She said that when the brother tried to + throw himself under the train she was terrified and could + not speak or move, and that her mind got upset at once, "I + lost my memory." The others forgot her and left her alone + on the platform. Strangers put her on another train and she + knew nothing until she arrived at home. + + The mother added that at the time when the incident with + the brother happened, the patient was menstruating and that + this ceased at once. + + At home she sat about inactive and did not seem even to + worry. Whenever any one asked her about her brother she + replied that he was dead. For two weeks before admission + she said she was rich, that she owned all the property + around. She also said she was married to Mattie S. In this + connection the mother says that a foolish neighborwoman, + the mother of Mattie S., told the patient since her + sickness, by way of encouragement, that she should marry + her son (the man mentioned). Finally, the patient also + expressed the idea that her mother was a stranger, that her + real mother was dead. + + At the _Observation Pavilion_ she was described as + wandering about in a perplexed manner, restless, resistive, + answering few questions and in a low tone. She said things + were "changed," also that she was married to S. + + _Under Observation:_ 1. For about ten days the patient's + condition may be described as follows: The most striking + feature was a certain restlessness with insistence on going + out, with complaints that this and that had been done to + her and with senseless struggling when interfered with. But + all the motions were slow, the whole restlessness aimless + and impulsive. Although the facial expression was somewhat + perplexed, it changed remarkably little, and whenever asked + whether she felt worried or anxious she denied it, and, + indeed, there was only a suggestion of perplexity in her + face. + + The ideas which she expressed during this time referred to + a few topics only, namely, marriage, wealth, and State + prison. The remarkable fact was that all the ideas about + marriage and wealth were spoken of, often immediately, + again after some interval, now in the positive and again in + the negative sense. Thus she said she was "Mrs. S.," again + "You kept me from marrying Mattie S.," or "I am not + supposed to be here--I am a married person," but also "You + kept me from getting married." Or, "Take off that black + dress, I am a bride," again "You have taken my bridal crown + off my head," "The steamboats (seen from the window) are + mine--I own the ships, the oceans, the land and + everything," or again, she said she owned a kingdom, was + Sh.'s wife, a wealthy woman, had millions. Sometimes she + connected the millions with Sh. "Sh. has millions." On the + other hand, she said: "I owned all this before I came. I + have nothing now," or "You have taken the regal crown from + me," "You have made a pauper of me," "They did it again, + they took my millions away," or "Let me out, they are + taking my millions." + + Other ideas throughout this period were that this was a + State prison, that "bums" were around. On one occasion she + said "You can't put down all these things and make me out a + lunatic." At another time she pulled a patient's hair and + then said without fun: "I fixed the leading lady of the + dump--she knows a lot, but she does not know enough to + keep her soup cool." When questioned about this woman (who + at the time while cleaning had moved the furniture), she + said: "I don't know where I am at." + + The orientation during these days was not markedly + disordered, when one got down to it. Although she spoke of + State prison, it was always found she knew the name and the + location of the hospital, the names of people around her, + even the date approximately, though she was apt to say it + was February 19, 1492, or October 19, 1492, or when the + year was not given as 1492 she said it was "1900 or 1901, + or 1911 or 1912." Frequently, however, it was hard to hold + her attention. + + Finally, it should be mentioned that she very often wet + herself in bed or when standing, even when standing in the + examining room. + + 2. The period following and lasting for two months may be + given in the form of abstracts of each note. + + _November 7:_ Yesterday quiet, though struggling. Says + without change of expression, "I saw four people killed--my + mother, my brother, a priest, and my dear sister--we were + all killed." Again, "I don't know where I am," "I am an + orphan, my people died" (without affect). + + _November 20:_ More quiet recently, says little, but tries + to get out when brought to the examining room, but when not + prevented walks slowly about as before, says she wants to + go home. Looks peculiarly blank. + + _November 23:_ Has remained quiet, says she is Dr. M.'s + wife. But when told she is not married, she agrees. Her + attitude towards the doctor is not changed, but when the + nurses talk to him, she has tried to prevent it. + + _December 6:_ Has remained quietly in bed, gazing about. + Slow in motion. She has spoken of being Dr. M.'s wife, + again President Wilson's wife, again "Vincent (brother) is + the ruler of the world." + + At interview says little, seems abstracted, answers briefly + in low tone. (Does anything bother you?) "No." (Are you + natural?) "Yes." (Who are you?) "C. H." (correct). (You + said you were the President's wife?) "No." (Are you + married?) "No." (You talked about the kingdom?) "I own the + kingdom" (affectlessly). (Where is Vincent?) "Here." (Have + you heard him?) "Yes." (What did he say?) "Nothing." (Is + he all right?) "Yes." (Where is your mother?) "Home." (Why + don't you go home?) "I can't." (Why not?) "I can't." (Why + not?) "The family tree is broken, the Cardinal." (What + about him?) "Nothing." (Retrospectively she said later she + thought her brother was a cardinal.) + + _December 8:_ When her mother visited her she said "It is + about time you come--I thought you were dead." Has walked + down the hall "looking" for her dead cousin. When asked if + she wanted to see her brother, said, "Ain't he dead?" + + _December 12:_ Cries out in an affectless tone like a + huckster, "Father MacN., take me to Heaven," repeating this + over and over. + + _December 15:_ Quiet as a rule, then for a time at the + door, pulling at it and with whining voice but affectlessly + saying "Give me the key--I want to go to the river--you + can't keep me from Heaven--it is either Heaven or the + river, give me the keys, give me the keys, open the door," + "The niggers are taking possession." To the physician to + whom she had claimed to be married, often repeats "You + don't belong to me, I don't belong to you." (What about the + niggers?) "A band of niggers, that is all they are." (Are + the nurses niggers?) "That is all they are." Asked about + her people, she says "They are in Heaven." (Where are you?) + "I am in Heaven" (without change of expression). Again, + when asked where her people are, says "At home." Then she + went willingly back to bed and was quiet. In the afternoon + she again went to the door and tried to get out. When + questioned, she said "I don't want to be an animal," + "Everybody is making an animal of me" (pointing to an + animal picture). Then again, while trying the door, repeats + in the same affectless manner that she wants to go "to the + river," "to the bottom of the river," "to Heaven to see my + mother." This last was said in a whining tone, with some + tears. She kept turning the knob, tried to get the keys, + and struggled impulsively when prevented. + + _December 23:_ Though quiet on the whole, when a visitor + came yesterday, she ran after this woman saying "I want my + generations," and clung to her, and to-day at intervals + keeps talking about wanting to see her generations but is + often quiet. (Retrospectively she said she wanted to see + all her ancestors from the beginning of time.) + + _December 27:_ Of late often talks affectlessly about + wanting to die or wanting to go to Heaven, struggling + impulsively to get medicine away from the nurses, asking + for poison, trying to drink her own urine, or even the + fluid in the bed pan after she had been given an enema, all + evidently with suicidal intent. + + _December 28:_ Still constant, impulsive and apparently + affectless attempts at suicide, tries to get medicine away + from nurses, to get the fire extinguisher bottles, a bottle + of ink, etc., struggling when prevented. + + But when examined quiet, even smiles at a joke. When + questioned, denies feeling either worried or depressed. She + said she wanted to go home. She gave poor attention to the + questions. Later she threw a wet sheet over a patient and + laughed (this is rare). Later she slapped another patient. + Again she began to talk about wishing to go to the grave. + Calls Dr. M. "Uncle John." + + _December 30:_ Talks either about wanting to die, or + wanting to go to Heaven, or wanting to go to Ireland, all + this as usual in an affectless way. Calls Dr. M. "Uncle + John." Keeps shouting "Take me to Ireland." + + _January 9, 1914:_ Often quiet in bed, again goes to door, + talks about wanting to go "to Heaven" or "to Ireland." On + the whole, says little. + + It seems, then, that the transition was not abrupt, that + many traits of the first period remained, but that she was + on the whole much quieter, with the exception of some + spells when she insisted on going out or killing herself. + At such times she showed an affectless, impulsive + excitement. Whether there was an element of perplexity then + is not clear from the notes. The topics of which she spoke + also changed. The idea of wealth was rarely expressed, also + the idea of marriage was much in the background, but + prominent ideas were those of death, Heaven, killing + herself, going to Ireland--all of which she produced in an + affectless way. It should be added that she persistently + wet and soiled during this, as well as in the first period. + + 3. Then followed three months of greater inactivity. She + lay in bed gazing, moving very little, not even when her + meals were brought. She answered but little and + consistently wet and soiled. This state lasted from about + the middle of February until the beginning of April. + + 4. From this stuporous state she emerged during the next + four weeks, the awakening being associated with persistent + efforts to arouse her. She then was, for six or seven + weeks, nearly normal, so far as her mood went, but had a + tendency to cling to some of her ideas and was + overtalkative. Her memory for the earlier phases of the + psychosis was good, as she recalled not only many external + events but most of her false ideas. She said, however, that + her mind had been a blank for the third stage and she + remembered nothing of it. At the end of this time she + cleared up entirely and was discharged as "recovered." She + continued well for some months, during which she was + occasionally examined. + +This case gives an excellent example of the relationship of stupor to +other manic-depressive reactions. She begins with an absorbed state, +showing elements of perplexity and mania. With this there are expansive +ideas but, also, statements about losing everything and being in prison, +which suggest abandonment of life. Next, with increasing apathy, she +begins to speak of death and soon makes impulsive suicidal attempts. +Evidently her mind was becoming more and more focused on death and with +this there was an appropriate emotional change. She was either apathetic +or the affect exhibited itself in pure impulsiveness. Then comes the +stupor, when all ideas disappear and mentation is reduced or absent. +When the stupor lifts, the original ideas appear not only in memory but +occasion a wavering insight. It is appropriate that she recalled all of +her psychosis fairly well with the exception of the pure stupor, which +she remembered only as a time when her mind was a blank. + +FOOTNOTES: + +[7] Hoch, August, and Kirby, George H.: "A Clinical Study of Psychoses +Characterized by Distressed Perplexity." _Archives of Neurology and +Psychiatry_, April, 1919, Vol. I, pp. 415-458. + +[8] Hoch, August: "A Study of the Benign Psychoses." _Johns Hopkins +Hospital Bulletin_, May, 1915, XXVI, 165. + +A book on "the psychology of manic-depressive insanity" will shortly +appear by the editor. + + + + +CHAPTER IX + +THE PHYSICAL MANIFESTATIONS OF STUPOR + + +We must now discuss the most difficult of all the aspects of the stupor +problem. The subject is so involved and the evidence so inconclusive +that observers will probably interpret the phenomena here reported +according to their individual preconceptions. What we have to say is +therefore published not so much to convince as to stimulate further +work. The problem is wider than that of the mere etiology of the stupors +we are considering. Their relationship to manic-depressive insanity is +so intimate that we must tentatively consider this affectless reaction +as belonging to that larger group. A discussion of the basic pathology +of manic-depressive insanity is outside the sphere of this book. The +author, therefore, thinks it advisable to state somewhat dogmatically +his view, as to the etiology of these affective reactions, merely as a +starting point for the argument concerning stupors specifically. + +It is our view that the manic-depressive psychoses may be, and probably +are, determined remotely but fundamentally by an inherent neuropsychic +defect, but this physical and constitutional blemish is non-specific. +The actual psychosis is determined by functional, that is, +psychological factors. A predisposed individual exposed to a certain +psychic stress develops a manic-depressive psychosis. Naturally any +physical disease reduces the capacity for normal response to mental +difficulties; hence physical illness may facilitate the production of a +psychosis. But this intercurrent factor is also non-specific. + +Such is our view of the etiology of manic-depressive insanity as a +whole. When we approach the study of benign stupors, however, difficult +problems appear. As will be discussed in a later chapter on the +literature, reactions resembling benign stupors occur as a result of +toxins, particularly following acute rheumatism. Recently the medical +profession has been called on to treat many cases of encephalitis +lethargica where similar symptoms are observed. If the resemblance +amounted to identity, we would have to admit that a specific toxin may +produce a specific mental reaction which we have concluded on other +grounds to be psychogenic. As a matter of fact, in two particulars these +reactions show relationship to organic delirium. Knauer reports that in +post-rheumatic stupors illusions are frequent--an ice bag thought to be +a cannon, or a child, etc.--and there are bizarre misinterpretations of +the physical condition, such as lying on glass splinters, animals +crawling on the body, and so on. Such illusions are, in our experience, +not found in stupor, and, on the other hand, are cardinal symptoms of +delirium. Further, Knauer reports that even at the height of +post-rheumatic stupor, external stimuli make some impression, in that a +thoughtful facial expression appears. In deep stupors, such as occurred +in our series, this response is not seen. The same phenomenon of +"rousing," larval in Knauer's cases, is often well marked in +encephalitis lethargica and is, of course, a pathognomonic symptom of +delirium. We might therefore think that these conditions are mixtures of +two organic tendencies, namely, delirium and coma. It is not impossible +that resemblances to benign stupor are due to functional elements +appearing in the reduced physical state as additions to the organic +symptoms. The prominence of pain might be taken as a likely cause for an +instinctive reaction of withdrawal, which would account for the +emotional palsy of these conditions on psychogenic grounds. [This +argument can be better understood when the chapter on Psychological +Explanation of Stupor has been read.] We therefore feel justified in +holding that the resemblance of the symptoms of certain plainly organic +reactions to those of benign stupor do not necessitate a splitting of +these stupors from the manic-depressive group. + +When we consider certain bodily manifestations of these typical stupors, +however, fresh difficulties are encountered. Unlike depressions, +elations and anxieties, certain physical symptoms appear with frequency, +even regularity. This would seem to indicate the presence of physical +disease. Inasmuch as the most constant of them is fever, the natural +conclusion would be that we are dealing with an infection which +produces a mental state called stupor. If we were not faced with an +obvious relationship to manic-depressive insanity, where such symptoms +are usually accidental and intercurrent, we would accept this +explanation, but this quandary necessitates further analysis. + +Let us first consider the fever. In 35 cases, on whom data of +temperature could be found from the records extant, 28 showed fever +usually running between 99 deg. and 100 deg., often up to 101 deg. or +slightly over this point. When these cases were analyzed, however, it +was found that 27 were typical and 8 atypical, showing pictures +resembling those described in the last chapter. Of the latter only one +had a rise of temperature, while of the typical group only one was +afebrile. Therefore, since out of 27 typical cases 26 had the typical +slight fever, we must conclude it to be a highly specific symptom. Of +these 28 cases the incidence of the fever was as follows: 8 showed it +only on admission; in 7 it was highest on admission but continued at a +low rate throughout the rest of the psychosis; in 5 it extended without +much variation throughout the psychosis; in 4 it appeared +intermittently, while in 2 it was accentuated during periods when the +mental symptoms were most pronounced. We see, then, that there is a +distinct tendency for the fever to be associated with the onset of the +disease. + +When we look for other data from which we might discover causes for the +fever, we find less than we would like. The records are of observations +made, some of them, twenty years ago. Although the mental examinations +were careful, the records of the physical symptoms either were not made +or were lost in many cases. Consequently our description must be +tentative and is published merely to stimulate further research as cases +come to the attention of psychiatrists. + +One looks, first, for other evidence of infection. Some of the cases +were thoroughly examined with modern methods and nothing whatever found. +Blood examinations were made in five cases; three of these had rather +high temperature with the following blood pictures: Charles O., 103 +deg., leucocytosis of 23,000, with 91.5% polymorphonuclears; Annie G. +(Case 1), 103 deg., leucocytosis of 12,000 to 15,000, and 89% +polymorphonuclears; Caroline DeS. (Case 2), 104 deg., 15,000 leucocytes, +no differential made, Widal and diazo reaction negative. These three +cases, then, had marked febrile reactions and leucocytosis. It is quite +possible that they had infections which were not discovered. Of the +other two Rosie K. (Case 11) had a temperature of 100 deg. and 17,500 +leucocytes associated with a fetid diarrhea, an unquestioned infection, +while Mary C. (Case 7), with a temperature of only 100 deg., had no rise +in number of total white cells but 41% of lymphocytes. This last might +be due to an internal secretion or an involuntary nervous system +anomaly. The possibility of the three high temperatures with +leucocytosis being due to intercurrent infections must be considered. +Charles O. had high fever only for ten days during a psychosis of +several months. Annie G.'s high fever was of about the same duration. +Caroline DeS. had short periods of marked pyrexia in the first and +seventh months of her long psychosis. Except for these episodes, these +three patients had the typical slight elevation of temperature. Three +cases out of thirty-five, in which high fever and leucocytosis appeared +episodically, are hardly enough to justify the view that stupors are the +result of a specific infection. We must remember, too, that no focal +neurological symptoms are ever observed, which makes the possibility of +a central nervous system infection highly unlikely. + +An alternative view might be that the slight rise of fever is somehow +the result of stupor, not the cause of it. The editor consulted +Professor Charles R. Stockard, of Cornell Medical College, as to this +possibility. The following argument is the result of his suggestions: + +What we call a normal temperature is, of course, the result of a balance +maintained between heat production and heat loss. Either an increase in +the former or a decrease in the latter must produce fever. It is +possible that heat production may be increased in many stupors as a +result of the muscular rigidity. Some cases showed higher temperature +when this was more marked, but this was not sufficiently constant to +justify any conclusions being drawn. + +Heat loss occurs preponderantly as a result of radiation from the skin +and by sweating with consequent evaporation of the secretion. These +processes are functions of the skin and surface circulation. Are they +disturbed in our stupors? We find considerable evidence that they are. +Flushing or dermatographia occurred in six cases, cold or blue +extremities in four cases, greasy skin in four, marked sweating in +three, the hair fell out in two cases, while the skin was pathologically +dry in one case, in fact there were few patients who showed normal skin +function. Circulatory anomalies were also observed. The pulse was very +rapid in eleven cases, weak or irregular in two, and slow in one case. +All these symptoms are expressions of imbalance in the involuntary +nervous system, further evidence of which is found in the rapid +respiration of six cases and the shallow breathing of one patient. These +pulse and respiration findings are the more striking in that individuals +in stupor are, by the very nature of their disease, free from emotional +excitement. + +This imbalance could result from a poverty of circulating adrenalin +which is necessary for the activation of the sympathetic nerves. A cause +for low suprarenal function is to be found in the apathy of the stupor +case. As Cannon and his associates have so conclusively demonstrated, +any emotion which was open to investigation resulted in an increase of +adrenalin output. As our emotions are constantly operating during the +day--and often enough during sleep as well in connection with dreams--we +must presume that emotional stimulus is a normal excitant for the +production of adrenalin. It is therefore inconceivable that the blood +could receive its normal supply of adrenalin with an apathy of the +degree seen in stupor unless some purely hypothetically substitutive +excitant were found. + +We may therefore tentatively assume that the fever which marks the onset +and frequently the course of these benign stupors is the result of a +failure of the heat loss function, this being due to an imbalance in the +involuntary nervous system that is occasioned, in turn, by insufficient +circulating adrenalin, and the final cause for the poor suprarenal +function is to be traced to the most consistent symptom of the stupor, +namely, apathy. This hypothesis is welcome, not only because it would +account adequately for the fever, but it also tends to accentuate the +relationship with other forms of manic-depressive insanity, all of which +are marked fundamentally by a pathological emotion. Naturally enough, +one turns to the records again to see if the blood-pressure of these +patients was low, as would be expected with a poor adrenalin supply. +Unfortunately record was made of