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."