Finally we must consider the meaning of the deep stupor where no mentation of any kind can be proven and where none but vegetative functions seem to be operating. This state is either one of organic coma, in which case it marks the appearance of a physical factor not evidenced in the milder stages, or else it is the acme of this regression by withdrawal of interest. As has been stated, back of the period of primitive childish ideas there lies a hypothetical state of mental nothingness. If we accept the principle of regression we find historically an analogue to what is apparently the mental state of deep stupor in the earliest phases of infancy. This view receives justification from the study of the phenomenon of variations in symptoms. Mental faculties at birth are larval, and if such condition be artificially produced mental activity must be potentially present (as it would not be if we were dealing with coma). In Chapter IV phenomena of interruption of stupor symptoms were detailed. One case that was mentioned is now of particular importance as demonstrating that an appropriate stimulus may dispel the vacuity of complete stupor by raising mental functions to a point where delusions are entertained. This patient retrospectively recalled only certain periods of her deepest stupor, occasions when she was visited by her mother. At these times, as she claimed, she thought she was to be electrocuted and told her mother so, adding, "Then it would drop out of my mind again." Otherwise her memory for this state was a complete blank. Here we see a normal stimulus producing not normality but something on the way towards it, that is, a condition less profound than the state out of which the patient was temporarily lifted.

This case exemplifies the principle of levels in the stupor reaction which we have found to be of great value in our study. These levels are correlated with degrees of regression, as a review of the symptoms discussed above may show. In the first place, the dissatisfaction with life, the first phase of regression, leads to the quietness—the inactivity and apathy, which are the most fundamental symptoms of the stupor reaction as a whole. Initiative is lost and with this comes a tendency for the acceptance of other people's ideas. That is the probable basis for the suggestiveness which we concluded was a prominent factor in catalepsy. Indifference and stolidity may exist with those milder degrees of regression which do not conflict with one's critical sense, and hence may be present without any false ideas. The next stage in regression is that where the idea of death appears. Although not accepted placidly by the subject, its non-acceptance is demonstrated by the idea being projected—by its appearance as a belief that the patient will be killed. This notion of death coming from without has again two phases, one with anxiety where normality is so far retained that the patient's instinct of self-preservation produces fear, and a second phase where this instinct lapses and the patient so far accepts the idea of being killed as to speak of it with indifference. The next step in regression is marked by the spoiled-child conduct, interest being so self-centered as to lead to autoerotic habits and the perverse reactions which we call negativism. When death is accepted but mental function has not ceased, the latter is confined to a dramatization of death in physical symptoms or to such speech and movements as indicate a belief that the patient is dead, under the water, or in some such unreal situation. Finally, when all evidence of mentation in any form is lacking, we see clinically the condition which we know as deep stupor and which we must regard psychologically as the profoundest regression known to psychopathology, a condition almost as close to physiological unconsciousness as that of the epileptic.

Naturally we do not see individual cases in which all these stages appear successively, each sharply defined from its predecessor. To expect this would be as reasonable as to look for a man whose behavior was determined wholly by his most recent experience. Any psychologist knows that every human being behaves in accordance with influences whose history is recent or represents the habit of a lifetime. At any given minute our behavior is not simply determined by the immediate situation, but is the product of many stages in our development. Quite similarly we should not expect in the psychoses to find evidences of regression to a given period of the individual's life appearing exclusively, but rather we should look for reactions at any given time being determined preponderantly by the type of mentation characteristic for a given stage of his development. As a matter of fact, we see in psychoses, particularly in stupor, more sharply defined regressions to different levels than we ever see in normal life.

Our psychological hypothesis would be incomplete and probably unsound if it could not offer as valid explanations for the atypical features in our stupor reactions as for the typical. The unusual features which one meets in the benign stupors are ideas or mood reactions occurring apparently as interruptions to the settled quietude or in more protracted mild mood reactions, such as vague distress, depression or incomplete manic symptoms, which have been described in the chapter on affect. The interruptions are easily explained by the theory of regression. If stupor represents a complete return to the state of nothingness, then the descent to the Nirvana or the re-ascent from it should be characterized by the type of thinking with the appropriate mood which belongs to less primitive stages of development. A review of our material seems to indicate that there is a definite relationship between the type of onset and the character of the succeeding stupor. For instance, in the cases so far quoted in this book, the onsets characterized by mere worry and unhappiness and gradual withdrawal of interest had all of them typical clinical pictures. On the other hand, of those who began with reactions of definite excitement, anxiety or psychotic depression, there were interruptions which looked like miniature manic-depressive psychoses in all but one case. This would lead one to think that these patients retraced their steps on recovery or with every lifting of the stupor process, moved slightly upward on the same path on which they had traveled in the first regression. The case of Charlotte W. (Case 12), which is fully discussed in the chapter on Ideational Content, offers excellent examples of these principles.

The next atypical feature is the phenomenon of reduction or dissociation of affect, the frequency of which is mentioned in Chapter V. As the law of stupor is apathy, normal emotions should be reduced to indifference and no abnormal moods, such as elation, anxiety or depression, should occur. What often happens is that these psychotic affects appear but incompletely, often in dissociated manifestations. This looks like a combination of two psychotic tendencies, the stupor reduction process which inhibits emotional response and the tendency to develop abnormal affects which characterize other manic-depressive psychoses. There is no general psychological law which makes this view unlikely. One cannot be anxious and happy at the same instant, although one can alternate in his feelings; but one can fail to react adequately to a given stimulus when inhibited by general indifference. In fact it is because apathy is, properly speaking, not a mood but an absence of it, that it can be combined with a true affect. It is possible, therefore, to have a combination of stupor and another manic-depressive reaction, while the others cannot combine but only alternate.[11]

Finally we must discuss the psychological meaning of cases, such as those described in Chapter VIII, where we concluded that there were psychoses resembling stupors superficially. It seemed likely that these patients were absorbed in their own thoughts, rather than being in a condition of mental vacuity. It is not difficult to explain the objective resemblance. All evidence of emotion (apart from subjective feeling tone which the subject may or may not report) is an expression of contact with the outer world. There must be externalization of attention to environment before a mood becomes evident. A moment's reflection will show this to be true, for no further proof is needed than the phenomena of dreaming. The attention being given wholly to fantasies, the subject lies motionless, mute and placid, although passing through varied autistic experiences. Only when the dream becomes too vivid, disturbs sleep and re-directs attention to the environment—only then is emotion objectively betrayed. There is an appearance of apathy and mental vacuity which the dreamer can soon declare to be false. He was feeling and thinking intensely. In any condition, therefore, such as that of perplexity or of an absorbed manic state, the patient may be objectively in the same condition as a typical stupor. The histories of the two psychoses differentiate the two reactions which may be indistinguishable at one interview. The keynote of one reaction is indifference, while that of absorption is distraction, a perversion of attention to an inner, unreal world.

In summary we may recapitulate our hypotheses. Stupor represents, psychologically speaking, the simplest and completest regression. Adaptation to the actual environment being abandoned, attention reverts to earlier interests, giving symptoms of other manic-depressive reactions in the onset or interruptions, and finally dwindles to complete indifference. The disappearance of affective impulse leads to objective apathy and inactivity, while the intellectual functions fail for lack of emotional power to keep them going. The complicated mental machine lies idle for lack of steam or electricity. The typical ideational content and many of the symptoms of stupor are to be explained as expressions of death, for a regression to a Nirvana-like state can be most easily formulated in such a delusion. Other clinical conditions may temporarily and superficially resemble stupor on account of the attention being misdirected and applied to unproductive imaginations. To employ our metaphor again, in these false stupors the current is switched to another, invisible machine but not cut off as in true stupor.

FOOTNOTES:

[11] The reader will note that this view is opposed to that of Kraepelin, who has written largely on so-called "mixed conditions" in manic-depressive insanity. We believe that careful clinical studies confirm our opinion and that his classification is based on less thorough observation and analysis. This subject will be discussed at greater length in a forthcoming book on "The Psychology of Morbid and Normal Emotions," by Dr. MacCurdy.