the blood-pressure in only two cases, +in both of which the reading was 110 m.m. Two such isolated observations +mean, of course, nothing whatever. It is possible that the drooling +which so many stupor cases show is not merely the result of the failure +of the swallowing reflex, but represents as well a compensation for +anhydrosis by excessive salivary secretion. + +Another symptom suggestive of involuntary nervous system or endocrine +disorder is the highly frequent suppression of the menstrual function. +At times this may occur as a sequel to mental shock, as it did in the +case of Celia H. (Case 19), who was menstruating when, frightened by the +suicidal attempt of her brother, the flow ceased abruptly. That purely +psychic factors can produce marked changes in such functions has been +demonstrated by Forel and other hypnotists time and again; presumably +the effect is produced by way of alteration in the endocrine or +involuntary nervous system influence. In such cases, however, we can +trace the menstrual suppression directly to an emotional cause. On the +other hand, most women in stupor fail to menstruate during the bulk of +the psychosis at a time when we believe emotions to be absent or greatly +reduced in their intensity. The recent work of Papanicolaou and +Stockard[9] offers a simple explanation for this phenomenon. They have +shown that in the guinea pig the oestrous cycle can be delayed by +starvation, while in weaker animals a period may be suppressed +completely. When one considers that even with the greatest care the +nutrition of tube-fed patients is bound to be poor, it would be only +natural to suppose that this malnutrition would cause such a disturbance +in the oestrous cycle and was evidenced objectively by a failure to +menstruate. Even in patients who are not tube-fed, under-nutrition is +to be expected and, as a matter of fact, is usually observed. The work +of Pawlow and Cannon has shown how essential psychic stimulus is for +gastric digestion. Any condition of apathy would therefore tend to +retard digestion and indirectly affect nutrition. + +Finally, under the heading of Physical Manifestations of Stupor, we must +consider epileptoid attacks, of which there was a history in two of our +cases, both of which have already been described in the first chapter of +this book. Anna G. (Case 1), in her second attack, was treated at +another hospital, and from the account which they sent it appears that +the stupor was immediately preceded by a seizure in which the whole body +jerked. This is, of course, rather thin evidence of the existence of a +definite convulsion, but in the case of Mary F. (Case 3) we have a +fuller description. During the two days when the stupor was incubating, +she had repeated seizures of the following nature. She sometimes said +that prior to the attacks it became dark before her eyes and that her +face felt funny or that she had a pain in the stomach which worked +toward her right shoulder. The attack would begin when sitting in a +chair, with the closing of her eyes, clenching her fists and pounding +the side of the chair. She would then get stiff and slide on to the +floor, where she would thrash her arms and legs about and move her head +to and fro. The warning of the pain working from the stomach to the +right shoulder is highly suggestive of an epileptic aura, although the +other symptoms mentioned so far could have been considered hysterical or +poorly described epileptic phenomena. The rest of the description +indicates an epileptic seizure more strongly. She frothed at the mouth +and once wet herself during an attack. They lasted only for a few +minutes and she would breathe heavily after them. At the end of one +attack she wiped the froth from her mouth with her handkerchief and gave +it to her aunt, saying, "Burn that, it is poison." This is perhaps a +little less like epilepsy. It is plainly impossible for us to say with +any positiveness that either these were or were not genuine convulsions, +but it is nevertheless important to record them, because such phenomena +are observed fairly frequently in dementia praecox cases but are +practically unknown in manic-depressive insanity. This, then, would be +another example of the resemblance to dementia praecox in these stupors +which are unquestionably benign.[10] + +We see, then, in reviewing all the physical manifestations of the +benign stupors, that none occurred which cannot be explained as +secondary to the mental changes, and therefore, until such time as +physical symptoms are reported which cannot be so explained, we see no +reason for changing our view that the benign stupor is to be regarded as +one of the manic-depressive reactions. + + +FOOTNOTES: + +[9] Papanicolaou, G. N., and Stockard, C. R., "Effect of Under-feeding +on Ovulation and the OEstrous Rhythm in Guinea-pigs." _Proceedings of +the Society of Experimental Biology and Medicine_, Vol. XVII, No. 7, +Apr. 21, 1920. + +[10] As a matter of fact, if the views of Clark and MacCurdy[B] be +accepted, some reason for these epileptic-like attacks may be imagined. +According to them, epilepsy is a disease characterized by a lack of the +natural instinctive interest in the environment which is expressed +chronically in the deterioration, and episodically in the attacks, the +most consistent feature of which is loss of consciousness. Now, in +stupor we have an analogous reaction where, although consciousness is +not disturbed in the sense in which it is in epilepsy, it is +nevertheless considerably affected, inasmuch as contact with the +environment is practically non-existent. The coincident thinking +disorder is quite similar, both in epileptic dementia and the torpor +following seizures and in these benign stupors. MacCurdy has suggested +tentatively that the epileptic convulsion may be secondary to a very +sudden loss of consciousness which removes a normal inhibition on the +muscles, liberating the muscular contractions which constitute the +convulsion. If this view were correct, it would not be hard to imagine +that during the onset of these stupors the tendency to part company with +the environment, which ordinarily comes on slowly, might occur with +epileptic suddenness and hence liberate convulsive movements. This is, +however, a pure speculation but not fruitless if it serves to draw +attention to the analogies existing between the stupor reaction and some +of the mental symptoms of epilepsy. These analogies are strong; aside +from the obvious clinical differences, the stupor and epileptic +reactions are dynamically unlike in that they are the product of +different temperaments and precipitated by different situations. + + +FOOTNOTES: + +[B] Clark, L. Pierce. "Is Essential Epilepsy a Life Reaction Disorder?" +_Am. Jour. of the Medical Sciences_, November, 1910, Vol. CLVIII, No. 5, +p. 703. This paper gives a summary of Dr. Clark's theories. + +MacCurdy, John T., "A Clinical Study of Epileptic Deterioration." +_Psychiatric Bulletin_, April, 1916. + + + + +CHAPTER X + +PSYCHOLOGICAL EXPLANATION OF THE STUPOR REACTION + + +In the previous chapter mention has been made of our view that +manic-depressive insanity is a disease fundamentally based on some +constitutional defect, presumably physical, but that its symptoms are +determined by psychological mechanisms. In accordance with this +hypothesis we seek, when studying the different forms of insanity +presented in this group, to differentiate between the different types of +mental mechanisms observed, and by this analysis to account for the +manifestations of the disease on purely psychological lines. If benign +stupors belong to this group, then we should be able to find some +specific psychology for this type of reaction. + +All speech and all conduct, except simple reflex behavior, are +presumably determined by ideas. When an individual is not aware of the +purpose governing his action, we assume, in psychological study, that an +unconscious motive is present, so that in either case the first step in +psychological understanding of any normal or abnormal condition is to +discover, if possible, what the ideas are that lead to the actions or +utterances observed. In the case of stupors the situation is fairly +simple, in that the ideational content is extremely limited. As has been +seen, it is confined to death and rebirth fancies, other ideas being +correlated with secondary symptoms, such as belong to mechanisms of +other manic-depressive psychoses. It is not necessary to repeat the +catalogue of the typical stupor ideas, as they have been given in an +earlier chapter. Our task is now to consider the significance of these +death and rebirth delusions and their meaning for the stupor reaction. + +Thoughts concerned with future and new activities require energy for +their completion in action and are therefore naturally accompanied by a +sense of effort which gives pleasure to an active mind. When the sum of +energy is reduced, one observes a reverse tendency called "regression." +It is easier to go back over the way we know than to go forward, so the +weakened individual tends to direct his attention to earlier actions or +situations. To meet a new experience one must think logically and keep +his attention on things as they are, rather than imagine things as one +would like to have them. + +Progressive thinking is therefore adaptive, while regressive thinking is +fantastic in type, as well as concerned with the past--a past which in +fancy takes on the luster of the Golden Age. Sanity and insanity are, +roughly speaking, states where progressive or regressive thinking rule. +The essence of a functional psychosis is a flight from reality to a +retreat of easeful unreality. + +Carried to the extreme, regression leads one in type of thinking and in +ideas back to childhood and earliest infancy. The final goal is a state +of mental vacuity such as probably characterizes the infant at the time +of birth and during the first days of extra-uterine life. In this state +what interest there is, is directed entirely to the physical comfort of +the individual himself, and contact with the environment is so +undeveloped that efforts to obtain from it the primitive wants of warmth +and nutrition are confined to vague instinctive cries. Evolution to true +contact with the world around implies effort, the exercise of +self-control, and also self-sacrifice, since the child soon learns that +some kind of _quid pro quo_ must be given. Viewed from the adult +standpoint, the emptiness of this early mental state must seem like the +Nirvana of death. At least death is the only simple term we can use to +represent such a complete loss of our habitual mental functions. When +life is difficult, we naturally tend to seek death. Were it not for the +powerful instinct of self-preservation, suicide would probably be the +universal mode of solving our problems. As it is, we reach a compromise, +such as that of sleep, in which contact with reality is temporarily +abandoned. In so far as sleep is psychologically determined, it is a +regressive phenomenon. It is interesting that the most frequent +euphemism or metaphor for death is sleep. Sleep is a normal regression. +It does not always give the unstable individual sufficient relaxation +from the demands of adaptation and so pathological regressions take +place, one of which we believe stupor to be. It is important to note +that objectively the resemblance between sleep and stupor is striking. +So far as mental activity in either state can be discovered by the +observer, either the sleeper or the patient in stupor might be dead. +Briefly stated, then, our hypothesis of the psychological determination +of stupor is that the abnormal individual turns to it as a release from +mental anguish, just as the normal human being seeks relief in his bed +from physical and mental fatigue. When this desire for refuge takes the +shape of a formulated idea, there are delusions of death. + +The problem of sleep is, of course, bound up with the physiology of +rest, and as recuperation, in a physical sense, necessitates temporary +cessation of function, so in the mental sphere we see that relaxation is +necessary if our mental operations are to be carried on with continued +success. This is probably the teleological meaning of sleep in its +psychological aspects, for in it we abandon diurnal adaptive thinking +and retire to a world of fancy, very often solving our problems by +"sleeping over them." The innate desire for rest and a fresh start is +almost as fundamental a human craving as is the tendency to seek release +in death. In fact the two are closely associated both in literature and +in daily speech, for in many phases we correlate death with new life. If +one is to visualize or incorporate the conception of new life in one +term, rebirth is the only one which will do it, just as death is the +only word which epitomizes the idea of complete cessation of effort. +Not unnaturally, therefore, we find in the mythology of our race, in our +dreams and in the speech of our insane patients, a frequent correlation +of these two ideas, whether it comes in the crude imagery of physical +rebirth or projected in fantasies of destruction and rebuilding of the +world. Many of our psychotic patients achieve in fancy that for which +the Persian poet yearned: + + "Ah Love! could you and I with Him conspire + To grasp this Sorry Scheme of Things entire, + Would we not shatter it to bits--and then + Re-mold it nearer to the Heart's Desire!" + +A vision of a new world is a content occurring not infrequently in manic +states, but before the universe can be remolded it must be destroyed. +Before the individual can enjoy new life, a new birth, he must die, and +stupor often marks this death phase of a dominant rebirth fantasy. In +this connection it was not without significance to note that stupors +almost universally recover by way of attenuation of the stupor symptoms, +or in a hypomanic phase where there seems to be an abnormal supply of +energy. Antaeus-like, they rise with fresh vigor from the Earth. They do +not pass into depressions or anxieties. + +Rebirth fancies unquestionably, then, contain constructive and +progressive elements, but, as has been stated above, any thinking which +implies a lapse of contact with the environment is, in so far as that +lapse is concerned, regressive, and in consequence rebirth fancies, as +dramatized by the stupor patients, are regressive, just as are the +delusions of death itself. + +It is obvious that an acceptance of death implies rather thorough mental +disintegration. Before that takes place there may be some mental +conflict. The instinct of self-preservation may prevent the individual +from welcoming the notion of dissolution, so that this latter idea, +though insistent, is not accepted but reacted to with anxiety; hence we +often meet with onsets of stupor characterized by emotional distress. It +has already been suggested that death may foreshadow another existence. +Often in the psychoses we meet with the idea of eternal union in death +with some loved one whom the vicissitudes and restrictions of this life +prevent from becoming an earthly partner. This fancy is frequently the +basis of elation. Similarly, new life in a religious sense as expressed +in the delusion of translation to Heaven, is a common occasion for +ecstasy. These formulations of the death idea may occur as tentative +solutions of the patient's problems leading to temporary manic episodes +while the psychosis is incubating. It seems that stupor as such appears +only when death and nullity are accepted. + +The above are more or less a priori reasons for regarding the stupor as +a regressive reaction. We must now consider the clinical evidence to +support this view. In the first place, we always find that stupor occurs +in an individual who is unhappy and who has found no other solution +than regression for the predicament in which he is. There is nothing +specific in the cause of this unhappiness. At times the factors +producing it are mainly environmental; at others, the problem is +essentially of the patient's own making. Of course almost any type of +functional psychosis may emerge from such a state of dissatisfaction, +but it is important to note that unlike manic states, for instance, +stupors invariably develop from a situation of unhappiness. Quite +frequently the choice of the stupor regression is determined by some +definitely environmental event which suggests death. This often comes as +the actual death of the patient's father (in the case of a woman) or +employer, events which inflate the already existing, although perhaps +unconscious, desire for mutual death. Again, the precipitating factor +may be a situation which adds still another problem and makes the burden +of adaptation intolerable, forcing on him the desire for death. In these +cases the actual psychosis is sometimes ushered in dramatically with a +vision of some dead person (often a woman's father) who beckons, or +there are dream-like experiences of burial, drowning, and so on. + +A few cases taken at random from our material exemplify these features +of the unhappiness in which the psychosis appears as a solution with its +development of the death fancy. + +Alice R., at the age of 25, was much troubled by worrying over her +financial difficulties and the shame of an illegitimate child. +Retrospectively she stated, "I was so disgusted I went to bed--I just +gave up hope." Shortly before admission she said she was lost and +damned, and to the nurse in the Observation Pavilion she pleaded, "Don't +let me murder myself and the baby." + +Caroline DeS. (Case 2) for some time was worried over the engagement of +her favorite brother to a Protestant (herself a Catholic) and the +threatened change of his religion. At his engagement dinner she had a +sudden excitement, crying out, "I hate her--I love you--papa, don't kill +me." This excitement lasted for three weeks, during two of which she was +observed, when she spoke frequently of being killed and going to Heaven. +The conflict was frankly stated in the words, "I love my father but +don't want to die." Then for two weeks she had some fever, was tube-fed, +muttered about being killed or showed some elation, there being +apparently interrupted stuporous, manic and, possibly, anxiety episodes. +Finally she settled down to a year of deep stupor. + +Laura A. had for three months poor sleep with depression over her +failure in study. Another cause for worry was that her father was home +and out of work. She reached a point where she did not care what +happened but continued working. Ten days before admission she was not +feeling well. The next morning she woke up confused and frightened, +speedily became dazed, stunned, could not bring anything to her memory. +This rather sudden stupor onset was not accompanied by any false ideas, +at least none which the family remembered. + +Mary C. (Case 7) was an immigrant who felt lonely in the new country. +Two weeks before admission her uncle with whom she was living died. She +thought she had brought bad luck, complained of weakness and dizziness, +then suddenly felt mixed up, her "memory got bad," and she thought she +was going to die. Next she was frightened, heard voices, thought there +was shooting and a fire. For a short time she was inactive and later +began shouting "Fire!" When taken to the Observation Pavilion, she was +dazed, uneasy, thought she was on a boat or shut up in a boat which had +gone down; all were drowned. Then came a mild stupor. + +Maggie H. (Case 14), while pregnant, fancied that her baby would be +deformed and that she would die in childbirth. Three weeks before +admission this event took place. For five days she worried about not +having enough milk, about her husband losing his job (he did lose it) +and thought her head was getting queer. On the fifth day she cried, said +she was going to die, that there was poison in the food, that her +husband was untrue to her. She became mute but continued to attend to +her baby. She saw dead bodies lying around, and by the time she was +taken to the Observation Pavilion was in a marked stupor. + +Turning now to the symptoms of the stupor proper, we note, first, the +effects of the loss of energy which regression implies. The inactivity +and apathy which these patients show is too obviously evidence of this +to require further comment. Another proof of the withdrawal of the +libido or interest is found in the thinking disorder. Directed, accurate +thinking requires effort, as we all know from the experience of our +laborious mistakes when fatigued. So in stupor there is an inability to +perform simple arithmetical problems, poor orientation is observed, and +so on. Similarly what we remember seems to be that which we associate +with the impressions received by an active consciousness. Actual events +persist in memory better than those of fancy, in proof of which one +thinks at once of the vanishing of dreams on waking, with its +reestablishment of extroverted consciousness. This registration of +impressions requires interest and active attention. Without interest +there is no attention and no registration. The patient in stupor +presents just the memory defect which we would expect. Indifference to +his environment leads to a poor memory of external events, while on +recovery there may be such a divorce between consciousness of normal and +abnormal states that the past delusions are wiped from the record of +conscious memory. Withdrawal of energy then produces not only inactivity +and apathy but grave defects in intellectual capacity. + +The natural flow of interest in regression is to earlier types of +ambition and activity. This is betrayed not merely by the thought +content dealing with the youth and childhood of the patient, but also is +manifested in behavior. Excluding involution melancholia there is +probably no psychosis in which the patients exhibit such infantile +reactions as in stupor. Except for the stature and obvious age of these +patients, one could easily imagine that he was dealing with a spoiled +and fractious infant. One thinks at once of the negativism which is so +like that of a perverse child and of the unconventional, personal habits +to which these patients cling so stubbornly. Masturbation, for instance, +is quite frequent, while willful wetting and soiling is still more +common. We sometimes meet with childishness, both in vocabulary and mode +of expression. In one case there was evidently a delusion of a return to +actual childhood, for she kept insisting that she was "in papa's house." + +The frequency with which the delusion of mutual death occurs in stupor +is another evidence of its regressive psychology. The partner in the +spiritual marriage is rarely, if ever, the natural object of adult +affection, but rather a parent or other relative to whose memory the +patient has unconsciously clung for many years, reawakening in the +psychosis an ambition of childhood for an exclusive possession that +reaches its fulfillment in this delusion. Closely allied with this is +another delusion, that of being actually dead, which the patients +sometimes express in action, even when not in words. The anesthesia to +pin pricks, the immobility and the refusal to recognize the existence of +the world around, in patients who give evidence of some intellectual +operations still persisting, are probably all part of a feigned death, +with the delusion expressing itself in corpse-like behavior. + +Finally we must consider the meaning of the deep stupor where no +mentation of any kind can be proven and where none but vegetative +functions seem to be operating. This state is either one of organic +coma, in which case it marks the appearance of a physical factor not +evidenced in the milder stages, or else it is the acme of this +regression by withdrawal of interest. As has been stated, back of the +period of primitive childish ideas there