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.