CHAPTER XI

MALIGNANT STUPORS

As we have seen, the benign stupors are characterized by apathy, inactivity, mutism, a thinking disorder, catalepsy and negativism. All these symptoms are also found in the stupors occurring in dementia praecox. In fact this symptom complex has usually been regarded as occurring only in a malignant setting. There can be no question about the resemblance of benign to dementia praecox stupors. Even such symptoms as poverty and dissociation of affect, usually regarded as pathognomonic of dementia praecox, have been described in the foregoing chapters. Either recovery in our cases was accidental or there is a distinct clinical group with a good prognosis. If the latter be true, the symptoms must follow definite laws; if they did not, we would have to abandon our principles of psychiatric classification. Naturally, then, we seek to find the differences between the cases that recover and those that do not. There is never any difficulty in diagnosis where a stupor appears as an incident in the course of a recognized case of catatonic dementia praecox. We shall therefore consider only such clinical pictures as resemble those described in this book, in that the symptoms on admission to a hospital or shortly after are those of stupor. It should be our ambition to make a positive diagnosis before failure to recover in a reasonable time leads to a conclusion of chronicity.

It is probably safe to assume, on the basis of as large a series as ours, that the symptoms of stupor per se imply no bad prognosis. Further, it has been noted that a relatively pure type of reaction is seen, the symptoms appearing with tolerable consistency. In analyzing the histories of dementia praecox patients, therefore, one looks for inconsistencies among, or additions to, the stupor symptoms. We may say at the outset that we have been able to find no case of malignant stupor that showed what we regard as a typical benign stupor reaction, and it is questionable whether partial stupor as we have described it, ever occurs with a bad prognosis. Usually the discrepant symptoms in the dementia praecox cases are sufficiently marked to enable one to make a positive diagnosis quite soon after the case comes under observation.

The law of benign stupor is a limitation of energy, emotion and ideational content. In dementia praecox we have a re-direction of attention and interest to primitive fantastic thoughts and a consequent perversion of energy and emotion. In many malignant stupors one can detect evidence of this second type of reaction in symptoms that are anomalous for stupor. For instance, one meets with frequent silly and inexplicable giggling. Then, too, smiling, tears or outbursts of rage, the occasions for which are not manifest, are much more frequent than in typical stupor. Similarly, delusional ideas (not concerned with death at all) may appear or the patient may indulge in speech that is quite scattered, not merely fragmentary. Two cases may be cited briefly to illustrate these dementia praecox symptoms superadded to those of stupor.

CASE 20.—Winifred O'M. Age: 19. Single. Admitted to the Psychiatric Institute May 6, 1911.

F. H. The occurrence of other nervous or mental disease in the family was denied.

P. H. The patient seems to have been rather shy and goody-goody in disposition. According to her mother this seclusiveness did not begin to be markedly noticeable until the winter before her psychosis, when there was some trouble about getting work. She had previously been to a business school. Then she held a position as stenographer temporarily. When this job was over she had a number of positions that did not last long and was once idle for two months. In February (three months before admission) her father was out of work, which added to her worry.

Onset of Psychosis: Nine days before admission a young man died in the house where they lived. The next day her mother insisted on the patient and her sister going to the funeral. On coming home the patient complained of being afraid and having a funny feeling. She woke up at 2:30 that night and lit all the gas, for which she could give no explanation. The day following, or a week before admission, she was slow, confused, could not get her clothes together. The next day she was restless and worried, giving a superficial explanation for the latter. She played the piano a great deal. The following day she was fidgety and cried. At 4 p.m. she was put to bed and appeared to fall asleep. At midnight when a priest called she said to him privately that she was all over the world, that she went to the 12th floor of the Metropolitan Building, that she sat down and took the man's money, $7, and came right away. She recognized the priest. Three days before admission she wanted to stay in bed, kept her eyes closed. When spoken to she would smile but did not open her eyes. She did not pass her urine all day. Her mother then gave her some medicine which the doctor had left. The patient immediately had a peculiar attack in which she heaved her breast, drew her head back, clenched her fists and worked her feet. Saliva escaped from the side of her mouth. This attack lasted some three to five minutes.

Her mother then called an ambulance and she was taken to the Observation Pavilion. She thought that the ambulance doctor was an uncle, a soldier in the Philippines, of whom she was very fond. There she remained in bed, with all her muscles relaxed, her mouth constantly open, saying nothing and indeed resisting efforts which were made to get her to open her eyes.

Under Observation: She sat or lay down with her eyes closed and usually limp, although occasionally resistive. There was practically no reaction to pin pricks. Sometimes she opened her mouth as if to speak but rarely did so except in a very low tone and after repeated questioning. Her answers were rarely relevant. To the usual orientation questions she gave no answers that would indicate that she knew where she was. Sometimes she said "Jimmy" when asked her name, and replied to another question, "Jimmy big smile on." Once she said, "I don't know myself—what I am talking for—what I am doing." In general her speech seemed to indicate that her thought was directed entirely inward and that she paid no attention whatever to the questions. In most benign cases such a condition is accompanied by perplexity or a dreamy, dazed expression. This the patient had not. On the other hand, she was sometimes definitely scattered. For example, when asked, How do you feel? she replied, "Large all name." Again to the command, Tell me your trouble, her answer was, "I couldn't tell my mother last night and I can't tell her this night and I can't tell my proud." She referred in a fragmentary way to being crazy and to having been dead. She admitted hearing voices but may not have understood the question.

A week after admission, when visited by her mother, the latter asked her to kiss her. The patient opened her mouth widely and put out her tongue. This is a type of response which we have never seen in our benign cases.

Two days later repeated questioning made it evident that the patient knew more about her environment than would be expected, judging from her other symptoms. She gave the month correctly knew that she was in a hospital and told of having recently been visited by her father. At the same interview she spoke of masturbation, of wanting to marry her uncle, and of having been in bed with her father. The last she referred to as a "fall." Such frank incest ideas are never found in benign psychosis in our experience. Other dementia praecox ideas appeared quite soon, for within three days, when she was talking slightly more freely, she spoke of having often imagined she was having sexual experiences as a result of the influence of a man who lived upstairs, and that even when sitting with her family at the table she felt sexual sensations.

Her condition then remained essentially the same for some time. Then about six weeks after admission she became somewhat less resistive, was frequently seen sitting up in bed, moving her lips considerably (without speech) and regarding the surroundings with a bright interested expression and occasionally smiles. About this time she began exposing herself and chewing her finger nails.

Four months after admission she was noted as being very resistive and negativistic, allowing saliva to accumulate in her mouth and making no attempt to keep the flies off her. At the same time she would keep in her mouth food that had been put there without chewing it.

Two months later she seemed to laugh occasionally when other patients did so, but at the same time she showed a cataleptic tendency and was quite mute.

Six months after admission she began to feed herself but rather sloppily. When one would speak to her, she would occasionally smile, but if shaken she would weep silently. About this time she began to do a little work in the ward, pushing a floor polisher.

For the next couple of months her condition was about the same. She would stand around the ward, doing a little work if urged, might even dance if forced to. She was consistently mute. She was dirty but often decorated herself. Rarely she was assaultive.

Then ten months after admission she one day suddenly became talkative, distractible and emotional, laughing and crying. There was with this, however, no open elation. Her talk was obscene, at times flighty, at times definitely scattered. All her habits were filthy.

This pseudomanic episode lasted for a couple of months, and then she settled down to a fairly consistent deterioration with indifference, silly laughter, occasional assaultiveness, destructiveness and untidiness.

Nearly two years after admission she had another period of excitement lasting about a couple of months. Shortly after this she began to fail physically, and in November, 1913, two years and five months after her admission, she died of pulmonary tuberculosis.

In summary, then, we see that this patient exhibited symptoms of dementia praecox from the outset of her stupor, with scattering, genital sensations and incest ideas. The stupor symptoms gradually gave way to the typical indifference, negativism, obscenity, filthiness and inexplicable conduct of dementia praecox. At the beginning, however, the condition was superficially similar to that of a benign stupor, it being only on careful observation that other symptoms were noted.

CASE 21.—Rose S. Age: 23. Admitted to the Psychiatric Institute April 5, 1905.

F. H. The mother was living, the father dead. Otherwise no pertinent information was secured.

P. H. The patient was said always to have been somewhat seclusive, mingling little with other people; this tendency was so strong that she would leave the room when visitors came. She always slept a great deal. It was stated that she was able to do heavy housework quite well, but never learned cooking.

At 16 she hired out as a servant for a year and a half, and then did laundry work. When 18 she had an illegitimate child by a co-worker.

History of Psychosis: About a year before admission the patient's sister was burned to death. When the patient heard of this she said that something had come up in her throat. Henceforth she often complained of a lump in her throat, and often bit her nails. Two months before admission she suddenly left the laundry, again spoke of the lump in her throat, and claimed to have seen the dead sister. Two weeks later when the family had an anniversary mass for the sister the patient appeared sad, but the following day laughed, said she had seen her "sister beckoning her to come." She also thought she saw her picture "and Heaven was behind it." She also talked of "dead relatives and friends." A reaction of levity in connection with a sister's death is highly suggestive of a malignant psychosis.