lies a hypothetical state of +mental nothingness. If we accept the principle of regression we find +historically an analogue to what is apparently the mental state of deep +stupor in the earliest phases of infancy. This view receives +justification from the study of the phenomenon of variations in +symptoms. Mental faculties at birth are larval, and if such condition be +artificially produced mental activity must be potentially present (as it +would not be if we were dealing with coma). In Chapter IV phenomena of +interruption of stupor symptoms were detailed. One case that was +mentioned is now of particular importance as demonstrating that an +appropriate stimulus may dispel the vacuity of complete stupor by +raising mental functions to a point where delusions are entertained. +This patient retrospectively recalled only certain periods of her +deepest stupor, occasions when she was visited by her mother. At these +times, as she claimed, she thought she was to be electrocuted and told +her mother so, adding, "Then it would drop out of my mind again." +Otherwise her memory for this state was a complete blank. Here we see a +normal stimulus producing not normality but something on the way towards +it, that is, a condition less profound than the state out of which the +patient was temporarily lifted. + +This case exemplifies the principle of levels in the stupor reaction +which we have found to be of great value in our study. These levels are +correlated with degrees of regression, as a review of the symptoms +discussed above may show. In the first place, the dissatisfaction with +life, the first phase of regression, leads to the quietness--the +inactivity and apathy, which are the most fundamental symptoms of the +stupor reaction as a whole. Initiative is lost and with this comes a +tendency for the acceptance of other people's ideas. That is the +probable basis for the suggestiveness which we concluded was a prominent +factor in catalepsy. Indifference and stolidity may exist with those +milder degrees of regression which do not conflict with one's critical +sense, and hence may be present without any false ideas. The next stage +in regression is that where the idea of death appears. Although not +accepted placidly by the subject, its non-acceptance is demonstrated by +the idea being projected--by its appearance as a belief that the patient +will be killed. This notion of death coming from without has again two +phases, one with anxiety where normality is so far retained that the +patient's instinct of self-preservation produces fear, and a second +phase where this instinct lapses and the patient so far accepts the +idea of being killed as to speak of it with indifference. The next step +in regression is marked by the spoiled-child conduct, interest being so +self-centered as to lead to autoerotic habits and the perverse reactions +which we call negativism. When death is accepted but mental function has +not ceased, the latter is confined to a dramatization of death in +physical symptoms or to such speech and movements as indicate a belief +that the patient is dead, under the water, or in some such unreal +situation. Finally, when all evidence of mentation in any form is +lacking, we see clinically the condition which we know as deep stupor +and which we must regard psychologically as the profoundest regression +known to psychopathology, a condition almost as close to physiological +unconsciousness as that of the epileptic. + +Naturally we do not see individual cases in which all these stages +appear successively, each sharply defined from its predecessor. To +expect this would be as reasonable as to look for a man whose behavior +was determined wholly by his most recent experience. Any psychologist +knows that every human being behaves in accordance with influences whose +history is recent or represents the habit of a lifetime. At any given +minute our behavior is not simply determined by the immediate situation, +but is the product of many stages in our development. Quite similarly we +should not expect in the psychoses to find evidences of regression to a +given period of the individual's life appearing exclusively, but rather +we should look for reactions at any given time being determined +preponderantly by the type of mentation characteristic for a given stage +of his development. As a matter of fact, we see in psychoses, +particularly in stupor, more sharply defined regressions to different +levels than we ever see in normal life. + +Our psychological hypothesis would be incomplete and probably unsound if +it could not offer as valid explanations for the atypical features in +our stupor reactions as for the typical. The unusual features which one +meets in the benign stupors are ideas or mood reactions occurring +apparently as interruptions to the settled quietude or in more +protracted mild mood reactions, such as vague distress, depression or +incomplete manic symptoms, which have been described in the chapter on +affect. The interruptions are easily explained by the theory of +regression. If stupor represents a complete return to the state of +nothingness, then the descent to the Nirvana or the re-ascent from it +should be characterized by the type of thinking with the appropriate +mood which belongs to less primitive stages of development. A review of +our material seems to indicate that there is a definite relationship +between the type of onset and the character of the succeeding stupor. +For instance, in the cases so far quoted in this book, the onsets +characterized by mere worry and unhappiness and gradual withdrawal of +interest had all of them typical clinical pictures. On the other hand, +of those who began with reactions of definite excitement, anxiety or +psychotic depression, there were interruptions which looked like +miniature manic-depressive psychoses in all but one case. This would +lead one to think that these patients retraced their steps on recovery +or with every lifting of the stupor process, moved slightly upward on +the same path on which they had traveled in the first regression. The +case of Charlotte W. (Case 12), which is fully discussed in the chapter +on Ideational Content, offers excellent examples of these principles. + +The next atypical feature is the phenomenon of reduction or dissociation +of affect, the frequency of which is mentioned in Chapter V. As the law +of stupor is apathy, normal emotions should be reduced to indifference +and no abnormal moods, such as elation, anxiety or depression, should +occur. What often happens is that these psychotic affects appear but +incompletely, often in dissociated manifestations. This looks like a +combination of two psychotic tendencies, the stupor reduction process +which inhibits emotional response and the tendency to develop abnormal +affects which characterize other manic-depressive psychoses. There is no +general psychological law which makes this view unlikely. One cannot be +anxious and happy at the same instant, although one can alternate in his +feelings; but one can fail to react adequately to a given stimulus when +inhibited by general indifference. In fact it is because apathy is, +properly speaking, not a mood but an absence of it, that it can be +combined with a true affect. It is possible, therefore, to have a +combination of stupor and another manic-depressive reaction, while the +others cannot combine but only alternate.[11] + +Finally we must discuss the psychological meaning of cases, such as +those described in Chapter VIII, where we concluded that there were +psychoses resembling stupors superficially. It seemed likely that these +patients were absorbed in their own thoughts, rather than being in a +condition of mental vacuity. It is not difficult to explain the +objective resemblance. All evidence of emotion (apart from subjective +feeling tone which the subject may or may not report) is an expression +of contact with the outer world. There must be externalization of +attention to environment before a mood becomes evident. A moment's +reflection will show this to be true, for no further proof is needed +than the phenomena of dreaming. The attention being given wholly to +fantasies, the subject lies motionless, mute and placid, although +passing through varied autistic experiences. Only when the dream becomes +too vivid, disturbs sleep and re-directs attention to the +environment--only then is emotion objectively betrayed. There is an +appearance of apathy and mental vacuity which the dreamer can soon +declare to be false. He was feeling and thinking intensely. In any +condition, therefore, such as that of perplexity or of an absorbed manic +state, the patient may be objectively in the same condition as a typical +stupor. The histories of the two psychoses differentiate the two +reactions which may be indistinguishable at one interview. The keynote +of one reaction is _indifference_, while that of absorption is +_distraction_, a perversion of attention to an inner, unreal world. + +In summary we may recapitulate our hypotheses. Stupor represents, +psychologically speaking, the simplest and completest regression. +Adaptation to the actual environment being abandoned, attention reverts +to earlier interests, giving symptoms of other manic-depressive +reactions in the onset or interruptions, and finally dwindles to +complete indifference. The disappearance of affective impulse leads to +objective apathy and inactivity, while the intellectual functions fail +for lack of emotional power to keep them going. The complicated mental +machine lies idle for lack of steam or electricity. The typical +ideational content and many of the symptoms of stupor are to be +explained as expressions of death, for a regression to a Nirvana-like +state can be most easily formulated in such a delusion. Other clinical +conditions may temporarily and superficially resemble stupor on account +of the attention being misdirected and applied to unproductive +imaginations. To employ our metaphor again, in these false stupors the +current is switched to another, invisible machine but not cut off as in +true stupor. + + +FOOTNOTES: + +[11] The reader will note that this view is opposed to that of +Kraepelin, who has written largely on so-called "_mixed conditions_" in +manic-depressive insanity. We believe that careful clinical studies +confirm our opinion and that his classification is based on less +thorough observation and analysis. This subject will be discussed at +greater length in a forthcoming book on "The Psychology of Morbid and +Normal Emotions," by Dr. MacCurdy. + + + + +CHAPTER XI + +MALIGNANT STUPORS + + +As we have seen, the benign stupors are characterized by apathy, +inactivity, mutism, a thinking disorder, catalepsy and negativism. All +these symptoms are also found in the stupors occurring in dementia +praecox. In fact this symptom complex has usually been regarded as +occurring only in a malignant setting. There can be no question about +the resemblance of benign to dementia praecox stupors. Even such symptoms +as poverty and dissociation of affect, usually regarded as pathognomonic +of dementia praecox, have been described in the foregoing chapters. +Either recovery in our cases was accidental or there is a distinct +clinical group with a good prognosis. If the latter be true, the +symptoms must follow definite laws; if they did not, we would have to +abandon our principles of psychiatric classification. Naturally, then, +we seek to find the differences between the cases that recover and those +that do not. There is never any difficulty in diagnosis where a stupor +appears as an incident in the course of a recognized case of catatonic +dementia praecox. We shall therefore consider only such clinical pictures +as resemble those described in this book, in that the symptoms on +admission to a hospital or shortly after are those of stupor. It should +be our ambition to make a positive diagnosis before failure to recover +in a reasonable time leads to a conclusion of chronicity. + +It is probably safe to assume, on the basis of as large a series as +ours, that the symptoms of stupor _per se_ imply no bad prognosis. +Further, it has been noted that a relatively pure type of reaction is +seen, the symptoms appearing with tolerable consistency. In analyzing +the histories of dementia praecox patients, therefore, one looks for +inconsistencies among, or additions to, the stupor symptoms. We may say +at the outset that we have been able to find no case of malignant stupor +that showed what we regard as a typical benign stupor reaction, and it +is questionable whether partial stupor as we have described it, ever +occurs with a bad prognosis. Usually the discrepant symptoms in the +dementia praecox cases are sufficiently marked to enable one to make a +positive diagnosis quite soon after the case comes under observation. + +The law of benign stupor is a limitation of energy, emotion and +ideational content. In dementia praecox we have a re-direction of +attention and interest to primitive fantastic thoughts and a consequent +perversion of energy and emotion. In many malignant stupors one can +detect evidence of this second type of reaction in symptoms that are +anomalous for stupor. For instance, one meets with frequent silly and +inexplicable giggling. Then, too, smiling, tears or outbursts of rage, +the occasions for which are not manifest, are much more frequent than in +typical stupor. Similarly, delusional ideas (not concerned with death at +all) may appear or the patient may indulge in speech that is quite +scattered, not merely fragmentary. Two cases may be cited briefly to +illustrate these dementia praecox symptoms superadded to those of stupor. + + + CASE 20.--_Winifred O'M._ Age: 19. Single. Admitted to the + Psychiatric Institute May 6, 1911. + + _F. H._ The occurrence of other nervous or mental disease + in the family was denied. + + _P. H._ The patient seems to have been rather shy and + goody-goody in disposition. According to her mother this + seclusiveness did not begin to be markedly noticeable until + the winter before her psychosis, when there was some + trouble about getting work. She had previously been to a + business school. Then she held a position as stenographer + temporarily. When this job was over she had a number of + positions that did not last long and was once idle for two + months. In February (three months before admission) her + father was out of work, which added to her worry. + + _Onset of Psychosis:_ Nine days before admission a young + man died in the house where they lived. The next day her + mother insisted on the patient and her sister going to the + funeral. On coming home the patient complained of being + afraid and having a funny feeling. She woke up at 2:30 that + night and lit all the gas, for which she could give no + explanation. The day following, or a week before admission, + she was slow, confused, could not get her clothes together. + The next day she was restless and worried, giving a + superficial explanation for the latter. She played the + piano a great deal. The following day she was fidgety and + cried. At 4 p.m. she was put to bed and appeared to fall + asleep. At midnight when a priest called she said to him + privately that she was all over the world, that she went to + the 12th floor of the Metropolitan Building, that she sat + down and took the man's money, $7, and came right away. She + recognized the priest. Three days before admission she + wanted to stay in bed, kept her eyes closed. When spoken to + she would smile but did not open her eyes. She did not pass + her urine all day. Her mother then gave her some medicine + which the doctor had left. The patient immediately had a + peculiar attack in which she heaved her breast, drew her + head back, clenched her fists and worked her feet. Saliva + escaped from the side of her mouth. This attack lasted some + three to five minutes. + + Her mother then called an ambulance and she was taken to + the _Observation Pavilion_. She thought that the ambulance + doctor was an uncle, a soldier in the Philippines, of whom + she was very fond. There she remained in bed, with all her + muscles relaxed, her mouth constantly open, saying nothing + and indeed resisting efforts which were made to get her to + open her eyes. + + _Under Observation:_ She sat or lay down with her eyes + closed and usually limp, although occasionally resistive. + There was practically no reaction to pin pricks. Sometimes + she opened her mouth as if to speak but rarely did so + except in a very low tone and after repeated questioning. + Her answers were rarely relevant. To the usual orientation + questions she gave no answers that would indicate that she + knew where she was. Sometimes she said "Jimmy" when asked + her name, and replied to another question, "Jimmy big smile + on." Once she said, "I don't know myself--what I am talking + for--what I am doing." In general her speech seemed to + indicate that her thought was directed entirely inward and + that she paid no attention whatever to the questions. In + most benign cases such a condition is accompanied by + perplexity or a dreamy, dazed expression. This the patient + had not. On the other hand, she was sometimes definitely + scattered. For example, when asked, How do you feel? she + replied, "Large all name." Again to the command, Tell me + your trouble, her answer was, "I couldn't tell my mother + last night and I can't tell her this night and I can't tell + my _proud_." She referred in a fragmentary way to being + crazy and to having been dead. She admitted hearing voices + but may not have understood the question. + + A week after admission, when visited by her mother, the + latter asked her to kiss her. The patient opened her mouth + widely and put out her tongue. This is a type of response + which we have never seen in our benign cases. + + Two days later repeated questioning made it evident that + the patient knew more about her environment than would be + expected, judging from her other symptoms. She gave the + month correctly knew that she was in a hospital and told of + having recently been visited by her father. At the same + interview she spoke of masturbation, of wanting to marry + her uncle, and of having been in bed with her father. The + last she referred to as a "fall." Such frank incest ideas + are never found in benign psychosis in our experience. + Other dementia praecox ideas appeared quite soon, for + within three days, when she was talking slightly more + freely, she spoke of having often imagined she was having + sexual experiences as a result of the influence of a man + who lived upstairs, and that even when sitting with her + family at the table she felt sexual sensations. + + Her condition then remained essentially the same for some + time. Then about six weeks after admission she became + somewhat less resistive, was frequently seen sitting up in + bed, moving her lips considerably (without speech) and + regarding the surroundings with a bright interested + expression and occasionally smiles. About this time she + began exposing herself and chewing her finger nails. + + Four months after admission she was noted as being very + resistive and negativistic, allowing saliva to accumulate + in her mouth and making no attempt to keep the flies off + her. At the same time she would keep in her mouth food that + had been put there without chewing it. + + Two months later she seemed to laugh occasionally when + other patients did so, but at the same time she showed a + cataleptic tendency and was quite mute. + + Six months after admission she began to feed herself but + rather sloppily. When one would speak to her, she would + occasionally smile, but if shaken she would weep silently. + About this time she began to do a little work in the ward, + pushing a floor polisher. + + For the next couple of months her condition was about the + same. She would stand around the ward, doing a little work + if urged, might even dance if forced to. She was + consistently mute. She was dirty but often decorated + herself. Rarely she was assaultive. + + Then ten months after admission she one day suddenly + became talkative, distractible and emotional, laughing and + crying. There was with this, however, no open elation. Her + talk was obscene, at times flighty, at times definitely + scattered. All her habits were filthy. + + This pseudomanic episode lasted for a couple of months, and + then she settled down to a fairly consistent deterioration + with indifference, silly laughter, occasional + assaultiveness, destructiveness and untidiness. + + Nearly two years after admission she had another period of + excitement lasting about a couple of months. Shortly after + this she began to fail physically, and in November, 1913, + two years and five months after her admission, she died of + pulmonary tuberculosis. + +In summary, then, we see that this patient exhibited symptoms of +dementia praecox from the outset of her stupor, with scattering, genital +sensations and incest ideas. The stupor symptoms gradually gave way to +the typical indifference, negativism, obscenity, filthiness and +inexplicable conduct of dementia praecox. At the beginning, however, the +condition was superficially similar to that of a benign stupor, it being +only on careful observation that other symptoms were noted. + + + CASE 21.