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Title: Benign Stupors
       A Study of a New Manic-Depressive Reaction Type

Author: August Hoch

Release Date: September 22, 2009 [EBook #30065]

Language: English

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  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. In the ASCII version, the following characters were changed:
mid-dots to periods (in front matter); degree signs to deg.;
multiplication symbols to x; half fractions to -1/2; ae ligatures to ae;
o diaeresis/umlaut to o (e.g. cooperation) or oe (e.g. Loewenstein)
depending on context; u umlaut to ue/UE; a umlaut to ae; e diaeresis to
e; o circumflex to o; e acute to e; e grave to e; and a acute to a.]





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