Two weeks before admission her mother found her in a stupor, immovable, with her eyes closed. In 24 hours she woke up, began to sing "Rest for the Weary," prayed, then was stuporous again for six hours. When she came out of this, she said she was "going to die," God had told her so and talked of her own funeral arrangements. She again went into a stupor, in which she was sent to the Observation Pavilion.

At the Observation Pavilion she was described as happy, laughing, singing, saying she felt happy, but adding, "I like to be sad too, I am going to Heaven Easter Sunday." She claimed that her sister frequently stood in front of her, and that she knew she wanted her to go with her.

Under Observation: For about three weeks the patient showed a variable stupor. She would lie with a mask-like face inaccessible, cataleptic, drooling saliva, often with her mouth open. When taken up, she was usually perfectly flaccid, but once she let herself slide on the floor after she had stood immobile at the window. Sometimes there was marked resistance to passive motions, especially when attempts were made to open her mouth or eyes, or on one occasion when the examiner tried to open her hand in which she held her handkerchief. Yet when one persisted in urging her to respond there frequently could be elicited more or less marked reactions. Thus repeatedly she could be made to obey some commands, as showing the tongue, etc., even when she would not answer. Once when her eyes were opened, tears rolled down her cheeks—again, she usually reacted to pin pricks by slight flushing, once she said, "Stop! it hurts." Again, she said, "Leave me alone, I want to sleep."

So far the description of this reaction is that of a benign stupor. There were, however, other symptoms. In the first place, she could sometimes be made to open her eyes and write, although she would not speak. In spite of the penmanship being careless, there were no mistakes. This exhibition of an unhabitual and more difficult intellectual effort when the patient was mute is suggestive of an inconsistency. So was her habit of sometimes singing a hymn, "Rest for the Weary," when no other sign of mental life was given. But, more important than these, she could not infrequently be induced to answer questions and at such times she spoke promptly and with natural affective response.

A number of her replies were of the type to be expected in a benign stupor. In the first place, she spoke of her condition as "going off to sleep" and also as "death," "I was dead all day." "I died three times yesterday," or she merely described it by saying "I go off into states when I lie with my mouth open and eyes closed, and cannot speak or open my eyes." When asked how she got into this condition, she said "My sister died and I think it was on my mind." Again she said she became sad at the anniversary mass of the sister and had been sad ever since. On the other hand, she also stated that when she came home from the mass she first was silly and danced. Spontaneously she spoke of having frequently had visions of her dead sister; once she saw her with wings. In explanation of her singing "Rest for the Weary," she said it was the hymn sung at her father's funeral. An anomalous feature had to do with her description of her feelings. She claimed to have no memory of her stupor periods and yet said of them: "I feel peaceful-like," or "I feel awfully happy and sad together," or "I am sad and contented—I like it that way."

A striking symptom was that, when a sensory examination was made during the first few days during one of the periods when she responded well, she showed glove and stocking anesthesia, also anesthesia of neck and left breast.

But in addition to the above statements the patient also began to make others of a definite dementia praecox type. About ten days after admission she said, "What any one says goes right through my brain," or she talked of being hypnotized. "The typewriting machine turned my eyes—three or four girls turned my eyes—they look at me and get their chance, their left eye—turning me into images. I want to be the way I was born—turn my body! look how their bodies are turned before they die," or "Take it if you get it—he got the name out—I was over there to death—himself to death—of, you know—you played out—she is played out." ... This while she snickered between the sentences. As early as four weeks after admission she had begun to giggle or laugh, often in an empty fashion, and a transition from the more constrained stuporous state, with interruptions of laughter, to an indifferent silly, muttering to herself was gradual.

In 1909 she was described as not talking, standing around, showing no interest in anything, muttering. The only response obtained was "I don't know." In December, 1911, she was transferred to another hospital as a case of deteriorated dementia praecox.

To Recapitulate: We have here a young woman who for a year had indefinite mental symptoms and suddenly developed a stupor. This was atypical in that she sang and wrote when otherwise apparently deeply stuporous. When persuaded to talk, her utterances, even as early as ten days after admission, were of a malignant type and with such statements she giggled. This last is apparently a highly important sign. Quite frequently in our cases the first signal of a dementia praecox reaction has been giggling in a setting of what was apparently a typical benign stupor.

As has frequently been stated, symptoms of benign stupor are closely interrelated. Consequently the reaction is, when benign, a consistent one. We do not find free speech with profound apathy and inactivity, nor do we expect to meet with unimpaired intellectual functions when other evidences of deep stupor are present. The inconsistency of mental operations which characterize dementia praecox, however—the "splitting" tendency which Bleuler has emphasized in his term "schizophrenia"—is just that added factor which may produce disproportionate developments of the various stupor symptoms in the dementia praecox type of that reaction. Examples of this have been given in the two cases just quoted. The history of the following patient shows this tendency more prominently.

CASE 22.—Nellie H. Age: 20. Admitted to the Psychiatric Institute June 11, 1907.

F. H. The father had repeated depressions; he died of typhus fever. The mother was living.

P. H. The brother of the patient stated that she was like other girls, and very good at school. At 16 she became quieter, less energetic. She came to America at 17. After arriving here she has seemed low spirited, cranky and faultfinding. She often complained of indefinite stomach trouble and headaches; when at home she often had a cloth around her head. The informant recalled that she said, "I wish I could get sick for a long time and get either cured or die." However, she worked. For one and a half years prior to admission her "crankiness" is said to have become much worse. She complained continually of being tired; quarreled much with her mother; said she did not have enough to eat. It is also stated that she was constantly afraid of losing her job.

History of Psychosis: For six months before admission she said frequently that her boss was giving her hints that he liked her. (She did not know him socially at all.) Six days before admission she came home, saying the boss had told her he had no more work for her. Nevertheless, she went back next day and was again sent home. At home she sat gazing. Next day again wanted to go and see the boss, but was prevented. At times she tried to get out of the window; again sat gazing, repeating to herself "Always be true." She said she was in love with the boss. When the doctor gave her medicine she thought it was poison. Finally she began to be talkative and elated. At the Observation Pavilion she became very quiet.

Under Observation: She lay in bed indifferent, not eating, unless spoon-fed, when she would swallow. She soiled herself. She answered no questions as a rule, and only on one occasion, when urged considerably, said in answer to questions that this was a hospital, so that she evidently had more grasp on the nature of her environment than her behavior indicated. To her brother who called on her during the first ten days she said she could not find her lover here (an idea inconsistent with the benign stupor picture).

Then she became more markedly stuporous, drooling saliva, very stiff, often lying with head half raised, gazing stolidly, never answering, soiling. Later, after a month, this was less consistent. She now and then went to the closet, sometimes she smiled, ate some fruit brought to her, spoke a little. Repeatedly when people came she clung to them, wanted to go home, again was seen to weep silently. On another occasion she suddenly threw the dishes on the floor with an angry mood, without there being any obvious provocation. Again she got quite angry when urged to eat her breakfast, and on that occasion pulled out some of her own hair. Usually she had to be fed, was stiff, sitting with closed fists, not reacting as a rule in any other way, wholly inaccessible and has been that way for years. The stupor merged into a catatonic state merely by the development of the inconsistency in her affective reactions.

We see then that inconsistencies among the stupor symptoms themselves and the intrusion of definitely dementia praecox symptoms differentiate the malignant from the benign reactions. As a matter of fact, we find, as a rule, that careful examination of the onset reveals further atypical features, suggestions or definite evidences of a dementia praecox reaction before the stupor itself appears. One common occurrence is a slow deterioration of character and energy that proceeds for months or years before flagrantly psychotic symptoms appear.

Then when delusions or hallucinations are eventually spoken of by the patient, an appropriate or adequate reaction is lacking. In a benign psychosis false ideas do not appear with an equable mood unless the stupor reaction has already begun.

More important than this, although in benign stupors there may be a reduction or an insufficient affect, it is never inappropriate. This pathognomonic symptom of dementia praecox frequently occurs in the onset to malignant stupors. In fact we often find in reviewing such cases that a plain dementia praecox reaction has been in evidence, that a diagnosis has not been made simply because the stupor picture blotted out this earlier psychosis before an opinion was formed. Frequently these early symptoms are reported in the anamnesis and not actually observed by the physician.