--_Rose S._ Age: 23. Admitted to the Psychiatric + Institute April 5, 1905. + + _F. H._ The mother was living, the father dead. Otherwise + no pertinent information was secured. + + _P. H._ The patient was said always to have been somewhat + seclusive, mingling little with other people; this tendency + was so strong that she would leave the room when visitors + came. She always slept a great deal. It was stated that she + was able to do heavy housework quite well, but never + learned cooking. + + At 16 she hired out as a servant for a year and a half, and + then did laundry work. When 18 she had an illegitimate + child by a co-worker. + + _History of Psychosis:_ About a year before admission the + patient's sister was burned to death. When the patient + heard of this she said that something had come up in her + throat. Henceforth she often complained of a lump in her + throat, and often bit her nails. Two months before + admission she suddenly left the laundry, again spoke of the + lump in her throat, and claimed to have seen the dead + sister. Two weeks later when the family had an anniversary + mass for the sister the patient appeared sad, but the + following day laughed, said she had seen her "sister + beckoning her to come." She also thought she saw her + picture "and Heaven was behind it." She also talked of + "dead relatives and friends." A reaction of levity in + connection with a sister's death is highly suggestive of a + malignant psychosis. + + Two weeks before admission her mother found her in a + stupor, immovable, with her eyes closed. In 24 hours she + woke up, began to sing "Rest for the Weary," prayed, then + was stuporous again for six hours. When she came out of + this, she said she was "going to die," God had told her so + and talked of her own funeral arrangements. She again went + into a stupor, in which she was sent to the Observation + Pavilion. + + At the _Observation Pavilion_ she was described as happy, + laughing, singing, saying she felt happy, but adding, "I + like to be sad too, I am going to Heaven Easter Sunday." + She claimed that her sister frequently stood in front of + her, and that she knew she wanted her to go with her. + + _Under Observation:_ For about three weeks the patient + showed a variable stupor. She would lie with a mask-like + face inaccessible, cataleptic, drooling saliva, often with + her mouth open. When taken up, she was usually perfectly + flaccid, but once she let herself slide on the floor after + she had stood immobile at the window. Sometimes there was + marked resistance to passive motions, especially when + attempts were made to open her mouth or eyes, or on one + occasion when the examiner tried to open her hand in which + she held her handkerchief. Yet when one persisted in urging + her to respond there frequently could be elicited more or + less marked reactions. Thus repeatedly she could be made to + obey some commands, as showing the tongue, etc., even when + she would not answer. Once when her eyes were opened, tears + rolled down her cheeks--again, she usually reacted to pin + pricks by slight flushing, once she said, "Stop! it + hurts." Again, she said, "Leave me alone, I want to sleep." + + So far the description of this reaction is that of a benign + stupor. There were, however, other symptoms. In the first + place, she could sometimes be made to open her eyes and + write, although she would not speak. In spite of the + penmanship being careless, there were no mistakes. This + exhibition of an unhabitual and more difficult intellectual + effort when the patient was mute is suggestive of an + inconsistency. So was her habit of sometimes singing a + hymn, "Rest for the Weary," when no other sign of mental + life was given. But, more important than these, she could + not infrequently be induced to answer questions and at such + times she spoke promptly and with natural affective + response. + + A number of her replies were of the type to be expected in + a benign stupor. In the first place, she spoke of her + condition as "going off to sleep" and also as "death," "I + was dead all day." "I died three times yesterday," or she + merely described it by saying "I go off into states when I + lie with my mouth open and eyes closed, and cannot speak or + open my eyes." When asked how she got into this condition, + she said "My sister died and I think it was on my mind." + Again she said she became sad at the anniversary mass of + the sister and had been sad ever since. On the other hand, + she also stated that when she came home from the mass she + first was silly and danced. Spontaneously she spoke of + having frequently had visions of her dead sister; once she + saw her with wings. In explanation of her singing "Rest for + the Weary," she said it was the hymn sung at her father's + funeral. An anomalous feature had to do with her + description of her feelings. She claimed to have no memory + of her stupor periods and yet said of them: "I feel + peaceful-like," or "I feel awfully happy and sad together," + or "I am sad and contented--I like it that way." + + A striking symptom was that, when a sensory examination was + made during the first few days during one of the periods + when she responded well, she showed glove and stocking + anesthesia, also anesthesia of neck and left breast. + + But in addition to the above statements the patient also + began to make others of a definite dementia praecox type. + About ten days after admission she said, "What any one says + goes right through my brain," or she talked of being + hypnotized. "The typewriting machine turned my eyes--three + or four girls turned my eyes--they look at me and get their + chance, their left eye--turning me into images. I want to + be the way I was born--turn my body! look how their bodies + are turned before they die," or "Take it if you get it--he + got the name out--I was over there to death--himself to + death--of, you know--you played out--she is played out." + ... This while she snickered between the sentences. As + early as four weeks after admission she had begun to giggle + or laugh, often in an empty fashion, and a transition from + the more constrained stuporous state, with interruptions of + laughter, to an indifferent silly, muttering to herself was + gradual. + + In 1909 she was described as not talking, standing around, + showing no interest in anything, muttering. The only + response obtained was "I don't know." In December, 1911, + she was transferred to another hospital as a case of + deteriorated dementia praecox. + +_To Recapitulate:_ We have here a young woman who for a year had +indefinite mental symptoms and suddenly developed a stupor. This was +atypical in that she sang and wrote when otherwise apparently deeply +stuporous. When persuaded to talk, her utterances, even as early as ten +days after admission, were of a malignant type and with such statements +she giggled. This last is apparently a highly important sign. Quite +frequently in our cases the first signal of a dementia praecox reaction +has been giggling in a setting of what was apparently a typical benign +stupor. + +As has frequently been stated, symptoms of benign stupor are closely +interrelated. Consequently the reaction is, when benign, a consistent +one. We do not find free speech with profound apathy and inactivity, +nor do we expect to meet with unimpaired intellectual functions when +other evidences of deep stupor are present. The inconsistency of mental +operations which characterize dementia praecox, however--the "splitting" +tendency which Bleuler has emphasized in his term "schizophrenia"--is +just that added factor which may produce disproportionate developments +of the various stupor symptoms in the dementia praecox type of that +reaction. Examples of this have been given in the two cases just quoted. +The history of the following patient shows this tendency more +prominently. + + + CASE 22.--_Nellie H._ Age: 20. Admitted to the Psychiatric + Institute June 11, 1907. + + _F. H._ The father had repeated depressions; he died of + typhus fever. The mother was living. + + _P. H._ The brother of the patient stated that she was like + other girls, and very good at school. At 16 she became + quieter, less energetic. She came to America at 17. After + arriving here she has seemed low spirited, cranky and + faultfinding. She often complained of indefinite stomach + trouble and headaches; when at home she often had a cloth + around her head. The informant recalled that she said, "I + wish I could get sick for a long time and get either cured + or die." However, she worked. For one and a half years + prior to admission her "crankiness" is said to have become + much worse. She complained continually of being tired; + quarreled much with her mother; said she did not have + enough to eat. It is also stated that she was constantly + afraid of losing her job. + + _History of Psychosis:_ For six months before admission she + said frequently that her boss was giving her hints that he + liked her. (She did not know him socially at all.) Six days + before admission she came home, saying the boss had told + her he had no more work for her. Nevertheless, she went + back next day and was again sent home. At home she sat + gazing. Next day again wanted to go and see the boss, but + was prevented. At times she tried to get out of the window; + again sat gazing, repeating to herself "Always be true." + She said she was in love with the boss. When the doctor + gave her medicine she thought it was poison. Finally she + began to be talkative and elated. At the _Observation + Pavilion_ she became very quiet. + + _Under Observation:_ She lay in bed indifferent, not + eating, unless spoon-fed, when she would swallow. She + soiled herself. She answered no questions as a rule, and + only on one occasion, when urged considerably, said in + answer to questions that this was a hospital, so that she + evidently had more grasp on the nature of her environment + than her behavior indicated. To her brother who called on + her during the first ten days she said she could not find + her lover here (an idea inconsistent with the benign stupor + picture). + + Then she became more markedly stuporous, drooling saliva, + very stiff, often lying with head half raised, gazing + stolidly, never answering, soiling. Later, after a month, + this was less consistent. She now and then went to the + closet, sometimes she smiled, ate some fruit brought to + her, spoke a little. Repeatedly when people came she clung + to them, wanted to go home, again was seen to weep + silently. On another occasion she suddenly threw the dishes + on the floor with an angry mood, without there being any + obvious provocation. Again she got quite angry when urged + to eat her breakfast, and on that occasion pulled out some + of her own hair. Usually she had to be fed, was stiff, + sitting with closed fists, not reacting as a rule in any + other way, wholly inaccessible and has been that way for + years. The stupor merged into a catatonic state merely by + the development of the inconsistency in her affective + reactions. + +We see then that inconsistencies among the stupor symptoms themselves +and the intrusion of definitely dementia praecox symptoms differentiate +the malignant from the benign reactions. As a matter of fact, we find, +as a rule, that careful examination of the onset reveals further +atypical features, suggestions or definite evidences of a dementia +praecox reaction before the stupor itself appears. One common occurrence +is a slow deterioration of character and energy that proceeds for months +or years before flagrantly psychotic symptoms appear. + +Then when delusions or hallucinations are eventually spoken of by the +patient, an appropriate or adequate reaction is lacking. In a benign +psychosis false ideas do not appear with an equable mood unless the +stupor reaction has already begun. + +More important than this, although in benign stupors there may be a +reduction or an insufficient affect, it is never inappropriate. This +pathognomonic symptom of dementia praecox frequently occurs in the onset +to malignant stupors. In fact we often find in reviewing such cases that +a plain dementia praecox reaction has been in evidence, that a diagnosis +has not been made simply because the stupor picture blotted out this +earlier psychosis before an opinion was formed. Frequently these early +symptoms are reported in the anamnesis and not actually observed by the +physician. + +Three cases may be cited as examples of dementia praecox onsets. It will +be noted that the ensuing stupors were, like those already quoted, +atypical. + + + CASE 23.--_Catherine H._ Age: 21. Admitted to the + Psychiatric Institute October 10, 1904. + + _F. H._ The mother's brother had two attacks of delirium + tremens. The mother died when the patient was eleven years + old; she is said to have been normal. The father was + living. + + _P. H._ The patient was always a nervous child, had very + bad dreams, but she was smart at school up to ten or + eleven, and played with other girls. Then she began to work + less well, got thin, more nervous, complained of headaches. + It was about that time that her mother died. (The reaction + to the death was said not to have been different from that + of her sister.) She was kept at home and was quiet.... "You + could see something was working on her." She began to + menstruate at 14, and it was claimed that she then wakened + up a little. It was further stated that she was always + "stuck up" about her clothes. + + At 16 she went to work in a factory, but her sister thought + the work was too much for her, so she was taken home. + Thereafter she lived alone with her father, doing his + housework, her sister having married about that time. At 17 + her hair began to come out excessively, so that she had to + cut it, and when it grew again it was gray. She became very + sensitive about this, even refused to take positions + because she thought people would remark about it. + + For two years before admission she evidently was different. + Although she did her father's housework well enough, she + turned against her sister and refused to speak to her + because, she alleged, the sister had not come to help her + in her housework. Another pronounced manifestation during + that time was her frequent talk about her bowels. She + complained of constipation, creepy, crawling sensations in + the stomach which she thought was a "tapeworm." She got + pamphlets and took patent medicines. She was taken to a + physician nine months before admission, who operated on her + for piles. While still in the hospital she asked her father + to take her home to die (although there was no reason for + such a request). Again she said the gauze had been left in + the rectum too long and that the rectum was full of wind. + Later she said the rectum was closing up. After this, the + sister stated, she was extremely nervous if she passed a + day without a movement of the bowels. She was quiet + henceforth, went out less and said little, claiming it was + better for her head if she said little. She often sat, head + in hand, in the hall. All through the summer she frequently + remarked, "I am a good girl." Four months before admission + during a period of five weeks she would let her bowels move + when standing up. This was relieved by enemas. The father + states that she was cranky to him, that sometimes when he + merely asked a question she would say, "You hurt my + feelings," and once, "You break my heart." Occasionally she + seemed to worry about the money spent for her on doctors + and medicine. + + About two months before admission she said everybody was + looking at her. Ten days before admission she said, "I have + been sick all this time and thought I was going to die. Now + I think Tom (her brother) is going to die." She became + fearful of being left alone. Finally she went to the + priest, who told her to go home. Then she prayed, leaving + the candles burning in the room. That night she was found + kneeling before a church in her nightgown. Again she threw + a lot of articles into the yard, saying a curse had been + put on her by her father, and she did not wish to give him + anything. When she was taken to the Observation Pavilion + she said, "I am a good girl--my mother is dead--it is all + my father's fault." + + At the _Observation Pavilion_ she put her arm under a hot + water faucet "to save the world," prayed and laughed--again + sank back and appeared as if asleep. She said, "I hear + angels telling me how to pray when I lose my + thoughts--sisters and nuns are all around me here, to save + and purify the world now and forever, and at the hour of + our death." + + _Under Observation:_ On admission the patient kept her eyes + closed, sang hymns in measured tones, or prayed, or showed + a certain ecstasy in her face while her lips quivered and + tears ran down her cheeks. On the whole, she answered few + questions. When asked how she felt, she said she was happy. + (Why do you cry?) "I was crying when I asked God to save + souls." (Are you afraid?) "Not now, I have been afraid of + everything on Earth ever since my mother died." (What do + you mean?) "No one would look at me or talk to me--they + said I was a bad girl, but I was pure." Again she said, + "They laughed about me, talked about me--and they drew up a + play about me--Devil's Island." Or she spoke about having + had stomach trouble, bowel trouble, teeth trouble, eye + trouble, compound, complicated trouble. (What do you mean?) + "Father scolding all the time, he sent me to get bug + medicine (true). God gives that medicine to the one that + started all the trouble--Devil's Island." + + She soiled her bed and was asked why she did it. She said + "I have been transformed into a baby, the Lord said I was + too pure to be a woman--I had to become a baby to save the + world." Or when asked her name she called herself "Baby + Chadwick of the whole world--divine Irish Catholic + World--Amen," or again "I am the Roman Catholic Irish + Divine Baby." + + Although she was not essentially disoriented she called the + place "mid-heaven," or "a holy house, sort of a hospital." + She also said, "In two years more there will be a new world + and it will be more happy and holy." + + The day after entrance the patient, though in part as + described, had a spell when she kept her eyes closed and + was rigid. Spells like these returned. (About a month after + admission she became completely stuporous.) She prayed at + times, at other times was constrained, or kept her eyes + closed. Her orientation throughout was good. The content of + her psychosis, in addition to the praying attitude, had a + more or less vague religious coloring. Thus she called the + hospital the "House of God." Again, when on one occasion + she had jumped at the window guard and was asked "why?" she + said "holy communion." Again she said she was "Mary, Virgin + Mother." But this religious trend was intermingled with + remarkable elements of another sort. Thus when in order to + study her knowledge of the events after admission, she was + asked what she had done when she was brought into the ward, + she said, "I went into the sanctuary where my bowels moved + and water passed from me." (Why do you call it sanctuary?) + "Because Jesus did the same thing I did." + + Possibly vague sexual allusions are also contained in the + following: She said one day to the doctor, "Everything went + wrong last night, good, pure, true and holy doctor, I led + you astray and you were dying last night, may the Almighty + God forgive me, I ought to have died, but I fought it out, + for, if I had died, my mother's soul would not have been + saved in Heaven and from the flames of Hell." Again, "I + will not look at you again, good, pure, holy doctor of the + world." (Why?) "I am afraid I will lead you astray." And + also: "I led James. Peter astray too." It should be added + that she sometimes masturbated rather shamelessly. + + She said she heard her mother's voice. (What did she say?) + "Something in the sky for me, angels call for me." (What do + the angels say?) "The name of my good mother in Heaven." + Again she said she had heard her mother the night she came + here. (What did she say?) "It was like a voice--feed the + calf--that means me, I suppose." + + Then after a month the stupor became more continuous. She + lay totally inactive for the most part, had to be fed, + soiled herself, drooled saliva, was at times cataleptic, + often rigid. Her limbs became cyanotic. A few times tears + were seen. On other occasions she whispered "peace," or + "peace for hazing," or "pray--peace," or "I like to be + good." Usually no responses could be obtained. + + After some months she was at times seen laughing. This + gradually passed into a state of total disinterestedness + and inaccessibility. She could finally be made to polish + the floor in an automatic fashion, but never spoke, and + five years after admission she was transferred to another + hospital, where she died (eleven years after admission to + the ward of the Institute) without any change in her mental + condition having taken place. + + + CASE 24.--_Adele M._ Age: 22. Admitted to the Psychiatric + Institute November 11, 1904. + + _P. H._ The father stated that the patient was always + "cranky," had outbursts of temper, even when a small child + and was quarrelsome; also said that she was "seclusive," + had few friends, was averse to meeting people, never had a + beau. She was taken out of school at 14 because she was not + promoted on two successive occasions from the same class. + Then she was put to work, but she was usually discharged + for incompetency. + + _Onset of Psychosis:_ Three years before admission it was + noted that she laughed occasionally without cause. She was + idle. This laughing, and also crying, was sometimes more + frequent, again less noticeable. + + Six months before admission she began to say she wanted to + leave home, but made no move to do so. Then she began to + speak of bad odors, made some remarks about the neighbors + talking about her--saying she should kill herself; again + she said the family would be brought to death, or the + mother was falling to pieces, the father looked sick. She + also said her head was swelling and was getting thick. + Finally she wanted to hire a furnished room and kill + herself and asked if 75 cents which she had was enough to + do it with. + + Two weeks before admission she left home, wandered about + all night, was picked up by the Salvation Army, and + returned to her home. She said she wanted to die. + + At the _Observation Pavilion_ she stated that her mother + was falling to pieces and her father sick. She also said + she wanted to die. + + _Under Observation:_ The patient was at first petulant, + saying "I don't want to stay here," turning her face away + from the doctor, generally uninterested. Though it could be + established that she was quite oriented, often her answers + were "I don't know," or she did not answer. But she was + also seen crying at times, and she was apt to bite her + finger nails. She had to be tube-fed. Gradually these + tendencies increased so that she lay in her bed with head + covered, saying in a peevish tone, when spoken to, "Oh, let + me alone." And for years she was mute, lying with her head + covered, tube-fed. When reexamined in 1914 (ten years + later), she was found lying in bed with an empty smile. + There was paper stuffed in her ears. When approached, she + turned her head away and would not talk. + + + CASE 25.--_Catherine W._ Age: 42. Admitted to the + Psychiatric Institute November 11, 1904. + + _F. H._ The father died at 75, the mother at 44. Two + sisters died of tuberculosis. A brother wanted to marry but + was opposed by the father; he set fire to the house of the + girl and then drowned himself. + + _P. H._ The patient came to this country when 20, and + worked for some years as a servant. Then she married after + a short acquaintance. The husband, according to his own + statement, drank, and there was friction from the first. + She left him a few weeks after marriage, and a few months + later he went to Ireland; she also went some time later but + did not go to see him. Then they lived together again. They + had four children, but had had no intercourse for nine + years. + + _Development of Psychosis:_ Eight years before admission + the patient became nervous, slept badly, but got better. It + was claimed that for six years she had been quieter and + more sullen than before. Three years before admission the + patient had to take a place as janitress, since she needed + the money. From the first she had trouble with the tenants + and accused everybody of being in league against her. Some + six or eight weeks after she had taken the position, she + developed what was called typhoid fever, and some time + later the daughter came down with the same disease. After + the typhoid she was more antagonistic towards her husband, + accused him of infidelity, repeatedly locked him out of the + house, but continued to do her housework. About six months + after this illness she left her home, but returned in a + week. She had vague ideas thereafter that the priests were + saying things against the family, and she often quarreled + with the tenants. For a year she had done no work but sat + about. Ten days before admission she stopped eating. + + _Under Observation:_ The patient was mute, stolid, gazing + straight ahead, sometimes cataleptic. She had to be + tube-fed, was usually very resistive to any passive + motions; quite often she retained her urine, but she did + not hold her saliva. Yet there was some quick responses at + least in the beginning. At such times it was found that she + was oriented, but nothing could ever be obtained about her + feelings, etc., except that she once said, when asked + whether she was worried, that she "felt weak," had "nothing + to worry about." Occasionally she was seen to cry silently; + at times she would breathe faster when questioned, or + flush; once she took hold of the doctor's hand when he + questioned her, and cried, but made no reply. On another + occasion she was affectionate to her son, kissed him, + although she paid no attention to her daughter who + accompanied the son. Later she said to the nurses, "He is + the best son that ever lived." But more and more she became + disinterested, totally inaccessible, resistive, had to be + tube-fed. In this condition she remained for five and a + half years. At the end of that time she died of tubercular + pneumonia. + + + + +CHAPTER XII + +DIAGNOSIS OF STUPOR + + +In any functional psychosis an offhand diagnosis is dangerous. When one +deals with such a condition as stupor, however, the problem is exacting, +for, although "stupor" may be seen at a glance, what is seen is really +only a symptom or a few symptoms. "Stupor," then, is more of a +descriptive than a diagnostic term. The real problem is to determine the +psychiatric group into which the case should be placed. This is a +difficult task, for the differential diagnosis rests on the observation +and utilization of minute and unobtrusive details. A correct +interpretation can be only reached by obtaining a complete history of +the onset and observing the behavior and speech of the patient for a +long period, usually of weeks, sometimes of months. With these +precautionary words in mind, it may be well to summarize briefly the +diagnostic problems in connection with benign stupor. + +In the first place one naturally considers the differentiation from +conditions of organic stupor or coma. Since psychotic stupors never +develop without some signs of mental abnormality, the history is usually +a sufficient basis for final judgment. In case no anamnesis is +obtainable the functional nature of the trouble may be recognized by the +absence of those physical signs which characterize the organic stupors. +One sees no violent changes in respiration, pulse or blood-pressure, +such as are present in the intoxication comas of diabetes or nephritis. +There is no characteristic odor to the breath, and the urine is +relatively normal. The unconsciousness of trauma or apoplexy is +accompanied by focal neurological signs. Even in aerial concussion (so +frequently seen in the war) where no one part of the brain is +demonstrably affected more than another, there are neurological +evidences of what one might call "physiological" unconsciousness. The +eyes roll independently, the pupils fail to react to light. On the other +hand, there are definite symptoms characteristic of the functional +state. Mental activity is evidenced by a muscular resistiveness or +retention of urine. Even in states of complete relaxation the eyes move +in unison, the pupils react to light, and almost universally the corneal +reflex is present. The patient appears in a deep sleep rather than +actually unconscious. + +The post-epileptic sleep may resemble a stupor strongly. But this +condition is temporary and the situation and appearance of the patient +betrays the fact that he has just had a convulsion. Rarely, protracted +stuporous states occur in epilepsy which closely resemble the conditions +described in this book. In fact it is probable the true stupors may +occur in epilepsy just as in dementia praecox or manic-depressive +insanity. + +There is usually little difficulty in the discrimination of hysterical +stupor. Occasionally it shows, superficially, a similarity to the +manic-depressive type. Fundamentally, there is a wide divergence between +the two processes, in that in the hysterical form a dissociation of +consciousness takes place, the patient living in a reminiscent, +imaginary or artificially suggested environment, while in a true stupor +there is a withdrawal of interest as a whole and a consequent diffuse +reduction of all mental processes. This difference is sooner or later +manifested by the appearance in the hysteric of conduct or speech +embodying definite and elaborated ideas. + +As has been stated fully in the last chapter (to which the reader is +referred), the stupor of dementia praecox is to be differentiated from +that of manic-depressive insanity by the inconsistency of the symptoms +in the former and the appearance of dementia praecox features during the +stupor, such as inappropriate affect, giggling, or scattering. Further, +the nature of the disorder is usually manifest before the onset of the +stupor as such. + +Sometimes very puzzling cases occur in more advanced years when it is +difficult to say whether one is dealing with involution melancholia or +stupor. Such patients show inactivity, considerable apathy and wetting +and soiling, and with these a whining hypochondria, negativism, and +often a rather mawkish sentimental death content without the dramatic +anxiety which usually characterizes the involution state. In these cases +the diagnosis is bound to be a matter of taste. In our opinion it is +probably better to regard these as clinically impure types. They may be +looked on as, fundamentally, involution melancholias (the course of the +disease is protracted, if not chronic) in whom the regressive process +characteristic of stupor is present as well as that of involution. + +Great difficulties are also met with in the manic-depressive group +proper. So often a stupor begins with the same indefinite kind of upset +as does another psychosis that the development may furnish no clew. Any +condition where there is inactivity, scanty verbal productivity and poor +intellectual performance resembles stupor. This triad of symptoms occurs +in retarded depressions, in absorbed manic states and in perplexities. +Negativism and catalepsy are never well developed except in stupor. So +if these symptoms be present the diagnosis is simplified. But they are +often absent from a typical stupor. Let us consider these three groups +separately. + +The most important difference between stupor and depression lies in the +affect. Although inactive and sometimes appearing dull the depressive +individual is not apathetic but is suffering acutely. He feels himself +wicked, paralyzed by hopelessness, and finds proof of his damnation in +the apparent change of the world to his eyes and in the slowness of his +mind. But he is acutely aware of these torments. The stupor patient, on +the other hand, does not care. He is neither sad nor happy nor anxious. +This contrast is revealed not only by the patients' utterances but by +their expressions. The stuporous face is empty, that of the other lined +with melancholy. The intellectual defect, too, is different. In retarded +depression the patient is morbidly aware of difficulty and slowness, but +on urging often performs tests surprisingly well. In the stupor, +however, one is faced with an unquestionable defect, a sheer +intellectual incapacity. + +In Chapter VIII the differential diagnosis between perplexity and stupor +has already been touched upon. Here again the affect is a point of +contrast. The patient has not too little emotion but too much. The +feeling of intangible, puzzling ideas and of an insecure environment +causes the subject distress, of which complaint is made and which can be +witnessed in the furrowed brow and constrained expression. There is +also, as we have seen, a rich ideational content in these cases, if one +can get at it. The mind is not a blank, as in the stupor, or concerned +only with delusions of death. + +Finally, there are the absorbed manic states. These are the most +difficult, inasmuch as the patient is often so withdrawn and so +introverted that at any given interview there may be no objective +evidence of mood or ideas. Here the development of the psychosis is +often an aid to diagnosis. The patient passes through phases of +hypomania to great exultation, the flight becomes less intelligible, +with this the activity diminishes until finally expression in any form +disappears. If this sequence has not been observed, continued +observation tells the tale. The patient still has his ideas and may be +seen smiling contentedly over them (not vacuously as does the +schizophrenic) or he may break into some prank or begin to sing. Any +protracted familiarity with the case leads to a conviction that the +patient's mind is not a blank, but that his attention is merely directed +exclusively inward. Then, too, when his ideas are discovered, it is +found that they are not exclusively occupied with the topic of death. + + + + +CHAPTER XIII + +TREATMENT OF STUPOR + + +In dealing with cases of benign stupor the first duty of physician and +nurse is naturally the physical hygiene of the patient. More is needed +to be done in the bodily care of these persons than for most of the +inmates of our hospitals for the insane. It is perhaps no exaggeration +to claim that a deeply stuporous patient needs as much attention as a +suckling babe. In the first place, the patient must be fed. It is +important for mental recovery that the individual in stupor should be +stimulated to effort as much as possible. Consequently there is an +economy of time in the long run in taking pains to get the patient to +feed himself in so far as that is possible. He should be led to the +table and assisted in handling his own spoon and cup. If this is not +practicable, he should then be spoon-fed, and if this in turn is found +to be out of the question, tube-feeding should be resorted to. But this +last should never be looked on as a permanent necessity, but only as a +method of maintaining the patient's health until such time as he may be +capable of independent taking of nourishment. In exactly the same way it +is of prime importance to get the patient to attend to the natural +habits of excretion. He should be led to the toilet or to a chair +commode, and efforts to this end should be persistent, just as are those +of a good child's nurse who has the ambition of making her charge +develop normal habits. Naturally those who retain urine and feces should +be watched to see that this retention does not last long enough to +menace health. The physical aspects of treatment are exhausted with +consideration for cleanliness. On account of the stupor patients' +inactivity and frequent tendency to wetting and soiling, this is a +particularly important consideration. It goes without saying that the +perineal region should be kept scrupulously clean. If any infections are +to be avoided, eyes, nose and mouth should also be cleansed frequently. +A patient who is so indifferent as to keep the eyelids open for such a +long time that the sclera dry and ulcerate is also apt to let flies +settle and produce serious ophthalmic disease. + +Less obvious and more important are the measures undertaken for the +mental hygiene of the case. On account of the tendency present in so +many patients for sudden action while in the midst of an apparently deep +and permanent inactivity, it is necessary that these cases be not +isolated but remain under constant observation. This is particularly +true of those who have demonstrated impulsive suicidal explosions. + +Not only on the basis of the psychological theory of the stupor process, +but from the observed phenomena of recovery, we gather that mental +stimulation is of first importance if an amelioration of the condition +is to be attempted. If the stupor reaction be a regression, which is +essentially a withdrawal of interest and energy rather than a fixation +on a false object, then excitement is desirable and interest must be +reawakened. The withdrawal is temporary (inasmuch as the psychosis is +benign), but just as a normal person wakes more readily on a clear +sunshiny day than when it rains, so the more cheering the environment +the more rapid the recovery. + +Consequently, although trying to those in charge, persistent attention +should be given the patient. Feeding and hygienic measures probably have +considerable value in this work. As soon as it is at all possible the +patients should be got out of bed and dressed. When up, efforts should +be directed towards making them do something, even if it be something as +simple as pushing a floor polisher. On account of their lack of +enthusiasm the stupor cases are often omitted from the list of those +given occupation and amusement. Even if they go through the motions of +work or play with no sign of interest, such exercise should not be +allowed to lapse. Then, too, the environment should be changed when +practicable. A patient may improve on being moved to another building. + +Perhaps the most potent stimulus that we have observed is that of family +visits. In most manic-depressive psychoses visits of relations have a +bad effect. The patients become excited, treat the visitors rudely, +perhaps even assault them, and all their symptoms are aggravated. But +the stupor needs excitement, and an habitual emotional interest is more +apt to arouse him than an artificial one. In another point the situation +differs. As a rule manic-depressive patients have delusional ideas or +attitudes in connection with their nearest of kin, so that contact with +these stirs up the trouble. The stupor regression going beneath the +level of such attachments leaves family relationships relatively +undisturbed. Hence, while the visit of a husband is likely to produce +nothing but vituperation or blows from a manic wife, the stuporous woman +may greet him affectionately and regain thereby some contact with the +world. + +So many cases begin recovery in this manner that it cannot be mere +chance. One patient's improvement, for instance, dated definitely from +the day a nurse persuaded her to write a letter home. It is striking, +too, how quickly a patient, while somewhat dull and slow, will brighten +up when allowed to return home. A similar improvement under these +circumstances is often seen in partially recovered cases of involution +melancholia, in whom a psychological regression similar to that of +stupor takes place. Such experiences make one wonder whether perhaps +these alone of all our insane patients would not recover more quickly at +home than in hospitals, provided nursing care could be given them. + +This is a mere suggestion. Before treatment can be rational the nature +of any disease process must be known, and we do not pretend to have done +more as yet than outline the probable mental pathology of the benign +stupors. The next step is to put theory into practice and experiment +widely with various means to see if by appropriate stimulation the +average duration of these psychoses cannot be reduced. It is largely +with the hope of inducing other psychiatrists to carry on such work that +this book is written. There is no other manic-depressive psychosis +which, theoretically, offers such hope of simple psychological measures +being of therapeutic value. + + + + +CHAPTER XIV + +SUMMARY OF THE STUPOR REACTION + + +Having discussed in detail the various symptoms and theoretic aspects of +the benign stupors, it may be well to have these observations and +speculations summarized. + +It being established that stupors occur as a temporary form of +insanity[12] psychiatry is faced at once with the problem of describing +these conditions accurately in order to ascertain their nosological +position. To this end we first examined typical cases of deep stupor and +found that the clinical picture is made up of the following symptoms: In +the foreground stands _poverty of affect_. The patients are almost +unbelievably apathetic, giving no evidence by speech or action of +interest in themselves or their environment, unmoved even by painful +stimuli. Their faces are wooden masks; their voices as colorless when +words are uttered. In some cases sudden mood reactions break through at +rare intervals. The second cardinal symptom is _inactivity_. As a rule +there is a complete cessation of both spontaneous and reactive movements +and speech. So profound may this inhibition be that swallowing and +blinking of the eyes are often absent. The trouble is not a paralysis, +however, for reflexes without psychic components are unaffected. +Possibly related to the inactivity is the preservation of artificial +positions which is called _catalepsy_, a fairly frequent phenomenon. A +tendency opposite to the inactivity is seen in _negativism_. This +perversity is present in all gradations from outbursts of anger with +blows and vituperation to sullen, or even emotionless, muscular +rigidity. This last occurs most often when the patient is approached but +may be seen when observations are made at a distance. Frequently +_wetting_ and _soiling_ are due to negativism, when the patient has been +led to the toilet but relaxes the sphincters so soon as he leaves it. A +constant feature is a _thinking disorder_. On recovery memory is largely +a blank even for striking experiences during the psychosis and, when +accessible during the stupor to any questioning, a failure of +intellectual functions is apparent. An _ideational content_ may be +gathered while the stupor is incubating, during interruptions, or from +the recollections of recovered patients. Its peculiarity is a +preoccupation with the theme of death, which is not merely a dominant +topic but, often, an exclusive interest. Probably to be related to this +is a tendency, present in some cases, to sudden suicidal impulses, that +are as apparently planless and unexpected as the conduct of many +catatonics. Finally the disease is prone to exhibit certain _physical_ +peculiarities. A low fever is common and so are skin and circulatory +anomalies. A loss of weight is the rule, and menstruation is almost +always suppressed. + +As to the frequency of stupor no figures are available, for the simple +reason that the diagnosis in large clinics has not been made with +sufficient accuracy to justify any statistics. Most of these cases are +usually called catatonia, depression, allied to manic-depressive +insanity or allied to dementia praecox. The majority of the stupors +reported in this book were in women, but this is merely the result of +chance, since it has been easier in the Psychiatric Institute to study +functional psychoses in the female division, while the male ward has +been reserved largely for organic psychoses. The majority of the +patients seem to be between 15 and 25 years of age, so that it is, +presumably, a reaction of youthful years. In our experience most cases +occur among the lower classes, which agrees with the opinion of Wilmanns +who found this tendency among prisoners. + +This gives a brief description of the deep stupor. But even our typical +cases did not present this picture during the entire psychosis. They +showed phases when, superficially viewed, they were not in stupor but +suffered from the above symptoms as tendencies rather than states. There +are also many psychoses where complete stupor is never developed. This +gives us our justification for speaking of the _stupor reaction_, which +consists of these symptoms (or most of them) no matter in how slight a +degree they may be present. The analogy to mania and hypomania is +compelling. The latter is merely a dilution of the former. Both are +forms of the manic reaction. We consequently regard stupor and partial +stupor as different degrees of the same psychotic process which we term +the stupor reaction. To understand it the symptoms should be separately +analyzed and then correlated. + +The most fundamental characteristic of the stupor symptoms is the change +in affect which can be summed up in one word--apathy. It is fundamental +because it seems as if the symptoms built around apathy constitute the +stupor reaction. The emotional poverty is evidenced by a lack of +feeling, loss of energy and an absence of the normal urge of living. +This is quite different from the emotional blocking of the retarded +depression, for in the latter the patient shows either by speech or +facial expression a definite suffering. The tendency to reduction of +affect produces two effects on such emotions as internal ideas or +environmental events may stimulate. Exhibitions of emotion are either +reduced or dissociated. For instance, anxiety is frequently diminished +to an expression of dazed bewilderment; or, isolated and partial +exhibitions of mood occur, as when laughter, tears or blushing are seen +as quite isolated symptoms. This latter--the dissociation of +affect--seems to occur only in stupor and dementia praecox. It should be +noted, however, that inappropriateness of affect is never observed in a +true benign stupor. A final peculiarity is the tendency to interruption +of the apathetic habit, when the patient may return to life, as it were, +for a few moments and then relapse. + +Closely related to the apathy, and probably merely an expression of it, +is the inactivity which is both muscular and mental. It exists in all +gradations from that of flaccidity of voluntary muscles, with relaxation +of the sphincters, and from states where there is complete absence of +any evidence of mentation to conditions of mere physical and psychic +slowness. After recovery the stupor patient frequently speaks of having +felt dead, paralyzed or drugged. + +By far the commonest cause of emotional expression or interruption in +the inactivity is negativism. This is a perversity of behavior which +seems to express antagonism to the environment or to the wishes of those +about the patient. In the partial stupors it is seen as active +opposition and cantankerousness. In the more profound conditions it is +represented by muscular resistiveness or rigidity, or refusal to swallow +food when placed in the mouth. Occasionally, too, the patient may even +in a deep stupor retain urine so long that catheterization is necessary. +All the explanations which one may gather from the patients' own +utterances, mainly retrospective, seem to point to negativism expressing +a desire to be left alone. The appearance of perverse behavior in +aimless striking or mere muscular rigidity seems to be an example of +dissociation of affect. + +Catalepsy is an important symptom because, although it occurred in +slightly less than a third of our cases, it seems to be a peculiarity of +the stupor reaction found but rarely in other benign psychoses. It seems +never to occur without there being some evidence of mental activity, +and, consequently, we are forced to conclude that it is of mental rather +than of physical origin. Just what it means psychically it is impossible +to state without much more extended observations. We conjecture +tentatively, however, that the retention of fixed positions is in part +merely a phenomenon of perseveration, and in part an acceptance of what +the patient takes to be a command from the examiner, and sometimes a +distorted form of muscular resistiveness. + +The intellectual processes suffer more seriously in stupor than in any +other form of manic-depressive insanity. Not only do the deep stupors +betray no evidence of mentation during the acme of the psychosis, but +retrospectively they usually speak of their minds being a blank. +Incompleteness and slowness of intellectual operations are highly +characteristic features of the partial stupors and of the incubation +period of the more profound reactions. The features of this defect are a +difficulty in grasping the nature of the environment, a slowness in +elaborating what impressions are received, with resulting +disorientation, poor performance of any set tests and incomplete memory +for external events when recovery has taken place. At times the thinking +disorder may develop with great suddenness or improve as quickly, and a +tendency to isolated evidences of mental acuity is another example of +the inconsistency which is so highly characteristic of stupor. We should +note, however, that these sporadic exhibitions of mentality are always +associated with brief emotional awakening. + +When we turn to examine the fragmentary utterances of stupor patients, +we are surprised by the narrowness and uniformity of the ideational +content. It seems to be confined to thoughts of death or closely related +conceptions. Thirty-five out of thirty-six consecutive cases at one time +or another referred literally to death. It is commonest during the +onset, as all but five of these patients spoke of it during the +incubation of their psychoses. Hence we conclude that death ideas and +stupor are consecutive phenomena in the same fundamental process. As +two-thirds of the series interrupted the stupor to speak of death or to +attempt suicide, we assume that this relationship persists. Only a +quarter gave any retrospective account of these fancies, so we presume +that their psychotic experiences were repressed with recovery. + +The usual form in which the idea appears is as a delusion of going to +die or, literally, of being dead. It may appear as being in Heaven or +Hell. A theoretically important group is that which includes the +patients who, in addition, speak of being in situations such as under +the water or underground, which we have mythological and psychological +evidence to believe are formulations of a rebirth fantasy. Not rarely, +preoccupation with death is expressed in sudden impulsive suicidal +attempts. + +The affective setting of these different formulations is important. A +delusion of literal death occurs with complete apathy. The wish to die +is apt to appear without the usual accompaniment of sadness or distress +but still with considerable energy when impulsive suicidal attempts are +made. A prospect of death, particularly when there is anticipation of +being killed, is apt in manic-depressive insanity to occur in a setting +of anxiety. Similarly one ordinarily observes fear in the patient who +has delusions of drowning or burial. In the stupor cases, however, this +painful affect seems to be reduced to a mere dazed bewilderment or +feeble exhibitions of a desire for safety, such as the slow swimming +movements of a patient who thought she was under the water. When these +ideas of danger become allied to everyday interests--husband or child +imperiled, etc.