Three cases may be cited as examples of dementia praecox onsets. It will be noted that the ensuing stupors were, like those already quoted, atypical.

CASE 23.—Catherine H. Age: 21. Admitted to the Psychiatric Institute October 10, 1904.

F. H. The mother's brother had two attacks of delirium tremens. The mother died when the patient was eleven years old; she is said to have been normal. The father was living.

P. H. The patient was always a nervous child, had very bad dreams, but she was smart at school up to ten or eleven, and played with other girls. Then she began to work less well, got thin, more nervous, complained of headaches. It was about that time that her mother died. (The reaction to the death was said not to have been different from that of her sister.) She was kept at home and was quiet.... "You could see something was working on her." She began to menstruate at 14, and it was claimed that she then wakened up a little. It was further stated that she was always "stuck up" about her clothes.

At 16 she went to work in a factory, but her sister thought the work was too much for her, so she was taken home. Thereafter she lived alone with her father, doing his housework, her sister having married about that time. At 17 her hair began to come out excessively, so that she had to cut it, and when it grew again it was gray. She became very sensitive about this, even refused to take positions because she thought people would remark about it.

For two years before admission she evidently was different. Although she did her father's housework well enough, she turned against her sister and refused to speak to her because, she alleged, the sister had not come to help her in her housework. Another pronounced manifestation during that time was her frequent talk about her bowels. She complained of constipation, creepy, crawling sensations in the stomach which she thought was a "tapeworm." She got pamphlets and took patent medicines. She was taken to a physician nine months before admission, who operated on her for piles. While still in the hospital she asked her father to take her home to die (although there was no reason for such a request). Again she said the gauze had been left in the rectum too long and that the rectum was full of wind. Later she said the rectum was closing up. After this, the sister stated, she was extremely nervous if she passed a day without a movement of the bowels. She was quiet henceforth, went out less and said little, claiming it was better for her head if she said little. She often sat, head in hand, in the hall. All through the summer she frequently remarked, "I am a good girl." Four months before admission during a period of five weeks she would let her bowels move when standing up. This was relieved by enemas. The father states that she was cranky to him, that sometimes when he merely asked a question she would say, "You hurt my feelings," and once, "You break my heart." Occasionally she seemed to worry about the money spent for her on doctors and medicine.

About two months before admission she said everybody was looking at her. Ten days before admission she said, "I have been sick all this time and thought I was going to die. Now I think Tom (her brother) is going to die." She became fearful of being left alone. Finally she went to the priest, who told her to go home. Then she prayed, leaving the candles burning in the room. That night she was found kneeling before a church in her nightgown. Again she threw a lot of articles into the yard, saying a curse had been put on her by her father, and she did not wish to give him anything. When she was taken to the Observation Pavilion she said, "I am a good girl—my mother is dead—it is all my father's fault."

At the Observation Pavilion she put her arm under a hot water faucet "to save the world," prayed and laughed—again sank back and appeared as if asleep. She said, "I hear angels telling me how to pray when I lose my thoughts—sisters and nuns are all around me here, to save and purify the world now and forever, and at the hour of our death."

Under Observation: On admission the patient kept her eyes closed, sang hymns in measured tones, or prayed, or showed a certain ecstasy in her face while her lips quivered and tears ran down her cheeks. On the whole, she answered few questions. When asked how she felt, she said she was happy. (Why do you cry?) "I was crying when I asked God to save souls." (Are you afraid?) "Not now, I have been afraid of everything on Earth ever since my mother died." (What do you mean?) "No one would look at me or talk to me—they said I was a bad girl, but I was pure." Again she said, "They laughed about me, talked about me—and they drew up a play about me—Devil's Island." Or she spoke about having had stomach trouble, bowel trouble, teeth trouble, eye trouble, compound, complicated trouble. (What do you mean?) "Father scolding all the time, he sent me to get bug medicine (true). God gives that medicine to the one that started all the trouble—Devil's Island."

She soiled her bed and was asked why she did it. She said "I have been transformed into a baby, the Lord said I was too pure to be a woman—I had to become a baby to save the world." Or when asked her name she called herself "Baby Chadwick of the whole world—divine Irish Catholic World—Amen," or again "I am the Roman Catholic Irish Divine Baby."

Although she was not essentially disoriented she called the place "mid-heaven," or "a holy house, sort of a hospital." She also said, "In two years more there will be a new world and it will be more happy and holy."

The day after entrance the patient, though in part as described, had a spell when she kept her eyes closed and was rigid. Spells like these returned. (About a month after admission she became completely stuporous.) She prayed at times, at other times was constrained, or kept her eyes closed. Her orientation throughout was good. The content of her psychosis, in addition to the praying attitude, had a more or less vague religious coloring. Thus she called the hospital the "House of God." Again, when on one occasion she had jumped at the window guard and was asked "why?" she said "holy communion." Again she said she was "Mary, Virgin Mother." But this religious trend was intermingled with remarkable elements of another sort. Thus when in order to study her knowledge of the events after admission, she was asked what she had done when she was brought into the ward, she said, "I went into the sanctuary where my bowels moved and water passed from me." (Why do you call it sanctuary?) "Because Jesus did the same thing I did."

Possibly vague sexual allusions are also contained in the following: She said one day to the doctor, "Everything went wrong last night, good, pure, true and holy doctor, I led you astray and you were dying last night, may the Almighty God forgive me, I ought to have died, but I fought it out, for, if I had died, my mother's soul would not have been saved in Heaven and from the flames of Hell." Again, "I will not look at you again, good, pure, holy doctor of the world." (Why?) "I am afraid I will lead you astray." And also: "I led James. Peter astray too." It should be added that she sometimes masturbated rather shamelessly.

She said she heard her mother's voice. (What did she say?) "Something in the sky for me, angels call for me." (What do the angels say?) "The name of my good mother in Heaven." Again she said she had heard her mother the night she came here. (What did she say?) "It was like a voice—feed the calf—that means me, I suppose."

Then after a month the stupor became more continuous. She lay totally inactive for the most part, had to be fed, soiled herself, drooled saliva, was at times cataleptic, often rigid. Her limbs became cyanotic. A few times tears were seen. On other occasions she whispered "peace," or "peace for hazing," or "pray—peace," or "I like to be good." Usually no responses could be obtained.

After some months she was at times seen laughing. This gradually passed into a state of total disinterestedness and inaccessibility. She could finally be made to polish the floor in an automatic fashion, but never spoke, and five years after admission she was transferred to another hospital, where she died (eleven years after admission to the ward of the Institute) without any change in her mental condition having taken place.

CASE 24.—Adele M. Age: 22. Admitted to the Psychiatric Institute November 11, 1904.

P. H. The father stated that the patient was always "cranky," had outbursts of temper, even when a small child and was quarrelsome; also said that she was "seclusive," had few friends, was averse to meeting people, never had a beau. She was taken out of school at 14 because she was not promoted on two successive occasions from the same class. Then she was put to work, but she was usually discharged for incompetency.

Onset of Psychosis: Three years before admission it was noted that she laughed occasionally without cause. She was idle. This laughing, and also crying, was sometimes more frequent, again less noticeable.

Six months before admission she began to say she wanted to leave home, but made no move to do so. Then she began to speak of bad odors, made some remarks about the neighbors talking about her—saying she should kill herself; again she said the family would be brought to death, or the mother was falling to pieces, the father looked sick. She also said her head was swelling and was getting thick. Finally she wanted to hire a furnished room and kill herself and asked if 75 cents which she had was enough to do it with.

Two weeks before admission she left home, wandered about all night, was picked up by the Salvation Army, and returned to her home. She said she wanted to die.

At the Observation Pavilion she stated that her mother was falling to pieces and her father sick. She also said she wanted to die.

Under Observation: The patient was at first petulant, saying "I don't want to stay here," turning her face away from the doctor, generally uninterested. Though it could be established that she was quite oriented, often her answers were "I don't know," or she did not answer. But she was also seen crying at times, and she was apt to bite her finger nails. She had to be tube-fed. Gradually these tendencies increased so that she lay in her bed with head covered, saying in a peevish tone, when spoken to, "Oh, let me alone." And for years she was mute, lying with her head covered, tube-fed. When reexamined in 1914 (ten years later), she was found lying in bed with an empty smile. There was paper stuffed in her ears. When approached, she turned her head away and would not talk.

CASE 25.—Catherine W. Age: 42. Admitted to the Psychiatric Institute November 11, 1904.

F. H. The father died at 75, the mother at 44. Two sisters died of tuberculosis. A brother wanted to marry but was opposed by the father; he set fire to the house of the girl and then drowned himself.

P. H. The patient came to this country when 20, and worked for some years as a servant. Then she married after a short acquaintance. The husband, according to his own statement, drank, and there was friction from the first. She left him a few weeks after marriage, and a few months later he went to Ireland; she also went some time later but did not go to see him. Then they lived together again. They had four children, but had had no intercourse for nine years.

Development of Psychosis: Eight years before admission the patient became nervous, slept badly, but got better. It was claimed that for six years she had been quieter and more sullen than before. Three years before admission the patient had to take a place as janitress, since she needed the money. From the first she had trouble with the tenants and accused everybody of being in league against her. Some six or eight weeks after she had taken the position, she developed what was called typhoid fever, and some time later the daughter came down with the same disease. After the typhoid she was more antagonistic towards her husband, accused him of infidelity, repeatedly locked him out of the house, but continued to do her housework. About six months after this illness she left her home, but returned in a week. She had vague ideas thereafter that the priests were saying things against the family, and she often quarreled with the tenants. For a year she had done no work but sat about. Ten days before admission she stopped eating.

Under Observation: The patient was mute, stolid, gazing straight ahead, sometimes cataleptic. She had to be tube-fed, was usually very resistive to any passive motions; quite often she retained her urine, but she did not hold her saliva. Yet there was some quick responses at least in the beginning. At such times it was found that she was oriented, but nothing could ever be obtained about her feelings, etc., except that she once said, when asked whether she was worried, that she "felt weak," had "nothing to worry about." Occasionally she was seen to cry silently; at times she would breathe faster when questioned, or flush; once she took hold of the doctor's hand when he questioned her, and cried, but made no reply. On another occasion she was affectionate to her son, kissed him, although she paid no attention to her daughter who accompanied the son. Later she said to the nurses, "He is the best son that ever lived." But more and more she became disinterested, totally inaccessible, resistive, had to be tube-fed. In this condition she remained for five and a half years. At the end of that time she died of tubercular pneumonia.



CHAPTER XII

DIAGNOSIS OF STUPOR

In any functional psychosis an offhand diagnosis is dangerous. When one deals with such a condition as stupor, however, the problem is exacting, for, although "stupor" may be seen at a glance, what is seen is really only a symptom or a few symptoms. "Stupor," then, is more of a descriptive than a diagnostic term. The real problem is to determine the psychiatric group into which the case should be placed. This is a difficult task, for the differential diagnosis rests on the observation and utilization of minute and unobtrusive details. A correct interpretation can be only reached by obtaining a complete history of the onset and observing the behavior and speech of the patient for a long period, usually of weeks, sometimes of months. With these precautionary words in mind, it may be well to summarize briefly the diagnostic problems in connection with benign stupor.

In the first place one naturally considers the differentiation from conditions of organic stupor or coma. Since psychotic stupors never develop without some signs of mental abnormality, the history is usually a sufficient basis for final judgment. In case no anamnesis is obtainable the functional nature of the trouble may be recognized by the absence of those physical signs which characterize the organic stupors. One sees no violent changes in respiration, pulse or blood-pressure, such as are present in the intoxication comas of diabetes or nephritis. There is no characteristic odor to the breath, and the urine is relatively normal. The unconsciousness of trauma or apoplexy is accompanied by focal neurological signs. Even in aerial concussion (so frequently seen in the war) where no one part of the brain is demonstrably affected more than another, there are neurological evidences of what one might call "physiological" unconsciousness. The eyes roll independently, the pupils fail to react to light. On the other hand, there are definite symptoms characteristic of the functional state. Mental activity is evidenced by a muscular resistiveness or retention of urine. Even in states of complete relaxation the eyes move in unison, the pupils react to light, and almost universally the corneal reflex is present. The patient appears in a deep sleep rather than actually unconscious.

The post-epileptic sleep may resemble a stupor strongly. But this condition is temporary and the situation and appearance of the patient betrays the fact that he has just had a convulsion. Rarely, protracted stuporous states occur in epilepsy which closely resemble the conditions described in this book. In fact it is probable the true stupors may occur in epilepsy just as in dementia praecox or manic-depressive insanity.

There is usually little difficulty in the discrimination of hysterical stupor. Occasionally it shows, superficially, a similarity to the manic-depressive type. Fundamentally, there is a wide divergence between the two processes, in that in the hysterical form a dissociation of consciousness takes place, the patient living in a reminiscent, imaginary or artificially suggested environment, while in a true stupor there is a withdrawal of interest as a whole and a consequent diffuse reduction of all mental processes. This difference is sooner or later manifested by the appearance in the hysteric of conduct or speech embodying definite and elaborated ideas.

As has been stated fully in the last chapter (to which the reader is referred), the stupor of dementia praecox is to be differentiated from that of manic-depressive insanity by the inconsistency of the symptoms in the former and the appearance of dementia praecox features during the stupor, such as inappropriate affect, giggling, or scattering. Further, the nature of the disorder is usually manifest before the onset of the stupor as such.

Sometimes very puzzling cases occur in more advanced years when it is difficult to say whether one is dealing with involution melancholia or stupor. Such patients show inactivity, considerable apathy and wetting and soiling, and with these a whining hypochondria, negativism, and often a rather mawkish sentimental death content without the dramatic anxiety which usually characterizes the involution state. In these cases the diagnosis is bound to be a matter of taste. In our opinion it is probably better to regard these as clinically impure types. They may be looked on as, fundamentally, involution melancholias (the course of the disease is protracted, if not chronic) in whom the regressive process characteristic of stupor is present as well as that of involution.

Great difficulties are also met with in the manic-depressive group proper. So often a stupor begins with the same indefinite kind of upset as does another psychosis that the development may furnish no clew. Any condition where there is inactivity, scanty verbal productivity and poor intellectual performance resembles stupor. This triad of symptoms occurs in retarded depressions, in absorbed manic states and in perplexities. Negativism and catalepsy are never well developed except in stupor. So if these symptoms be present the diagnosis is simplified. But they are often absent from a typical stupor. Let us consider these three groups separately.

The most important difference between stupor and depression lies in the affect. Although inactive and sometimes appearing dull the depressive individual is not apathetic but is suffering acutely. He feels himself wicked, paralyzed by hopelessness, and finds proof of his damnation in the apparent change of the world to his eyes and in the slowness of his mind. But he is acutely aware of these torments. The stupor patient, on the other hand, does not care. He is neither sad nor happy nor anxious. This contrast is revealed not only by the patients' utterances but by their expressions. The stuporous face is empty, that of the other lined with melancholy. The intellectual defect, too, is different. In retarded depression the patient is morbidly aware of difficulty and slowness, but on urging often performs tests surprisingly well. In the stupor, however, one is faced with an unquestionable defect, a sheer intellectual incapacity.

In Chapter VIII the differential diagnosis between perplexity and stupor has already been touched upon. Here again the affect is a point of contrast. The patient has not too little emotion but too much. The feeling of intangible, puzzling ideas and of an insecure environment causes the subject distress, of which complaint is made and which can be witnessed in the furrowed brow and constrained expression. There is also, as we have seen, a rich ideational content in these cases, if one can get at it. The mind is not a blank, as in the stupor, or concerned only with delusions of death.

Finally, there are the absorbed manic states. These are the most difficult, inasmuch as the patient is often so withdrawn and so introverted that at any given interview there may be no objective evidence of mood or ideas. Here the development of the psychosis is often an aid to diagnosis. The patient passes through phases of hypomania to great exultation, the flight becomes less intelligible, with this the activity diminishes until finally expression in any form disappears. If this sequence has not been observed, continued observation tells the tale. The patient still has his ideas and may be seen smiling contentedly over them (not vacuously as does the schizophrenic) or he may break into some prank or begin to sing. Any protracted familiarity with the case leads to a conviction that the patient's mind is not a blank, but that his attention is merely directed exclusively inward. Then, too, when his ideas are discovered, it is found that they are not exclusively occupied with the topic of death.