--a weak affect in the form of depression is apt to +occur. + +Physical symptoms are more common than in any other benign psychosis. Of +these the most nearly constant is a low fever, the temperature running +between 99 deg. and 101 deg. Twenty-eight out of thirty-five cases had +this slight elevation with a tendency for it to occur immediately at the +beginning of marked stupor symptoms. Although the evidence does not +positively exclude any possibility of infection, it speaks distinctly +against this view. A possible explanation is that the low fever is a +secondary symptom. The suprarenal glands may function insufficiently as +a consequence of the emotional poverty, since all emotions which have +been experimentally studied seem to stimulate the production of +adrenalin. Without this normal hormone for the activity of the +sympathetic nervous system, there would be a disturbance of skin and +circulatory reactions that would interfere with the normal heat loss. +Suggestive evidence to support this view comes from the frequency with +which the extremities are cyanotic or cold, the skin greasy, sweating +profuse or absent, and so on. Further observations are necessary to +confirm or disprove this hypothesis, but we feel inclined to accept it +tentatively because it is plausible and consistent with the view that +stupor is essentially a psychogenic type of reaction. Another physical +anomaly, which is presumably of endocrine origin, is the suppression of +the menses. This probably results from lowered nutrition. In some cases +it ensues directly on a psychic crisis before any nutritional change can +have taken place. Finally, among the symptoms of possible physical +origin, epileptoid attacks were described in two of our cases. This is +chiefly of interest in that such phenomena are extremely rare in the +benign psychoses. + +We believe that the mental symptoms summarized above constitute a +specific psychotic type of reaction capable of appearing in any severity +from mere lethargy and indifference to profound stupor. Since the +prognosis is good, we feel obliged to classify this with the +manic-depressive reactions. Further justification for this grouping is +found in the occurrence of the stupor reaction as a phase in many +manic-depressive psychoses. A patient may swing from mania to stupor as +from mania to depression, and when the partial stupors are recognized as +milder forms of the same process, it seems to be a frequent type of +reaction. + +If stupor be a reaction type, its laws must be psychological. According +to the view of modern psychopathology, the essence of insanity is +regression with indolent thinking as opposed to progressive and +energetic mentation. One can look on stupor as being a profound +regression. Effort is abandoned (apathy and inactivity), while the +ideational content expresses a desire for a retreat from the world in +death. It is possible to think of this regression as a return to the +mental habit of the suckling period, when spontaneous effort is at its +minimum. This, too, is the time when petulance and tantrums are frequent +expression of a wish to be left alone, which may account for the +negativism as a consistent symptom of the same regressive progress. + +Just as we regress in sleep, to rise refreshed for a new day's duties, +so the stupor case often shows excessive energy in a hypomanic phase +before complete normality is reached. This corresponds again to the +age-old association of the ideas of death and rebirth which we see +together so frequently in stupor. It is the psychology of wiping the +slate clean for a fresh start. + +The development and symptoms of stupor furnish evidence in support of +the hypothesis of this type of regression. Dissatisfaction of any kind +is the setting in which the psychosis begins and the commonest +precipitating factor is some reminder of death. That loss of energy +appears with the stupor is evident from the inactivity and apathy, while +the thinking disorder can be shown to be the result of the same loss. +The different "levels" of the stupor reaction also conform to a theory +of regression. First there is mere indifference and quietness; then +appear false ideas when normality is so far abandoned as to mean a loss +of the sense of reality; withdrawal of interest from the environment, +with its consequent centering of self, leads to the next stage--that of +the spoiled child reaction; then follows the exclusion of the world +around in the dramatization of death; finally, in the deepest stupor, +mentation is so far abandoned that we can gather no evidence of even +this delusion being present. + +Atypical features in stupor have to do mainly with interruptions, +interludes as it were, of elation, anxiety or perplexity. These are +explicable as awakenings from the nothingness of stupor into +imaginations such as characterize the other manic-depressive psychoses. +When such tendencies are present, the co-existence of the stupor process +may tone down the emotional response or prevent its complete repression +so that insufficient or dissociated affects appear. A combination of the +stupor tendency to apathy with the mood of another reaction is probably +the only combination of affects to be met with in psychiatry. + +The stupor reaction, then, is a simple regression, with a limitation of +energy, emotion and ideational content, the last being confined to +notions of death. All functional psychoses are regressions. How do the +others differ from this? We need only answer this question in so far as +it concerns the clinical states resembling benign stupors. Stupors occur +frequently in catatonic dementia praecox. In this disease there is a +regression of interest to primitive fantastic thoughts, and with this a +perversion of energy and emotion. This corrupts the purity of the stupor +picture so that inconsistencies, such as empty giggling, atypical +delusions and scattered speech, occur. Other impurities are to be found +in the frequent orientation of the dementia praecox stupor patient which +is discovered to be astonishingly good, or in free speech associated +with apathy and inactivity. Such symptoms usually appear quite early and +should enable one to make a positive diagnosis within a short time after +patient comes under observation. As a matter of fact, in many if not +most cases there is a slow onset characterized by the pathognomonic +symptoms of dementia praecox before the actual stupor sets in. + +Other psychoses superficially resembling stupor are the perplexity and +absorbed manic (manic stupor) states. We have reason to believe that +both these conditions are essentially the result of absorption in +kaleidoscopic ideas. Their appearance is that of inactivity and +indifference to the outside world, just as a dreamer seems placid and +apathetic. But these reactions are not without emotion which may +sometimes be obvious, and the richness of the mental content is sooner +or later manifest. + +Finally, from a practical standpoint, an important peculiarity of benign +stupor is the tendency for response to stimulation in amelioration of +the process. Close attention to these patients is advisable, therefore, +not merely for the sake of their physical health, but also because any +attention tends to keep them mentally alive or revive their waning +energy. Visits of relations often initiate recovery in a striking way. +From occurrences such as these, psychiatrists should gain hints for +valuable therapeutic experiments. + +So much for the technical, psychiatric aspects of the stupor problem. We +have frequently spoken of it, however, as a psychobiological reaction. +If this be a sound view, similar tendencies should appear in everyday +life, the psychotic phenomena being merely the exaggerations of a +fundamental type of human and animal behavior. Shamming of death in the +face of danger and animal catalepsy come to mind at once, but since we +know nothing of the associated affective states we should be chary of +using them even as analogies. We are on safer ground in discussing +problems of human psychology. + +It is evident that there are psychological parallels between the stupor +reaction and sleep, while future work may show physiological +similarities as well. Apathy towards the environment, inactivity and a +thinking disorder are common to both. But sleep reactions do not occur +in bed alone. Weariness produces indifference, physical sluggishness, +inattention and a mild thinking disorder such as are seen in partial +stupors. The phenomena of the midday nap are strikingly like those of +stupor. The individual who enjoys this faculty has a facility for +retiring from the world psychologically and as a result of this psychic +release is capable of renewed activity (analogous to post-stuporous +hypomania) that cannot be the result of physiological repair, since the +whole affair may last for only a few minutes. + +In everyday life there are more protracted states where the comparison +can also be made. When life fails to yield us what we want, we tend to +become bored--a condition of apathy and inactivity, forming a nice +parallel to stupor inasmuch as external reminders of reality and demands +for activity are apt to call out irritability. A form of what is really +mental disease, although not called insanity, is permanent boredom, a +deterioration of interest, energy and even intelligence by which many +troubled souls solve their problems. A sudden withdrawal from the world +we call stupor. When the same thing happens insidiously, the condition +is labeled according to the financial and social status of the victim. +He is a bum, a loafer, a mendicant or, more politely, a disillusioned +recluse. Frequently this undiagnosed dement has satisfied himself with a +weak, cynical philosophy that life is not worth while. + +It is but a step from valueless life to death and the same tendency +which makes the patient fancy he is dead, leads the tired man to sleep, +the poet to sigh in verse for dissolution, and the myth maker to +fabricate rebirth. The religions of the world are full of this yearning, +which reaches its purest expression in the belief and philosophy of +Nirvana. The ideational content of stupor has also its analogue in +crime. The desire for perpetuation of relationships unprosperous in this +world is not seen only in the delusion of mutual death. One can hardly +pick up a newspaper without reading of some unhappy man or woman who has +slain a disillusioned lover and then committed suicide. + + +FOOTNOTES: + +[12] Kirby, George H.: "The Catatonic Syndrome and Its Relation to +Manic-Depressive Insanity." _Jour. of Nervous and Mental Disease_, Vol. +XL, No. 11, 1913. + + + + +CHAPTER XV + +THE LITERATURE OF STUPOR[C] + + +The cases of benign stupor which we report here are not clinical +curiosities. Taking the symptoms as the products of a reaction type, the +latter is really quite common. One, therefore, asks what other +psychiatrists have done with this material. How have they described +these stupors, how classified them? This chapter, essentially an +appendix, attempts to give a brief answer to this inquiry. No attempt is +made to catalogue all that has been written on or around this subject +but only to mention typical reports and viewpoints. + +The French, beginning with Pinel in the 18th Century, were the first to +write extensively of stupor. An excellent paper by Dagonet[13] appeared +in 1872, in which such literature as had appeared up to that time is +discussed. He defines "Stupidity" as a form of insanity in which +"delirious" ideas may or may not be present, which has for its +characteristic symptoms a state of more or less manifest stupor and a +greater or less incapacity to coordinate ideas, to elaborate sensations +experienced and accomplish voluntary acts necessary for adaptation. This +would seem to include our "partial stupor," as well as the more marked +cases. + +He quotes an excellent definition from Louyer Villermay (Dict. des sc. +med. t. LIII, p. 67). "Stupor is a term applied to stupefaction of the +brain. It is recognizable by the diminution or enfeeblement of internal +sensation and by a greater difficulty in exercising memory, judgment and +imagination. It is accompanied by a general numbness and a weakness of +feeling and movement. The patient, then, has an indefinite and stupid +expression, he understands questions put to him with difficulty, and +answers them with effort or not at all. He seems overwhelmed with sleep, +he forgets to withdraw his tongue after showing it to the doctor, he +complains of no uncomfortable sensation, of no illness, he seems to take +no interest in what goes on about him.... The stupor patient is a fool +who does not speak, in this being more tolerable than the one who speaks +[delightful naivete!]. One who is dumbfounded by surprise or fright is +also to be called stuporous." + +Dagonet says stupor results from various causes, such as exhaustion, or +emotional and intellectual factors. Clinically it varies in kind and +degree according to the situation in which it develops. When it develops +during normal mental health, it disappears when its cause does. In +insanity it appears in the course of a psychosis of some duration, of +which it seems a part, an exaggeration of some symptom of the general +condition. Evidently he views stupor as a type of reaction: as a more or +less complete suspension of the operation of intellectual faculties, a +more or less sudden subtraction of nervous forces. This reaction can +result from a fright or the memory of it, a brain lesion or trauma, the +action of narcotics, exhausting fevers, excessive grief, the terrors of +alcoholic hallucinations, epileptic seizures, profound anemia and +nervous exhaustion consequent on sexual excess. He is careful to say +that both symptoms and treatment vary with the varied etiologies. + +He credits Pinel with being the first to call attention to stupor. This +author claimed that some persons with extreme sensibility could be so +upset by any violent emotion as to have their faculties suspended or +obliterated. He noted, too, that stupors frequently terminated in manic +phases of 20 to 30 days' duration. Pinel also emphasized the apathy of +these cases. Esquirol called stupor "acute dementia," a term which +persisted in French literature for a long time. He described an +interesting circular case where alternations between mania and typical +stupor took place. He mentions too the dangerous, impulsive tendencies +of many patients. Georget emphasized the fact which Pinel had also +noted, that retrospectively the stupor patient says his mind was a blank +during the attack. In 1835 Etoc-Demazy published on the subject. He +regarded stupor not as a separate form of insanity but a complication +ensuing on monomania or mania. He recognized the partial as well as +complete stupor. He thought the condition was due to cerebral edema, as +did other writers of that period. Dagonet remarks about this last--a +lesson not learned in fifty years by the profession--that demonstrable +edema does _not_ produce the typical symptoms of stupor. Baillarger in +1843 (Annales Medico-psychologiques) was the first whose ambition to +simplify psychiatric types led to denial of a separate kind of reaction. +He claimed that stupor was not a form of insanity but an extension of a +"delire melancholique." As Dagonet remarks, every symptom by which he +characterizes stupor is a psychiatric symptom and insanity can consist +just as well in the diminution as the perversion or exaltation of normal +faculties. Some of Baillarger's cases had false ideas, some apparently +none at all. Dagonet thinks this justifies two types, one a dream-like +state and another where no ideas are present, although he admits one may +be an exaggeration of the other. Brierre de Boismont (Annales +Medico-psychologique, 1851, p. 442) compares these two kinds of stupors +to deep sleep when intelligence is completely suspended and to sleep +with dreams. (These two types would correspond to our "absorbed mania" +and true deep stupor.) He urges strongly the separation of stupor from +melancholia as an entirely different type of reaction, in this +connection citing the views pro and con of various authors. Of these +Delasiauve is particularly cogent in discriminating stupor from +melancholia on the grounds of the difference of the emotional reactions +and of the intellectual disorder and the real paucity of thought in the +former psychosis. + +After quoting these and other authors, Dagonet offers an explanation for +the diversity of opinion. He says that stupor following another +psychosis may retain some of its symptoms, so that a mixture obtains, as +often in medicine. He then gives excellent descriptions of three types: +the deep stupor with paralysis of the faculties, the cases that are +absorbed in false ideas, and ecstatic cataleptics. + +The remainder of his paper is concerned with cases and discussions about +them. He cites examples of stupor following fear or other emotional +shocks, following grave injuries such as the loss of a limb, following +head trauma and with typhoid fever. As to the last he points out that +delirious features are prominent. Many authors have assigned sexual +excesses as a cause of stupor. The psychosis, Dagonet says, is not pure +but more a mixture of hypochondria and depression. Relationship with +mania is next considered. He says that stupor may succeed, alternate +with or precede mania. His cases seem mainly to have been what we call +absorbed manics or manic stupors. In fact, he uses the last term. The +commonest introductory psychosis, he claims, is depression, but from his +brief case reports it would seem that most of his patients were not +stuporous, in the narrow sense of the term, but severely retarded +depressions. In fact, in perusing his case material comprising "stupors" +in the course of many types of functional insanity, or as a complication +of epilepsy or general paralysis, it is evident that in practice he does +not follow the discriminative definitions of the earlier portion of his +paper. For him, apparently, patients who are markedly inaccessible to +examination from whatever cause are "stuporous." He closes with +excellent remarks on physical and psychic treatment. As to prognosis he +has nothing to say beyond the opinion that most of the cases recover. + +If Dagonet be accepted as summarizing the early French work, we can +conclude that their generalizations were on the whole quite sound. These +were: that stupor is an abnormal mental reaction, usually psychogenic +but often the result of exhaustion, that it consists in a paralysis of +emotion, will and intelligence; that the prognosis is usually good; that +mental stimulation may produce recovery. What remained to be done after +this work was the refinement in detail of these generalizations, +particularly in respect to the differentiation of prognostically benign +and malignant types. But other Frenchmen did not take up this work, +apparently, for the brilliant psychopathologists of the next generations +attended to stupor only in so far as it was hysterical. + +An Englishman, however, soon took up the task, adding more exactness to +his formulations. Newington[14] published his important paper in 1874. +A nascent stage of stupor, he thinks, is a common reaction to great +exhaustion, "such as hard mental work, prolonged or acute illness, +dissipation, etc." Such conditions, like the grave psychotic forms, he +regarded as due to physical exhaustion of the brain cells, but, since he +thought psychic stress could produce this exhaustion, this "organic" +view did not bias his general formulations. He makes a division into two +stupors: Anergic Stupor and Delusional Stupor. The former may be +primary, being generally caused by a sudden intense shock (Esquirol's +"Acute Dementia"), or secondary (a) to convulsions of any kind, (b) to +mania in women, (c) to any other prolonged nervous exhaustion. The +delusional form results from (a) intense melancholia, (b) from general +paralysis in which it may be intercurrent, (c) from epileptic seizures. +When one examines his points of difference between these two types, it +becomes clear that Newington really gave an excellent differentiation of +benign and malignant stupor--in fact, it is the only serious attempt at +such discrimination prior to this present work. What is more remarkable +is the fact that, although he clearly saw the clinical differences, he +failed to see that the two types differed prognostically. His +description is given in a table sufficiently concise to justify its +quotation _in extenso_. + + _ANERGIC STUPOR_ _DELUSIONAL STUPOR_ + + _Etiology_--Hereditary and Hereditary. + individual liability to + sudden loss of _vis nervosa_. + + _Onset_--Rapid. Usually insidious, may be almost + instantaneous. + + _Symptoms_--Intellect greatly Conduct shows reasoning power. + impaired. + + _Memory_--Seems to be swept Found after recovery to have + away as far as possible. been preserved to a great + extent. + + _Emotional Capacity_--Nil or Evidence of grief, fear, etc., in + almost so. Tears frequent facial expressions and wringing + but due to relaxation of and clasping of hands. + sphincter muscles. Features Tears rare. Great contraction + relaxed, eyes vacant and not of features [grimacing?]