CHAPTER XIII

TREATMENT OF STUPOR

In dealing with cases of benign stupor the first duty of physician and nurse is naturally the physical hygiene of the patient. More is needed to be done in the bodily care of these persons than for most of the inmates of our hospitals for the insane. It is perhaps no exaggeration to claim that a deeply stuporous patient needs as much attention as a suckling babe. In the first place, the patient must be fed. It is important for mental recovery that the individual in stupor should be stimulated to effort as much as possible. Consequently there is an economy of time in the long run in taking pains to get the patient to feed himself in so far as that is possible. He should be led to the table and assisted in handling his own spoon and cup. If this is not practicable, he should then be spoon-fed, and if this in turn is found to be out of the question, tube-feeding should be resorted to. But this last should never be looked on as a permanent necessity, but only as a method of maintaining the patient's health until such time as he may be capable of independent taking of nourishment. In exactly the same way it is of prime importance to get the patient to attend to the natural habits of excretion. He should be led to the toilet or to a chair commode, and efforts to this end should be persistent, just as are those of a good child's nurse who has the ambition of making her charge develop normal habits. Naturally those who retain urine and feces should be watched to see that this retention does not last long enough to menace health. The physical aspects of treatment are exhausted with consideration for cleanliness. On account of the stupor patients' inactivity and frequent tendency to wetting and soiling, this is a particularly important consideration. It goes without saying that the perineal region should be kept scrupulously clean. If any infections are to be avoided, eyes, nose and mouth should also be cleansed frequently. A patient who is so indifferent as to keep the eyelids open for such a long time that the sclera dry and ulcerate is also apt to let flies settle and produce serious ophthalmic disease.

Less obvious and more important are the measures undertaken for the mental hygiene of the case. On account of the tendency present in so many patients for sudden action while in the midst of an apparently deep and permanent inactivity, it is necessary that these cases be not isolated but remain under constant observation. This is particularly true of those who have demonstrated impulsive suicidal explosions.

Not only on the basis of the psychological theory of the stupor process, but from the observed phenomena of recovery, we gather that mental stimulation is of first importance if an amelioration of the condition is to be attempted. If the stupor reaction be a regression, which is essentially a withdrawal of interest and energy rather than a fixation on a false object, then excitement is desirable and interest must be reawakened. The withdrawal is temporary (inasmuch as the psychosis is benign), but just as a normal person wakes more readily on a clear sunshiny day than when it rains, so the more cheering the environment the more rapid the recovery.

Consequently, although trying to those in charge, persistent attention should be given the patient. Feeding and hygienic measures probably have considerable value in this work. As soon as it is at all possible the patients should be got out of bed and dressed. When up, efforts should be directed towards making them do something, even if it be something as simple as pushing a floor polisher. On account of their lack of enthusiasm the stupor cases are often omitted from the list of those given occupation and amusement. Even if they go through the motions of work or play with no sign of interest, such exercise should not be allowed to lapse. Then, too, the environment should be changed when practicable. A patient may improve on being moved to another building.

Perhaps the most potent stimulus that we have observed is that of family visits. In most manic-depressive psychoses visits of relations have a bad effect. The patients become excited, treat the visitors rudely, perhaps even assault them, and all their symptoms are aggravated. But the stupor needs excitement, and an habitual emotional interest is more apt to arouse him than an artificial one. In another point the situation differs. As a rule manic-depressive patients have delusional ideas or attitudes in connection with their nearest of kin, so that contact with these stirs up the trouble. The stupor regression going beneath the level of such attachments leaves family relationships relatively undisturbed. Hence, while the visit of a husband is likely to produce nothing but vituperation or blows from a manic wife, the stuporous woman may greet him affectionately and regain thereby some contact with the world.

So many cases begin recovery in this manner that it cannot be mere chance. One patient's improvement, for instance, dated definitely from the day a nurse persuaded her to write a letter home. It is striking, too, how quickly a patient, while somewhat dull and slow, will brighten up when allowed to return home. A similar improvement under these circumstances is often seen in partially recovered cases of involution melancholia, in whom a psychological regression similar to that of stupor takes place. Such experiences make one wonder whether perhaps these alone of all our insane patients would not recover more quickly at home than in hospitals, provided nursing care could be given them.

This is a mere suggestion. Before treatment can be rational the nature of any disease process must be known, and we do not pretend to have done more as yet than outline the probable mental pathology of the benign stupors. The next step is to put theory into practice and experiment widely with various means to see if by appropriate stimulation the average duration of these psychoses cannot be reduced. It is largely with the hope of inducing other psychiatrists to carry on such work that this book is written. There is no other manic-depressive psychosis which, theoretically, offers such hope of simple psychological measures being of therapeutic value.



CHAPTER XIV

SUMMARY OF THE STUPOR REACTION

Having discussed in detail the various symptoms and theoretic aspects of the benign stupors, it may be well to have these observations and speculations summarized.

It being established that stupors occur as a temporary form of insanity[12] psychiatry is faced at once with the problem of describing these conditions accurately in order to ascertain their nosological position. To this end we first examined typical cases of deep stupor and found that the clinical picture is made up of the following symptoms: In the foreground stands poverty of affect. The patients are almost unbelievably apathetic, giving no evidence by speech or action of interest in themselves or their environment, unmoved even by painful stimuli. Their faces are wooden masks; their voices as colorless when words are uttered. In some cases sudden mood reactions break through at rare intervals. The second cardinal symptom is inactivity. As a rule there is a complete cessation of both spontaneous and reactive movements and speech. So profound may this inhibition be that swallowing and blinking of the eyes are often absent. The trouble is not a paralysis, however, for reflexes without psychic components are unaffected. Possibly related to the inactivity is the preservation of artificial positions which is called catalepsy, a fairly frequent phenomenon. A tendency opposite to the inactivity is seen in negativism. This perversity is present in all gradations from outbursts of anger with blows and vituperation to sullen, or even emotionless, muscular rigidity. This last occurs most often when the patient is approached but may be seen when observations are made at a distance. Frequently wetting and soiling are due to negativism, when the patient has been led to the toilet but relaxes the sphincters so soon as he leaves it. A constant feature is a thinking disorder. On recovery memory is largely a blank even for striking experiences during the psychosis and, when accessible during the stupor to any questioning, a failure of intellectual functions is apparent. An ideational content may be gathered while the stupor is incubating, during interruptions, or from the recollections of recovered patients. Its peculiarity is a preoccupation with the theme of death, which is not merely a dominant topic but, often, an exclusive interest. Probably to be related to this is a tendency, present in some cases, to sudden suicidal impulses, that are as apparently planless and unexpected as the conduct of many catatonics. Finally the disease is prone to exhibit certain physical peculiarities. A low fever is common and so are skin and circulatory anomalies. A loss of weight is the rule, and menstruation is almost always suppressed.

As to the frequency of stupor no figures are available, for the simple reason that the diagnosis in large clinics has not been made with sufficient accuracy to justify any statistics. Most of these cases are usually called catatonia, depression, allied to manic-depressive insanity or allied to dementia praecox. The majority of the stupors reported in this book were in women, but this is merely the result of chance, since it has been easier in the Psychiatric Institute to study functional psychoses in the female division, while the male ward has been reserved largely for organic psychoses. The majority of the patients seem to be between 15 and 25 years of age, so that it is, presumably, a reaction of youthful years. In our experience most cases occur among the lower classes, which agrees with the opinion of Wilmanns who found this tendency among prisoners.

This gives a brief description of the deep stupor. But even our typical cases did not present this picture during the entire psychosis. They showed phases when, superficially viewed, they were not in stupor but suffered from the above symptoms as tendencies rather than states. There are also many psychoses where complete stupor is never developed. This gives us our justification for speaking of the stupor reaction, which consists of these symptoms (or most of them) no matter in how slight a degree they may be present. The analogy to mania and hypomania is compelling. The latter is merely a dilution of the former. Both are forms of the manic reaction. We consequently regard stupor and partial stupor as different degrees of the same psychotic process which we term the stupor reaction. To understand it the symptoms should be separately analyzed and then correlated.

The most fundamental characteristic of the stupor symptoms is the change in affect which can be summed up in one word—apathy. It is fundamental because it seems as if the symptoms built around apathy constitute the stupor reaction. The emotional poverty is evidenced by a lack of feeling, loss of energy and an absence of the normal urge of living. This is quite different from the emotional blocking of the retarded depression, for in the latter the patient shows either by speech or facial expression a definite suffering. The tendency to reduction of affect produces two effects on such emotions as internal ideas or environmental events may stimulate. Exhibitions of emotion are either reduced or dissociated. For instance, anxiety is frequently diminished to an expression of dazed bewilderment; or, isolated and partial exhibitions of mood occur, as when laughter, tears or blushing are seen as quite isolated symptoms. This latter—the dissociation of affect—seems to occur only in stupor and dementia praecox. It should be noted, however, that inappropriateness of affect is never observed in a true benign stupor. A final peculiarity is the tendency to interruption of the apathetic habit, when the patient may return to life, as it were, for a few moments and then relapse.