. + constantly fixed. Eyes fixed on one + point, usually upwards or + downwards, or else obstinately + closed. + + _Volition_--Almost absent. Frequently great stubbornness, + refusal to do what is + wanted. On the other hand, + intense determination in + following out own plan. + + _Motor System_--Weak and uncertain. But little interfered with, + Patient has to be independently of sheer + led about and if placed on a asthenia, produced by + seat or in some position does patient's conduct. May stand + not move. ("Cataleptoid" behind door or kneel on floor + condition.) in constrained position even + for days. + + _Sensory System_}--Both dull. Ditto. There seems to be a + _Reflex System_ } much greater ability to bear + severe pain. + + _Pupils_--Dilated. Tendency to contraction. + + _Sleep_--Generally good. Intense sleeplessness. + + _General bodily condition_-- Affected _pari passu_ with + Emaciation, sometimes extreme, mental state and seems + usually rapid, with governed by it. + rapid recovery of flesh. + Often not much loss of + weight, though whole tone is + lowered. + + _Vascular System_--Pulse slow, Pulse weak and often quick + sometimes almost imperceptible. and thready. Complexion + Cyanotic appearance, edema anemic and sallow. The + and iciness of extremities. other appearances may be + Great decrease of vitality present but come on later + in peripheral structures, and are less marked. + as shown by asthenic + eruptions and production of + vermin. + + _Digestive System_--Tongue Tongue dry, small and furred. + clean or if furred it is moist. Refusal of food. Great + Appetite _apathetic_, bowels constipation. Dirtiness of + not irregular, but habits habits rare. + very dirty. + +If one compares these data with those given in the chapter on Malignant +Stupors, it is seen that in the main Newington has made the same +discrimination as we have. He is certainly wrong in denying "negativism" +to his anergic type. Probably, too, he attempts too fine a distinction +between the physical symptoms of the two groups. His conclusions are +interesting: that in the anergic cases there is an _absence_ of +cerebration, while amongst the delusional there is an abnormal +_presence_ of intense but perverted cerebration. This is not unlike our +own view. He thinks the difference in memory is the most important +differential point. Sex is important in determining the nature of the +stupor, for he found the anergic type following mania in females only. +He observed such an end to manic attacks in 6 out of 36 cases. All his +cases were under 30 and he regards the prognosis as good on the whole. +As to treatment he emphasizes the necessity for "moral pressure" as a +stimulus and cites a case of rapid improvement after a change of scene. + +Since 1874 very little advance has been made by British psychiatrists, +as seen by a perusal of Clouston's[15] summary in 1904. He regards sex +exhaustion as a highly frequent cause, although Dagonet had shown 32 +years before that sex abuse does not produce a true stupor. He thinks +stupor usually follows depression or mania and says that "the +'Confusional Insanity' of German and American authors is just a lesser +degree of stupor." Omitting his stupors in general paralysis and +epilepsy he makes three clinical divisions: _melancholic or conscious +stupor_, which is not a product of delusions, although delusions of +death or great wickedness may be present, impulsiveness and fits may be +observed; _anergic or unconscious stupor_, which corresponds roughly to +our deep, benign stupor; and _secondary stupor_ after acute mental +disease, which resembles our partial stupor. He warns against a rash +diagnosis of dementia in this last group. His views on the importance of +mental causation and the relation to manic-depressive insanity may be +gathered from these sentences: "The condition of the mental portion of +the convolutions in stupor is probably analogous to the stupidity of a +nervous child when terrified or bullied." "Stupor is frequently one of +the stages of alternating insanity following the exalted condition. It +is more apt to occur in those where the exalted period is acutely +maniacal. The stupor is usually melancholic in form." Since he claims +that the anergic is a "very curable form of mental disease," while only +50% of the melancholic cases recover, it seems clear that this division +is not prognostically final. The "melancholic" is evidently Newington's +"delusional" without his more accurate discrimination of symptoms. + +From the standpoint of accurate description the opinion may be ventured +that there is a gap in the literature from the early French writers and +Newington up to the paper by Kirby, which has been discussed in the +first chapter. This gap is filled by literature of the German schools +and their adherents in other countries. German psychiatry has been +concerned mainly with classification or the elaborate examination of +certain symptoms. Inevitably such a program militates against detached +objective clinical description. It is hard to record symptoms that +interfere with classification. German psychiatry has tended to make the +insane patient a type rather than an individual. Hence the gap in the +descriptive literature of stupor. + +The necessity of establishing the possibility of some stupors having a +good prognosis has arisen from Kraepelin's work. He can rightly be +viewed as the father of modern psychiatry because he introduced a +classification based on syndromes and taught us to recognize these +disease groups in their early stages. Inevitably with such an ambitious +scheme as the pigeon-holing of all psychotic phenomena some mistakes +were made. Most of these appear in the border zone between dementia +praecox and manic-depressive insanity. The latter group being narrowly +defined, the former had to be a waste basket containing whatever did not +seem to be a purely emotional reaction. Clinical experience soon proved +that many cases which, according to Kraepelin's formulae, were in the +dementia praecox group, recovered. Adolf Meyer was one of the first to +protest and offered categories of "Allied to Manic-Depressive Insanity" +or "Allied to Dementia Praecox," as tentative diagnostic classifications +to include the doubtful cases. + +Difficulties with stupor furnish an excellent example of the confusion +which results from the adoption of rigid terminology. The earlier +psychiatrists were free to regard a patient in stupor as capable of +recovery as well as deterioration. When Kahlbaum included stupor with +"Catatonia," the situation was not changed, for he did not claim a +hopeless prognosis for this group. But when Kraepelin made catatonia a +subdivision of dementia praecox, all stupors (except obvious phases of +manic-depressive insanity) had to be hysterical or malignant. Faced with +this dilemma psychiatrists have either called recoveries "remissions" +or, like E. Meyer, claimed that one-fifth or one-fourth of catatonics +really get well. + +As a matter of fact it seems clear that stupor is a psychobiological +reaction that can occur in settings of quite varied clinical conditions. +It is not necessary to detail publications describing stupors in +hysteria, epilepsy, dementia praecox or in the organic psychoses. It may +be of interest, however, to cite some examples of acute, benign stupors +and the discussion of them which appear in the literature of recent +years. + +An important group is that of stupors occurring as prison psychoses. +Stern[16] mentions that acute stupors are found in this group. +Wilmanns[17] examined the records for five years in a prison and +discovered that there were two forms of psychotic reaction, a paranoid +and a stupor type. It is interesting psychologically that the former +appeared largely among prisoners in solitary confinement, while the +stupors developed preponderantly among those who were not isolated. The +stupors recovered more quickly. He describes the psychosis thus: The +prisoner becomes rather suddenly excited, destructive and assaultive; +then soon passes into an inactive state, where he lies in bed, mute, +with open expressionless eyes. He is clean, however; eats spontaneously +and attends to his own hygienic needs. Some cases are roused by +transport from the jail to the hospital but sink into lethargy again +when they reach their beds. Physically, they show disturbances of +sensation which vary from analgesia to hypesthesia. There are a rapid +pulse, positive Romberg sign, exaggerated reflexes, fibrillary twitching +of the tongue and tremor of the hands. Recovery takes place gradually. +They begin to react to physical stimuli and to answer questions, +although still inhibited, until consciousness is quite clear. When +speech begins, it is found that they are usually disoriented for place +and time as the result of an amnesia which sets in sharply with the +excitement. This memory defect gradually improves _pari passu_ with the +other symptoms. + +Two attacks in the same prisoner of what seem to have been typical +stupor are reported by Kutner[18] and Chotzen.[19] The patient was a +recidivist of unstable mental make-up. At the age of 34 he was sent to +prison for three years. Shortly after confinement began, he became +stuporous, being mute and negativistic, soiling, refusing food and +showing stereotypy. On being shifted to another institution he appeared +suddenly much better, although he remained apathetic and dull for some +months. A striking feature was a complete amnesia, not merely for the +stupor but also for his trial and entrance to the prison. At the age of +42, he was again incarcerated. A practically identical picture again +developed, with recovery when his environment was changed, and with a +similar amnesia. Recovery seemed to be complete and there were no +hysterical stigmata. The interesting features of this case are that a +typical stupor seems to have been precipitated by imprisonment, while +the retroactive amnesia covering a painful period of the patient's life +reminds one of hysteria. + +A case which is more difficult to interpret is reported briefly by +Seelig.[20] A man of 20 with bad inheritance tried to steal 100 marks. +When sent to jail he became ill shortly before his trial was due and was +sent to a hospital. There he seemed anxious, was shy, and gave slow +answers, with initial lip motions and had to be urged to take hold of +objects. All this sounds more like a pure depression than a stupor. But +he also had paralogia. This might make one think of a Ganser reaction on +the background of depression. S., however, calls it an hysterical +stupor, although he agreed with Moeli that it was hard to differentiate +from a catatonic state. + +Loewenstein[21] reports an interesting case of a degenere who had had +hysterical attacks. He suddenly developed stupor symptoms, which lasted +with interruptions for nearly two years. After recovery and during the +interruptions the patient explained his mutism, refusal to swallow, his +filthiness and general negativism as all occasioned by delusions. He was +commanded by God to act thus, the attendants were devils, and so on. He +spoke, too, of being under hypnotic influence. In addition there were +other delusions such as that he had killed his brother. The attack came +on with the belief that he was going to die, otherwise none of the ideas +were typical of the stupors we have studied. Another incongruous symptom +was that he did not seem to be really apathetic, he reacted constantly +to the environment. The author comments on the absence of senseless +motor phenomena, such as would be expected in a "catatonic." His +complete memory of the psychosis also speaks against the usual form of +stupor. It seems possible that this psychosis was neither hysterical nor +a benign stupor in our sense, but, rather, an acute schizophrenic +reaction such as one occasionally sees. From the account which +Loewenstein gives, one gathers that the patient was absorbed in a wealth +of imaginations. + +Gregor[22] tells of a stupor which is unusual in that it consisted only +of symptoms connected with inactivity, which did not affect the +intellectual processes. The patient was a rubber worker who suddenly +developed a depression with self-accusation and convulsions. She was +soon admitted to a clinic and then showed mutism and catalepsy. Later +she became totally immobile with no apparent psychic reactions, and +soiled. Gregor studied pulse, respiration and respiratory volume in +their reflex manifestations and found nothing unusual. Next he tried to +discover if there were voluntary alterations in respiration. He +discovered that the respiratory curve could be changed by calling out +words to her, by odors associated with suggestions, menaces, etc. [This +is suggestive of the dissociation of affect, which we have discussed.] +After two months she recovered, _with complete recollection of the +stupor period_. It was then proven that the absence of reactions was not +the same as the lack of perception of stimuli. + +Froederstroem[23] reports a case that suggests hysteria, where the stupor +lasted for 32 years. A girl at the age of 14 fell on the ice, had a +headache, went to bed and stayed there for 32 years. She lay there +immobile, occasionally spoke briefly and took nourishment, when it was +put at a definite place at the edge of the bed. At first (according to a +late statement of her brothers) this consisted only of water but was +soon changed to two glasses of milk a day. After being in this state for +ten years she was placed in a hospital for two weeks, where she was +mute, did not react to pin pricks and had to be fed. It seems that at +home she secretly looked after herself, for she kept her hair and nails +in condition. Sometimes she sat up and stared at the ceiling. + +After attending to the patient for 30 years, her mother died. The +patient cried for several days when told of it, and after this she took +nourishment of her own accord. Two years later a brother died. Again she +cried on hearing the news. Her father, who looked after her when the +mother was dead, also died. Then a governess came into the home, who +noticed that furniture was moved about when she was alone. + +At the age of 46 she suddenly woke up and asked at once for her mother. +She claimed total amnesia for the period of her stupor, including the +stay at the hospital. She could summon memories of her childhood, +however. Her brothers she did not recognize and said, "They must be +small." She recalled the fall on the ice and coming home with headache, +toothache and pain in the back. Her general knowledge was limited but +she could read and write. Her expression and appearance was that of a +young person, only her atrophic breasts and the fat on her buttocks +betraying her age. She had been well for four years at the time the +report was made. + +He thinks that a certain tendency to exaggeration and simulation speak +for hysteria. We would be more inclined to view the fact that she looked +after herself in spite of complete amnesia as evidence of hysteria. + +Another protracted case suggestive of hysteria is that reported by +Gadelius.[24] The patient was a tailor, 32 years old, who had always +been rather taciturn and slow. A year before admission he began to have +ideas of persecution and to shun people. Then he developed a stereotyped +response, "It is nice weather," whenever he was addressed. A month +before admission inactivity set in. He would sit immobile in his chair +with closed eyes and relaxed face; he resisted when an attempt was made +to put him to bed. His color was pale. + +He was taken to hospital on November 1, 1882, where he was observed to +be immobile and to have little reaction to pin pricks. When a limb was +raised, it fell limply. However, he would leave bed to go to the toilet. +Tube-feeding became necessary, but when the tube was inserted in his +nose, he woke up. He then showed an amnesia not merely for his illness +but for his whole life: he did not know his father, that he was married +or that he had a mother. Towards the end of November, he became limp +again and answered, "I don't know" to most questions. In December, +however, he improved again and for a few months these variations +occurred. From April, 1883, to May, 1886, he was in deep stupor, almost +absolutely immobile and close to being completely anesthetic even with +strong Faradic currents. Towards the end of this period he walked about +_whenever he thought he was not watched_. He was very cautious about +this and became motionless any time he became aware of observation. +(Gadelius thinks this was not simulation but the expression of an +automatism on the basis of a vague fixed idea.) + +This condition persisted apparently for five years more, by the end of +which time the anesthesia had turned into a hyperesthesia. A year later +he began to eat. It was now found that he had an amnesia for his illness +and former life, so that he did not even recognize a needle or pair of +scissors. He knew that he was born in the month of February and retained +some facility in calculation, in speech, walking and usual motions. Then +he regained all his memories and resumed his trade as tailor. He was +discharged in June, 1893, nearly eleven years after admission. + +It seems safe to say that elements at least of hysteria appear in this +history, such as the profound retroactive amnesia and appearance of +simulation in the conduct of the patient. Accurate and rapid grasp of +the environment is necessary for such a watch as he kept on the eye of +his attendants. Mental acuity of this grade combined with amnesia looks +more like an hysterical than a manic-depressive process. + +Leroy[25] describes a case much like ours which is interesting from a +therapeutic standpoint. The patient was a woman who passed from a severe +depression with hallucinations and anxiety into a long stupor, from +which she recovered completely. There was no negativism and no affect, +although the latter appeared so soon as contact began to be established. +When well she had a complete amnesia for the onset of the psychosis. +Leroy attributed the recovery, in part at least, to the thorough +attention given the patient. Kraepelinian rigidity is seen, however, in +the author's refusal to regard the case as "circular" because of the +lack of all cyclic symptoms. He takes refuge in the meaningless label +"Mental Confusion." + +An important group of cases is that of the stupors occurring during +warfare. Considering stupor as a withdrawal reaction, it is surprising +there were so few of them, although partial stupor reactions as +functional perpetuation of concussion were very common. The editor saw +several typical cases in young children in London who passed into long +"sleeps" apparently as a result of the air raids. Myers[26] has given +us the best account of stupors in actual warfare. A typical case was +that of a man who was found in a dazed condition and difficult to +arouse. He could give little information about himself, could neither +read nor write and never spoke voluntarily. A week later his speech was +still limited and labored and no account of recent events could be +obtained from him. Under hypnosis he was induced to talk of the accident +which had precipitated this disorder. He became excited in telling his +story, evidently visualizing many of the events. In several successive +seances, more data were obtained and a cure effected. Myers points out +that in all his cases there was a mental condition which varied from +slight depression to actual stupor, all had amnesias of variable extent +and all had headaches. The mental content seemed to be confined to +thoughts of bombardment, with a tendency for the mind always to wander +to this topic. The author thinks that pain is a guardian protecting the +patient from too distressing thoughts. An effort to speak would cause +pain in the throat of a case of mutism and, sometimes, when a +distressing memory was sought after under hypnosis, physical pain would +wake the sleeper. His view is that pains tend to preserve the mutism and +amnesia, so that there are "inhibitory processes" causing the stupor, +which prevent the patient from further suffering. He does not find +either in theory or experience reason to believe that these conditions +are the result of either suggestion or "fixed ideas." He thinks it +natural that the last symptom of the stupor to disappear should be +mutism, as speech and vision are the prime factors in communicating with +environment. [As has been noted frequently in this book, mutism is a +common residual symptom of the benign stupor.] Myers believes that in +nearly every instance mutism follows stupor and is merely an attenuation +of the latter process. When deafness is associated with mutism, he +thinks it is often due merely to the inattention of the stuporous state. + +In this connection we should mention that Gucci[27] points out that +stupor patients with mutism of long duration may, when requested, read +fluently and then relapse again into complete unreactiveness towards +auditory impressions. This, we would say, is probably an example of a +more or less automatic intellectual operation occurring when the patient +is sufficiently stimulated, although he cannot be raised to the point of +spontaneous verbal productivity. + +As these scattered reports about benign stupors are so unsatisfactory, +one naturally turns to text-books. Little more appears in them. +Kraepelin treats stupors occurring in manic-depressive insanity as +falling into two groups, the depressive and manic. The former seems to +be nearer to our cases, judging by the statements in his rather sketchy +account. He regards stupor as being the most extreme degree of +depressive retardation. [This possibility has been discussed in the +chapter on Affect.] His description seems perhaps to include cases which +we would regard as perplexity states or absorbed manias. Activity is +reduced, they lie in bed mute, do not answer, may retract shyly at any +approach, but on the other hand may not ward off pin pricks. Sometimes +there is catalepsy and lack of will, again there may be aimless +resistance to external interference. They hold anything put into their +hands, turning it slowly as if ignorant of how to get rid of it. They +may sit helpless before food or may allow spoon-feeding. Not rarely they +are unclean. As to the mental content, he says they sometimes utter a +few words, which give an insight into confused delusions that they are +out of the world, that their brains are split, that they are talked +about, or that something is going on in the lower part of the body. The +affect is indefinite except for a certain bewilderment about their +thoughts and an anxious uncertainty towards external interference. +Intellectual processes suffer. They are disoriented and do not seem to +understand the questions put to them. An answer "That is too +complicated" may be made to some simple command. Kraepelin thinks that +the disorder is sometimes more in the realm of the will than of +thinking, for one patient could do a complicated calculation in the same +time as a simple addition. After recovery the memory for the period of +the psychosis is poor and quite gone for parts of it. Occasionally there +may be bursts of excitement, when they leave the bed; they may scold in +a confused way or sing a popular song. + +His manic stupor is a "mixed condition," a combination of retardation +with elated mood. The condition is different from the depressive stupor +in that activity is more frequent, either in constant fumbling with the +bed clothes or in spasmodic scolding, joking, playing of pranks, +assaultiveness, erotic behavior or decoration. The affect is usually +apparent in surly expression or happy, or erotic, demeanor. They are +usually fairly clear and oriented and often with good memory for the +attack but with evasive explanations for their symptoms. One cannot make +any classification of the ideas he quotes, but it is apparent from all +his description that the minds of these "manic stupors" are not a blank +but rather that there is a fairly full mental content. + +Wernicke, unhampered by classifications of catatonia and +manic-depressive insanity with inelastic boundaries, calls all stupor +reactions akinetic psychoses with varying prognosis. He does not make +Kraepelin's mistake of confusing the apathy of stupor with the +retardation of depression, stating distinctly that the processes are +different. + +Bleuler also has grasped this discrimination. He points out that the +thinking disorder in what he terms "Benommenheit" (dullness) +differentiates such conditions from affectful depression with +retardation. He writes, of course, mainly of dementia praecox,[28] but +makes some remarks germane to our problem. In the first place he denies +the existence of stupor as a clinical entity, except perhaps as the +quintessence of "Benommenheit", it is the result of total blocking of +mental processes. Consequently, he