Closely related to the apathy, and probably merely an expression of it, is the inactivity which is both muscular and mental. It exists in all gradations from that of flaccidity of voluntary muscles, with relaxation of the sphincters, and from states where there is complete absence of any evidence of mentation to conditions of mere physical and psychic slowness. After recovery the stupor patient frequently speaks of having felt dead, paralyzed or drugged.

By far the commonest cause of emotional expression or interruption in the inactivity is negativism. This is a perversity of behavior which seems to express antagonism to the environment or to the wishes of those about the patient. In the partial stupors it is seen as active opposition and cantankerousness. In the more profound conditions it is represented by muscular resistiveness or rigidity, or refusal to swallow food when placed in the mouth. Occasionally, too, the patient may even in a deep stupor retain urine so long that catheterization is necessary. All the explanations which one may gather from the patients' own utterances, mainly retrospective, seem to point to negativism expressing a desire to be left alone. The appearance of perverse behavior in aimless striking or mere muscular rigidity seems to be an example of dissociation of affect.

Catalepsy is an important symptom because, although it occurred in slightly less than a third of our cases, it seems to be a peculiarity of the stupor reaction found but rarely in other benign psychoses. It seems never to occur without there being some evidence of mental activity, and, consequently, we are forced to conclude that it is of mental rather than of physical origin. Just what it means psychically it is impossible to state without much more extended observations. We conjecture tentatively, however, that the retention of fixed positions is in part merely a phenomenon of perseveration, and in part an acceptance of what the patient takes to be a command from the examiner, and sometimes a distorted form of muscular resistiveness.

The intellectual processes suffer more seriously in stupor than in any other form of manic-depressive insanity. Not only do the deep stupors betray no evidence of mentation during the acme of the psychosis, but retrospectively they usually speak of their minds being a blank. Incompleteness and slowness of intellectual operations are highly characteristic features of the partial stupors and of the incubation period of the more profound reactions. The features of this defect are a difficulty in grasping the nature of the environment, a slowness in elaborating what impressions are received, with resulting disorientation, poor performance of any set tests and incomplete memory for external events when recovery has taken place. At times the thinking disorder may develop with great suddenness or improve as quickly, and a tendency to isolated evidences of mental acuity is another example of the inconsistency which is so highly characteristic of stupor. We should note, however, that these sporadic exhibitions of mentality are always associated with brief emotional awakening.

When we turn to examine the fragmentary utterances of stupor patients, we are surprised by the narrowness and uniformity of the ideational content. It seems to be confined to thoughts of death or closely related conceptions. Thirty-five out of thirty-six consecutive cases at one time or another referred literally to death. It is commonest during the onset, as all but five of these patients spoke of it during the incubation of their psychoses. Hence we conclude that death ideas and stupor are consecutive phenomena in the same fundamental process. As two-thirds of the series interrupted the stupor to speak of death or to attempt suicide, we assume that this relationship persists. Only a quarter gave any retrospective account of these fancies, so we presume that their psychotic experiences were repressed with recovery.

The usual form in which the idea appears is as a delusion of going to die or, literally, of being dead. It may appear as being in Heaven or Hell. A theoretically important group is that which includes the patients who, in addition, speak of being in situations such as under the water or underground, which we have mythological and psychological evidence to believe are formulations of a rebirth fantasy. Not rarely, preoccupation with death is expressed in sudden impulsive suicidal attempts.

The affective setting of these different formulations is important. A delusion of literal death occurs with complete apathy. The wish to die is apt to appear without the usual accompaniment of sadness or distress but still with considerable energy when impulsive suicidal attempts are made. A prospect of death, particularly when there is anticipation of being killed, is apt in manic-depressive insanity to occur in a setting of anxiety. Similarly one ordinarily observes fear in the patient who has delusions of drowning or burial. In the stupor cases, however, this painful affect seems to be reduced to a mere dazed bewilderment or feeble exhibitions of a desire for safety, such as the slow swimming movements of a patient who thought she was under the water. When these ideas of danger become allied to everyday interests—husband or child imperiled, etc.—a weak affect in the form of depression is apt to occur.

Physical symptoms are more common than in any other benign psychosis. Of these the most nearly constant is a low fever, the temperature running between 99 deg. and 101 deg. Twenty-eight out of thirty-five cases had this slight elevation with a tendency for it to occur immediately at the beginning of marked stupor symptoms. Although the evidence does not positively exclude any possibility of infection, it speaks distinctly against this view. A possible explanation is that the low fever is a secondary symptom. The suprarenal glands may function insufficiently as a consequence of the emotional poverty, since all emotions which have been experimentally studied seem to stimulate the production of adrenalin. Without this normal hormone for the activity of the sympathetic nervous system, there would be a disturbance of skin and circulatory reactions that would interfere with the normal heat loss. Suggestive evidence to support this view comes from the frequency with which the extremities are cyanotic or cold, the skin greasy, sweating profuse or absent, and so on. Further observations are necessary to confirm or disprove this hypothesis, but we feel inclined to accept it tentatively because it is plausible and consistent with the view that stupor is essentially a psychogenic type of reaction. Another physical anomaly, which is presumably of endocrine origin, is the suppression of the menses. This probably results from lowered nutrition. In some cases it ensues directly on a psychic crisis before any nutritional change can have taken place. Finally, among the symptoms of possible physical origin, epileptoid attacks were described in two of our cases. This is chiefly of interest in that such phenomena are extremely rare in the benign psychoses.

We believe that the mental symptoms summarized above constitute a specific psychotic type of reaction capable of appearing in any severity from mere lethargy and indifference to profound stupor. Since the prognosis is good, we feel obliged to classify this with the manic-depressive reactions. Further justification for this grouping is found in the occurrence of the stupor reaction as a phase in many manic-depressive psychoses. A patient may swing from mania to stupor as from mania to depression, and when the partial stupors are recognized as milder forms of the same process, it seems to be a frequent type of reaction.

If stupor be a reaction type, its laws must be psychological. According to the view of modern psychopathology, the essence of insanity is regression with indolent thinking as opposed to progressive and energetic mentation. One can look on stupor as being a profound regression. Effort is abandoned (apathy and inactivity), while the ideational content expresses a desire for a retreat from the world in death. It is possible to think of this regression as a return to the mental habit of the suckling period, when spontaneous effort is at its minimum. This, too, is the time when petulance and tantrums are frequent expression of a wish to be left alone, which may account for the negativism as a consistent symptom of the same regressive progress.

Just as we regress in sleep, to rise refreshed for a new day's duties, so the stupor case often shows excessive energy in a hypomanic phase before complete normality is reached. This corresponds again to the age-old association of the ideas of death and rebirth which we see together so frequently in stupor. It is the psychology of wiping the slate clean for a fresh start.

The development and symptoms of stupor furnish evidence in support of the hypothesis of this type of regression. Dissatisfaction of any kind is the setting in which the psychosis begins and the commonest precipitating factor is some reminder of death. That loss of energy appears with the stupor is evident from the inactivity and apathy, while the thinking disorder can be shown to be the result of the same loss. The different "levels" of the stupor reaction also conform to a theory of regression. First there is mere indifference and quietness; then appear false ideas when normality is so far abandoned as to mean a loss of the sense of reality; withdrawal of interest from the environment, with its consequent centering of self, leads to the next stage—that of the spoiled child reaction; then follows the exclusion of the world around in the dramatization of death; finally, in the deepest stupor, mentation is so far abandoned that we can gather no evidence of even this delusion being present.

Atypical features in stupor have to do mainly with interruptions, interludes as it were, of elation, anxiety or perplexity. These are explicable as awakenings from the nothingness of stupor into imaginations such as characterize the other manic-depressive psychoses. When such tendencies are present, the co-existence of the stupor process may tone down the emotional response or prevent its complete repression so that insufficient or dissociated affects appear. A combination of the stupor tendency to apathy with the mood of another reaction is probably the only combination of affects to be met with in psychiatry.