says, one can observe the external +features of stupor in all akinetic catatonics, in marked depressive +retardation, when there is a lack of interest, affect or will, in +autism, with twilight states, as a result of negativism or, finally, +when numerous hallucinations distract the patient's attention into a +world of fancy. He notes that in all stupors (with the exception, +perhaps, of "Benommenheit") the symptoms may disappear with appropriate +psychic stimulation or that some reaction, no matter how larval, may be +observed. He speaks, for instance, of the visits of relatives waking the +patient up. + +His only real group is "Benommenheit," which he separates out as a true +clinical entity. This seems to correspond roughly with our "Partial +Stupors." It is essentially an affectless, thinking disorder, usually +acute, sometimes chronic, occurring among schizophrenics. He believes +that it is the result of some organic process (intracranial pressure or +toxin). Activity is much reduced or absent; they have poor +understanding, answer slowly or confusedly; their actions are sometimes +as ridiculous as those of people in panic (e.g., throwing a watch out +of the window when the house is on fire); the defect is best seen in +writing, for large elisions are found in sentences. He was able to +analyze only one case and she retained her affect; it was even labile +and marked. One suspects that such a case might, perhaps, not really +find a place in the "Benommenheit" group even as Bleuler himself +describes it. + +With the exception of Kirby, whose work has already been discussed in +the introduction, we have been able to find only one author who has +attempted any symptomatic discrimination of the recoverable and +malignant catatonic states. Raecke[29] made a statistical study and +found that 15.8% recovered, 10.8% improved, 54.4% remained in +institutions, while 30% died. With the etiology mainly exogenous 20% +recovered and 14.3% improved. A good outcome was seen in 30.2% of +hereditary cases, while only 22.7% did well in the non-hereditary group. +His most important contribution is in his formulation of good and bad +symptoms. He thinks that dull, apathetic behavior with uncleanliness and +loss of shame are not so unfavorable as has been thought. Malignant +symptoms are grimacing with prolonged negativism but without essential +affect anomaly, decided echopraxia and echolalia and protracted +catalepsy. We would agree with this, although command automatisms have +not been prominent either in our benign or malignant stupors. + +Two writers have made special observations that should be confirmed and +amplified before their significance can be established. Whitwell[30] +thinks that in addition to a diminished activity of the heart there +exists a pathological tension. Ziehen says that he also has frequently +seen angiospastic pulse-curves in exhaustion stupor or acute dementia, +but that other pulse pictures may be seen as well. Any such studies +should be correlated rigorously with the clinical states before they can +have any meaning. Wetzel[31] tested the psychogalvanic reflex in stupors +and in normal persons who simulated stupors. He found them different. + +Only one publication has come to our attention in which an attempt is +made at psychological interpretation of various symptoms in stupor. +Vogt[32] derives much from a restriction of the field of consciousness. +Only one idea is present at a time, hence there is no inhibition and +impulsiveness occurs. Similarly, if the idea appear from without, it, +too, is not inhibited, which produces the suggestibility that in turn +accounts for catalepsy. Stereotypy and perseveration are other evidences +of this narrowness of thought content. Negativism is a state, he says, +of perseverated muscular tension. [This would apply only to muscular +rigidity.] So far as it goes, this view seems sound. Of course it +leaves the problem at that interesting point, Why the restriction of +consciousness? + +If stupor be a psychobiological reaction, it should occur, occasionally, +in organic conditions just as the deliria of typhoid fever may contain +many psychogenic elements. Gnauck[33] reports such a case. The patient, +a woman, was poisoned by carbon dioxide. At first there was +unconsciousness. Then, as she became clearer, it was apparent that she +was clouded and confused. She soiled. Neurological symptoms were +indefinite; enlargement of the left pupil, difficult gait and +exaggerated tendon reflexes. Months later she was still apathetic, +although her inactivity was sometimes interrupted by such silly acts as +cutting up her shoes. After five months she recovered with only +scattered memories of the early part of her psychosis. What seems like a +typical stupor content was recalled, however. She thought she was +standing in water and heard bells ringing. + +Stupor-like reactions are not infrequent in connection with or following +fevers. Bonhoeffer[34] describes a type that follows a febrile +Daemmerzustand of a few hours or a day at most. The affect suddenly +goes, disorientation sets in. Although outbreaks of anxiety may be +intercurrent, the dominant picture is of stupor. Reactions are slowed, +often there is catalepsy. Sometimes there is a retention defect and +confabulation to account for the recent past. Again the retention may be +good. In the foreground stands a strong tendency to perseveration. This +may affect speech to the point of an apparent aphasia or produce +paragraphia. Plainly organic aphasia and focal neurological symptoms are +sometimes seen. + +As Knauer[35] has gone thoroughly into the question of the febrile +stupors, the reader is referred to his paper for a digest of the +literature on this topic. Mention has already been made in Chapter IX to +this publication, where the close resemblance of these rheumatic, to our +benign functional, stupors has been noted. Discrimination seems to be +possible only on the basis of delirium-like features being added in the +organic group. + + +FOOTNOTES: + +[C] This chapter has been written mainly from material in Dr. Hoch's +notes which was manifestly incomplete. No claim is made for its +exhaustiveness. + + _The Editor._ + +[13] Dagonet, M. H.: "De la Stupeur dans les Maladies Mentales et de +l'Affection mentale designee sous le Nom de Stupidite." _Annales +Medico-Psychologiques_, T. VII, 5e Serie, 1872. + +[14] Newington, H. Hayes: "Some Observations on Different Forms of +Stupor, and on Its Occurrence after Acute Mania in Females." _Journal of +Mental Science_, Vol. XX, 1874, p. 372. + +[15] Clouston: "Mental Diseases." J. & A. Churchill, 1904. + +[16] Stern: "Ueber die akuten Situations-psychosen der Kriminellen." +Abstracted, _Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate Bd. +V, S. 554. + +[17] Wilmanns, K.: "Statische Untersuchungen ueber Gefaengnisspsychosen." +_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 847. + +[18] Kutner: "Ueber katatonischer Zustandsbilder bei Degenerierten." +_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 375. + +[19] Chotzen: "Fall von degenerativem Stupor." Abstracted, _Zeitschr. f. +d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 1077. + +[20] Seelig: "Psychiatrischer Verein in Berlin, 1904." _Neurol. +Centralbl._, 1904, S. 421. + +[21] Loewenstein: "Beitrag zur Differentialdiagnose des katatonische u. +hysterische Stupors." _Allg. Zeitschr. f. Psychiatrie_, Bd. LXV. + +[22] Gregor: "UEber die Diagnose psychischer Prozesse im Stupor." Leipzig +Meeting, 1907. Reported in _Neurol. Centralbl._, 1907. S. 1083. + +[23] Froederstroem: "La Dormeuse d'Okno. 32 ans de Stupeur, Guerison +complete. Nouvelles Iconographies de la Salpetriere," 1912, No. 3. +Reviewed by E. Bloch, _Neur. Centralbl._, 1913, S. 852, and by Forster, +_Zeitschr. f. d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 510. + +[24] Gadelius: "Ett ovanligt fall af stupor med naera 9-arig oafbruten +tvangsmatning; uppvaknande; total amnesi; helsa" (_Hygiea_, 1894, LVI., +Part 2, No. 10, p. 355). Abstracted by Walker Berger, _Neurol. +Centralbl._, 1895, S. 186. + +[25] Leroy: "Un cas de stupeur, gueri au bout de deux ans et demi." +_Bull. de la Soc. Clin. de Med. Ment._, III, 276, 1910. Abstracted in +_Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate, Bd. II, S. 495. + +[26] Myers, Charles S.: "Contributions to the Study of Shell Shock." +_Lancet_, January 8, 1916, pp. 65-69. _Lancet_, September 6, 1916, pp. +461-467. + +[27] Gucci, R.: "Sopra una particolarita del mutismo per stupore +communicazione preventive." _Archivio italiano per le malattie nervose_, +1889, XXVI, 69-108. Reviewed in _Neurol. Centralbl._, 1889, S. 659. + +[28] "Dementia Praecox oder Gruppe der Schizophrenie" Aschaffenburg's +"Handbuch der Psychiatrie." + +[29] Raecke: "Zur Prognose der Katatonie." _Arch. f. Psychiatrie_, Bd. +XLVII, 1, 1910. + +[30] Whitwell: "A Study of the Pulse in Stupor." _Lancet_, Oct. 17, +1891. Reviewed by Ziehen, _Neurol. Centralbl._, 1892, S. 290. + +[31] Wetzel: "Die Diagnose von Stuporen." Baden-Baden Meeting of May, +1911. Reported in _Neurol. Centralbl._, 1911, S. 886. + +[32] Vogt, Ragner: "Zur Psychologie der Katatonischen Symptome." +_Centralbl. fuer Nervenheilkunde_, 1902, S. 433. + +[33] Gnauck, R.: "Stupor nach Kohlenoxydvergiftung" (_Charite-Annalen_, +1883, p. 409). Reviewed by Moeli, _Neurol. Centralbl._, 1883, S. 237. + +[34] Bonhoeffer: "Die Symptomatischen Psychosen," 1910. + +[35] Knauer, A.: "Die im Gefolge des akuten Gelenkrheumatismus +auftretenden psychischen Storungen." _Zeitschr. f. d. ges. Neurol. u. +Psychiatrie_, Bd. XXI, S. 491-559. + + + + +INDEX + + +absorption, 163 + +activity, reduction of, 36, 100, 120 + +acute dementia, 251 + +adaptation, 107, 192 + +adrenalin, 180 + +affect, 9, 22, 32, 44, 113, 116, 117, _123_, 170 + +affect, dissociation of, 128, 201, 205, 237 + +affect, inappropriate, 216, 237 + +affect, poverty of, 234 + +affect, shallow, 127 + +affectlessness, 171, 172 + +affects, combination of, 245 + +agitation, 156 + +akinesis, 121 + +akinetic psychoses, 4, 274 + +albuminuria, 40 + +allied to dementia praecox, 236, 260 + +allied to manic-depressive, 236, 260 + +allopsychic, 135 + +ambivalence, 147 + +amnesia, 9, 24, 68, 70, 267, 269 + +anergic or unconscious stupor, 258 + +anergic stupor, 255, 256 + +anesthesia, 196, 212, 268 + +anger, 118, 139 + +angiospastic, 276 + +animal, turning into, 171 + +Antaeus, 190 + +apathy, 36, 48, 112, 122, 123, 151, 152, 163, 181, 195, 225, 237 + +apathy, resemblance to absorption, 202 + +anxiety, 122, 123, 126, 137, 153, 162, 166, 198, 226 + +apoplexy, 224 + +arteriosclerotic dementia, 80 + +attention, 195 + +atypical features, explanation of, 200 + +autoerotism, 199 + +automatism, 268 + + +Baillarger, 252 + +behavior, 195 + +"Benommenheit," 67, 273, 274 + +bewilderment, 79, 112, 120, 126 + +Bleuler, 67, 273 + +blocking, 163 + +blood-pressure, 181 + +blushing, 9 + +Bonhoeffer, 277 + +boredom, 247 + +bowels, interest in, 217 + +brain tumor, 5 + +breath, holding, 62 + +Brierre de Boismont, 252 + +burial, 111, 192 + + +Calculation, 23, 24 + +Calvary, 111 + +Cannon, 180 + +Cases + Adele M. (Case 24), 220 + Alice R., 135, 140, _192_ + Anna G. (Case 1), _6_, 47, 48, 68, 74, 77, 109, 127, 136, 140, 145, + 147, 183 + Anna L. (Case 16), 135, _149_, 158 + Anna M., 135 + Annie K. (Case 5), _24_, 69, 72, 105, 110, 111, 136, 139, 141 + Bridget B., 135 + Caroline de S. (Case 2), _11_, 68, 109, 141, 178, 193 + Catherine H. (Case 23), _216_ + Catherine M. (Case 18), _158_ + Catherine W. (Case 25), _221_ + Celia C. (Case 17), _155_ + Celia H. (Case 19), _167_ + Charles O., 143, 144, 178 + Charlotte W. (Case 12), _83_, 106, 112, 113, 116, 127, 136, 141, 144, + 166, 201 + Emma K., 71, 140 + Harriett C., 138 + Helen M., 130 + Henrietta B., 138, 140 + Henrietta H. (Case 8), _42_, 74, 77, 105, 106, 110, 111, 115, 136 + Isabella M., 136, 144, 147 + Johanna B., 135, 138 + Johanna S. (Case 13), _91_, 120, 127, 136 + Josephine G., 138 + Laura A., 71, 77, 135, 138, 140, 142, 193 + Maggie H. (Case 14), 71, 96, 109, 140, 194 + Margaret C. (Case 10), _55_, 75, 78 + Mary C. (Case 7), _39_, 42, 71, 74, 77, 121, 136, 138, 178, 194 + Mary D. (Case 4), _20_, 47, 69, 70, 71, 74, 76, 109, 136, 145 + Mary F. (Case 3), _14_, 68, 105, 110, 111, 115, 140, 142, 164, 183 + Mary G., 140, 141 + Meta S. (Case 15), _99_, 109, 127, 135 + Nellie H. (Case 22), _214_ + Pearl F. (Case 9), _51_, 75, 142 + Rose S. (Case 21), _210_ + Rose Sch. (Case 6), _35_, 74, 75, 145 + Rosie K. (Case 11), _62_, 75, 105, 112, 178 + Winifred O'M. (Case 20), _207_ + +catalepsy, 13, 21, 31, 32, 36, 86, 94, 95, 102, 115, 128, _143_, 144, +145, 147, 209, 211, 235, 239 + +catatonia, 4, 5, 50, 128, 205, 236, 261 + +catheterization, 85, 86, 102 + +cemetery, 105, 112 + +childbirth, 159 + +childhood, 188, 195 + +Chotzen, 262 + +Christ, 86, 115 + +Christian Science, 150 + +circular psychosis, 5, 126 + +circulation, 180 + +Clark, 184 + +clouding, 67 + +Clouston, 258 + +cocoon, 109 + +coffin, 88, 106, 114 + +coma, 176, 223 + +concussion, aerial, 224 + +confusion, 163 + +constipation, 92 + +convent, 117 + +convulsive attacks, 15 + +crime, 248 + +crucifix, 88 + +crucifixion, 86, 106, 114, 161 + +crustaceans, 148 + +cut-up idea, 94 + +cyanosis, 32, 63, 180 + + +Dagonet, 3, 249, 250, 253, 254, 258 + +death, feigned, 5, 83, 137, 196, 246 + +death, mutual, 192 + +death, projected, 198 + +death, relation with affect, 110 + +death ideas, 3, 46, 47, 50, 52, 58, 65, 83, 97, _104_, 107, 109, 110, +111, 114, 115, 119, 122, 136, 137, 138, 152, 153, 156, 159, 163, 166, +187, 190, 191, 192, 199, 212, 225, 235, 240 + +death of others, 192 + +deep stupor, _1_, 6, 41, 199 + +deep stupor, explanation of, 197 + +Delasiauve, 253 + +delirium, 176 + +delusional stupor, 255, 256 + +delusions, 165 + +delire melancholique, 252 + +dementia praecox, 4, 5, 62, 123, 127, 128, 205, 225 + +depression, 5, 117, 123, 137, 156, 236, 253 + +depression, differentiation of, 48, 124, 226 + +dermatographia, 102, 180 + +deterioration, 210 + +diabetes, 224 + +diarrhea, 45, 64, 178 + +dissociation, 225 + +distress, 119, 122, 154, 156, 162 + +dreams, 161, 190 + +drooling, 132, 181 + +drowning, 87, 192 + + +Earth, 107, 111, 190 + +echolalia, 275 + +echopraxia, 275 + +ecstasy, 91, 162, 191 + +_elan vital_, 123 + +elation, 44, 91, 123, 127, 151, 157 + +electric chair, 85, 110, 119 + +electricity, 150 + +emaciation, 8, 32, 58 + +emotion, 62 + +emotion, inconsistency of, 126 + +emotions and contact with reality, 164 + +energy, 187, 194 + +epilepsy, 5, 183, 199, 224, 242, 254 + +epileptic aura, 184 + +epileptic confusion, 80 + +epileptic deterioration, 80 + +erotic, 161 + +erotic ideas, 90 + +Esquirol, 251 + +Etoc-Demazy, 251 + +Euripides, 2 + +excretion, habits of, 230 + +extroversion, 195 + + +family visits, 232 + +father, 104, 109, 110 + +fear, 111 + +fever, 8, 13, 26, 32, 38, 40, 45, 64, 102, 160, _176_, 235, 241 + +filthiness, 210 + +fire, 151, 157 + +flippancy, 129 + +flushing, 27, 127, 128, 180 + +food, refusal of, 99, 104 + +Forel, 182 + +Froederstroem, 265 + + +Gadelius, 267, 268 + +Ganser reaction, 263 + +Georget, 251 + +German psychiatry, 259 + +Gnauck, 277 + +giggling, 206 + +God, 115, 160, 162 + +Golden Age, 187 + +Gregor, 265 + +Gucci, 271 + +guilt, 157 + + +hair, loss of, 32, 58, 180 + +heat production and loss, 179, 181, 242 + +Heaven, 87, 88, 104, 106, 108, 109, 111, 114, 115, 117, 118, 160, 162, +166, 171, 191, 240 + +Hell, 240 + +Hoch, 164 + +hyperaemia, 8 + +hyperesthesia, 268 + +hypochondria, 225, 253 + +hypomania, 243 + +hypnotism (see mesmerism), 145, 213 + +hysteria, 3, 135, 184, 225, 264, 267, 269 + + +ideational content, 82, 235 + +immobility, 85, 94, 196 + +immorality, 150 + +impulsiveness, 50, 113, 128, 172 + +impurities in stupor reaction, 66 + +inaccessibility, 141 + +inactivity, 17, 30, 40, 48, 56, 62, 88, 97, 102, 123, _132_, 152, 163, +194, 225, 234, 238 + +inactivity, patients' explanation of, 134 + +incest ideas, 209 + +inconsistency of reaction, 134, 214, 215, 245 + +incontinence (see _wetting_ and _soiling_), 52, 57 + +indifference, 123, 124, 142 + +infantile reactions, 196 + +infections, 5, _178_, 241 + +insight, 157 + +insomnia, 39 + +instinct of self-preservation, 188, 191, 198 + +interest, 99, 195 + +internal secretions, 178 + +internal thoughts, 163 + +interruptions of stupor, 130, 197, 238, 244 + +introversion, 164, 227 + +involuntary nervous system, 178, 180 + +involution melancholia, 129, 195, 225, 226 + + +jaundice, 21 + +Jung, 107 + + +Kahlbaum, 4, 260 + +Kirby, 4, 6, 164, 234 + +Knauer, 175, 278 + +Kraepelin, 4, 260, 269, 271, 272, 273 + +Kutner, 262 + + +laughter, 56, 141 + +Leroy, 269 + +leucocytosis, 8, 13, 40, 64, 178 + +levels, principle of, 198, 244 + +Loewenstein, 264 + + +MacCurdy, 2, 184 + +make-up, mental, 5 + +malignant stupors, _205_ + +mania (or manic), 5, 126, 137 + +mania, absorbed, 125, 226, 245 + +manic content, 166 + +manic-depressive insanity, 149, 167 + +manic-depressive insanity, mixed conditions in, 202 + +manic-depressive insanity, pathology of, 174 + +manic episodes, 191 + +manic stupor, 125, 245, 253 + +marriage, 160, 169 + +masturbation, 196, 209, 219 + +melancholic or conscious stupor, 258 + +memory (see thinking disorder), 40, 67, 168, 195 + +menstruation, 8, 56, 61, 100, 168, _182_, 236, 242 + +mesmerism, 86, 114, 117, 141, 144 + +Meyer, Adolf, 260 + +Meyer, E., 261 + +midday nap, 247 + +mixed conditions, 202, 273 + +Moeli, 264 + +Moses, 108 + +mother's body, 108 + +movement, spontaneous, 133 + +muscular resistiveness, 224 + +mutism, 10, 22, 31, 57, 62, 88, 104, 124, 134, 209, 271 + +mutual death, 165, 192, 196, 248 + +Myers, 270, 271 + +mystics, 3 + +mythology, 107, 108, 190, 240 + + +negativism, 5, 31, 52, 56, 65, 128, _138_, 139, 199, 209, 225, 235, 238, +243, 276 + +negativism, explanation of, 196 + +nephritis, 224 + +neuropsychic defect, 174 + +neurotic, 150 + +nervous, 159 + +Newington, 3, 254, 255, 257 + +Nirvana, 166, 188, 200, 248 + +nourishment, 229, 242 + + +OEdipus, 165 + +oestrous cycle, 182 + +onset, 96 + +onset, depressive, 99 + +ophthalmic disease, 230 + +Orestes, 2 + +organic delirium, 175 + +organic dementia, 67 + +organic stupor, 223 + +orientation (see thinking disorder), 9, 53, 154, 156, 159, 170, 245 + +Osiris, 108 + + +pain, 133 + +Papanicolaou, 182 + +paragraphia, 80 + +paralysis, feeling of, 105 + +paralysis, general, 5, 254 + +partial stupor, _34_, 206 + +perplexity, 125, 152, 153, 154, 155, 156, 160, 162, 164, 165, 169, 172, +208, 226, 245 + +perplexity, differentiation of, 227 + +perseveration, 145, 148, 276 + +personality, 1 + +perversity, 138 + +physical disease, 175 + +physical symptoms, _174_, 176 + +Pinel, 249, 251 + +poison, 97, 172 + +primitive ideas, 108 + +prison, 105, 169 + +prognosis, 4, 5, _206_ + +prostitution, 157, 161 + +psychoanalysis, 161 + +psychobiological reaction, 246 + +psychogalvanic reflex, 276 + +psychological explanation, 186 + +psychological factors, 175 + +pulse, 63, 92, 128, 180 + + +Rank, 107 + +reality, 107, 187 + +recuperation, 189 + +rebirth, _107_, 110, 114, 115, 119, 120, 121, 122, 187, 189, 190, 191, +240 + +regression, 187, 188, 191, 192, 194, 198, 199, 243 + +religious visions or ideas, 2, 162 + +resentment, 98 + +resistiveness, 54, 97, 102, 112, 127, 129, 133, 141, 147, 156, 211, 225 + +respiration, 180 + +resurrection, 159 + +restlessness, 53, 120, 169 + +retention of urine, 224, 230 + +rheumatism, 175 + +rigidity, muscular, 142, 179 + +Romberg sign, 262 + +rousing, 176 + + +sadness, 111, 113, 121, 122, 124 + +St. Catherine of Siena, 2 + +St. Paul, 2 + +saliva, 30, 63, 181 + +scattered speech, 207, 208 + +schizophrenia, 67, 214 + +seclusiveness, 207 + +secondary stupor, 259 + +Seelig, 263 + +self-injury, _50_, 57 + +sexual excess, 251, 253, 258 + +sexual ideas, 209, 219 + +sexual sensations, 209 + +ship, 87, 106, 118 + +sick, 136 + +skin, dry, 180 + +skin, greasy, 43, 180 + +sleep, 188, 189, 247 + +slowing of thought, 125 + +slowness, 85, 119, 160 + +smearing of feces, 142 + +smiling, 127 + +social status, 236 + +soiling, 30, 132, 172, 196, 225, 230, 235 + +somatopsychic, 135 + +sphincters, control of, 133 + +spirits, 89 + +spoiled child reaction, 129, 139 + +starvation, 182 + +stereotypy, 276 + +Stern, 261 + +stimulation, mental, 231, 246 + +Stockard, 179, 182 + +stubbornness, 142 + +stupidity, 93 + +stupor, diagnosis of, _223_ + hysterical, 225 + malignant, _205_, 206 + organic, 223 + reaction, _35_, 236 + relation to manic-depressive insanity, 173 + +sudden mental loss, 71 + +suggestibility, 145, 198, 276 + +suicidal impulses, _50_, 84, 104, 116, 118, 128, 172, 230, 235, 240 + +suicide, 188 + +sulkiness, 129 + +sullenness, 142 + +suprarenals, 242 + +swallowing, 133 + +sweating, 63, 102, 179, 180 + +swimming movements, 94 + +syncopal attacks, 64 + + +tears, 95, 98, 117, 128, 153 + +tense of ideas, 116 + +thinking disorder, 22, 31, 37, 39, 41, 45, 48, 59, _67_, 75, 124, 125, +148, 152, 157, 235, 239, 247 + +thinking disorder, explanation of, 195 + +tongue, coated, 13 + +toxins, 175 + +trauma, 5, 224 + +treatment, _229_ + + +ulceration of eyes, 133 + +unconscious ideas, 163 + motives, 186 + +unconsciousness, physiological, 199, 224, 277 + +underground, 240 + +understanding, 67 + +uneasiness, 93, 94, 95, 121 + +unfaithfulness, 97 + +unhappiness, 192 + +urine, retention of, 31 + + +Villermay, 250 + +Vogt, 276 + +vomiting, 45 + + +water, 94, 95, 106, 107, 114, 120 + +weakness, 137, 160 + +wealth, 169 + +wedding ring, 117 + +weight (see emaciation), 38, 52, 61 + +Wernicke, 3, 273 + +wetting, 30, 40, 132, 151, 170, 172, 196, 225, 230, 235 + +Wetzel, 276 + +whining, 171, 225 + +Whitwell, 276 + +Wilmanns, 261 + +womb, 108 + +worry, 110 + +writing, 27 + + +Ziehen, 276 + + + + +[Transcriber's Note: + + +The following corrections have been made: + +p. 1: antequated to antiquated (antiquated methods) + +p. 11, 97, 100: period to colon (Under Observation:) + +p. 53: extra "when" removed (from "In June, 1914, when she was seen +smiling at times." to "In June, 1914, she was seen smiling at times.") + +p. 64: period to colon (Physical condition during the stupor:) + +p. 84: 24 italicized to match other dates (October 24) + +p. 91: missing blank line added between Case 12 and 13 + +p. 93: aswer to answer (in answer to questions) + +p. 150: fatiguable to fatigable (nervous and fatigable) + +p. 153: phenomenom to phenomenon (unusual phenomenon for a stupor +patient) + +p. 159: comma added (correcting his grammar, and cried easily.) + +p. 161: missing "in" added (appeared in the statement that her father) + +p. 171: missing open quote added (she wants to go "to the river,") + +p. 198: funadmental to fundamental (most fundamental symptoms) + +p. 211: salivia to saliva (drooling saliva) + +p. 220: inaccesibility to inaccessibility (disinterestedness and +inaccessibility) + +p. 252: dimunition to diminution (just as well in the diminution) + +p. 256: or to of (relaxation of sphincter muscles) + +p. 262, Footnote 19: v. to u. (Zeitschr. f. d. ges. Neur. u. +Psychiatrie) + +p. 265, Footnote 23: Zeitsch. to Zeitschr. to match other instances +(Zeitschr. f. d. ges. Neur. u. Psychiatrie) + +p. 271, Footnote 27: Archivo to Archivio (Archivio italiano per le +malattie nervose) + +p. 280, Index: catherization to catheterization + +p. 282, Index: ophtalmic to ophthalmic (ophthalmic disease) + +Irregularities in capitalization (e.g. Dementia vs. dementia) and +hyphenation (e.g. off-hand vs. offhand) have not been corrected. A +repetitive sentence on p. 46 (Then she became stupid, although neither +sad nor happy. Then, she claimed, she got stupid, but neither sad nor +happy.), and two spaced em-dashes on p. 87 have also been retained. +Minor punctuation errors (e.g. missing period, missing close or open +quote where intended placement is clear) have been corrected without +note. The abbreviations "p.m.", "e.g." and "i.e." have been +standardized, with no space. + +In the Latin-1 and ASCII versions, oe/OE ligatures have been changed to +oe/OE. 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