The stupor reaction, then, is a simple regression, with a limitation of energy, emotion and ideational content, the last being confined to notions of death. All functional psychoses are regressions. How do the others differ from this? We need only answer this question in so far as it concerns the clinical states resembling benign stupors. Stupors occur frequently in catatonic dementia praecox. In this disease there is a regression of interest to primitive fantastic thoughts, and with this a perversion of energy and emotion. This corrupts the purity of the stupor picture so that inconsistencies, such as empty giggling, atypical delusions and scattered speech, occur. Other impurities are to be found in the frequent orientation of the dementia praecox stupor patient which is discovered to be astonishingly good, or in free speech associated with apathy and inactivity. Such symptoms usually appear quite early and should enable one to make a positive diagnosis within a short time after patient comes under observation. As a matter of fact, in many if not most cases there is a slow onset characterized by the pathognomonic symptoms of dementia praecox before the actual stupor sets in.

Other psychoses superficially resembling stupor are the perplexity and absorbed manic (manic stupor) states. We have reason to believe that both these conditions are essentially the result of absorption in kaleidoscopic ideas. Their appearance is that of inactivity and indifference to the outside world, just as a dreamer seems placid and apathetic. But these reactions are not without emotion which may sometimes be obvious, and the richness of the mental content is sooner or later manifest.

Finally, from a practical standpoint, an important peculiarity of benign stupor is the tendency for response to stimulation in amelioration of the process. Close attention to these patients is advisable, therefore, not merely for the sake of their physical health, but also because any attention tends to keep them mentally alive or revive their waning energy. Visits of relations often initiate recovery in a striking way. From occurrences such as these, psychiatrists should gain hints for valuable therapeutic experiments.

So much for the technical, psychiatric aspects of the stupor problem. We have frequently spoken of it, however, as a psychobiological reaction. If this be a sound view, similar tendencies should appear in everyday life, the psychotic phenomena being merely the exaggerations of a fundamental type of human and animal behavior. Shamming of death in the face of danger and animal catalepsy come to mind at once, but since we know nothing of the associated affective states we should be chary of using them even as analogies. We are on safer ground in discussing problems of human psychology.

It is evident that there are psychological parallels between the stupor reaction and sleep, while future work may show physiological similarities as well. Apathy towards the environment, inactivity and a thinking disorder are common to both. But sleep reactions do not occur in bed alone. Weariness produces indifference, physical sluggishness, inattention and a mild thinking disorder such as are seen in partial stupors. The phenomena of the midday nap are strikingly like those of stupor. The individual who enjoys this faculty has a facility for retiring from the world psychologically and as a result of this psychic release is capable of renewed activity (analogous to post-stuporous hypomania) that cannot be the result of physiological repair, since the whole affair may last for only a few minutes.

In everyday life there are more protracted states where the comparison can also be made. When life fails to yield us what we want, we tend to become bored—a condition of apathy and inactivity, forming a nice parallel to stupor inasmuch as external reminders of reality and demands for activity are apt to call out irritability. A form of what is really mental disease, although not called insanity, is permanent boredom, a deterioration of interest, energy and even intelligence by which many troubled souls solve their problems. A sudden withdrawal from the world we call stupor. When the same thing happens insidiously, the condition is labeled according to the financial and social status of the victim. He is a bum, a loafer, a mendicant or, more politely, a disillusioned recluse. Frequently this undiagnosed dement has satisfied himself with a weak, cynical philosophy that life is not worth while.

It is but a step from valueless life to death and the same tendency which makes the patient fancy he is dead, leads the tired man to sleep, the poet to sigh in verse for dissolution, and the myth maker to fabricate rebirth. The religions of the world are full of this yearning, which reaches its purest expression in the belief and philosophy of Nirvana. The ideational content of stupor has also its analogue in crime. The desire for perpetuation of relationships unprosperous in this world is not seen only in the delusion of mutual death. One can hardly pick up a newspaper without reading of some unhappy man or woman who has slain a disillusioned lover and then committed suicide.

FOOTNOTES:

[12] Kirby, George H.: "The Catatonic Syndrome and Its Relation to Manic-Depressive Insanity." Jour. of Nervous and Mental Disease, Vol. XL, No. 11, 1913.



CHAPTER XV

THE LITERATURE OF STUPOR[C]

The cases of benign stupor which we report here are not clinical curiosities. Taking the symptoms as the products of a reaction type, the latter is really quite common. One, therefore, asks what other psychiatrists have done with this material. How have they described these stupors, how classified them? This chapter, essentially an appendix, attempts to give a brief answer to this inquiry. No attempt is made to catalogue all that has been written on or around this subject but only to mention typical reports and viewpoints.

The French, beginning with Pinel in the 18th Century, were the first to write extensively of stupor. An excellent paper by Dagonet[13] appeared in 1872, in which such literature as had appeared up to that time is discussed. He defines "Stupidity" as a form of insanity in which "delirious" ideas may or may not be present, which has for its characteristic symptoms a state of more or less manifest stupor and a greater or less incapacity to coordinate ideas, to elaborate sensations experienced and accomplish voluntary acts necessary for adaptation. This would seem to include our "partial stupor," as well as the more marked cases.

He quotes an excellent definition from Louyer Villermay (Dict. des sc. med. t. LIII, p. 67). "Stupor is a term applied to stupefaction of the brain. It is recognizable by the diminution or enfeeblement of internal sensation and by a greater difficulty in exercising memory, judgment and imagination. It is accompanied by a general numbness and a weakness of feeling and movement. The patient, then, has an indefinite and stupid expression, he understands questions put to him with difficulty, and answers them with effort or not at all. He seems overwhelmed with sleep, he forgets to withdraw his tongue after showing it to the doctor, he complains of no uncomfortable sensation, of no illness, he seems to take no interest in what goes on about him.... The stupor patient is a fool who does not speak, in this being more tolerable than the one who speaks [delightful naivete!]. One who is dumbfounded by surprise or fright is also to be called stuporous."

Dagonet says stupor results from various causes, such as exhaustion, or emotional and intellectual factors. Clinically it varies in kind and degree according to the situation in which it develops. When it develops during normal mental health, it disappears when its cause does. In insanity it appears in the course of a psychosis of some duration, of which it seems a part, an exaggeration of some symptom of the general condition. Evidently he views stupor as a type of reaction: as a more or less complete suspension of the operation of intellectual faculties, a more or less sudden subtraction of nervous forces. This reaction can result from a fright or the memory of it, a brain lesion or trauma, the action of narcotics, exhausting fevers, excessive grief, the terrors of alcoholic hallucinations, epileptic seizures, profound anemia and nervous exhaustion consequent on sexual excess. He is careful to say that both symptoms and treatment vary with the varied etiologies.

He credits Pinel with being the first to call attention to stupor. This author claimed that some persons with extreme sensibility could be so upset by any violent emotion as to have their faculties suspended or obliterated. He noted, too, that stupors frequently terminated in manic phases of 20 to 30 days' duration. Pinel also emphasized the apathy of these cases. Esquirol called stupor "acute dementia," a term which persisted in French literature for a long time. He described an interesting circular case where alternations between mania and typical stupor took place. He mentions too the dangerous, impulsive tendencies of many patients. Georget emphasized the fact which Pinel had also noted, that retrospectively the stupor patient says his mind was a blank during the attack. In 1835 Etoc-Demazy published on the subject. He regarded stupor not as a separate form of insanity but a complication ensuing on monomania or mania. He recognized the partial as well as complete stupor. He thought the condition was due to cerebral edema, as did other writers of that period. Dagonet remarks about this last—a lesson not learned in fifty years by the profession—that demonstrable edema does not produce the typical symptoms of stupor. Baillarger in 1843 (Annales Medico-psychologiques) was the first whose ambition to simplify psychiatric types led to denial of a separate kind of reaction. He claimed that stupor was not a form of insanity but an extension of a "delire melancholique." As Dagonet remarks, every symptom by which he characterizes stupor is a psychiatric symptom and insanity can consist just as well in the diminution as the perversion or exaltation of normal faculties. Some of Baillarger's cases had false ideas, some apparently none at all. Dagonet thinks this justifies two types, one a dream-like state and another where no ideas are present, although he admits one may be an exaggeration of the other. Brierre de Boismont (Annales Medico-psychologique, 1851, p. 442) compares these two kinds of stupors to deep sleep when intelligence is completely suspended and to sleep with dreams. (These two types would correspond to our "absorbed mania" and true deep stupor.) He urges strongly the separation of stupor from melancholia as an entirely different type of reaction, in this connection citing the views pro and con of various authors. Of these Delasiauve is particularly cogent in discriminating stupor from melancholia on the grounds of the difference of the emotional reactions and of the intellectual disorder and the real paucity of thought in the former psychosis.

After quoting these and other authors, Dagonet offers an explanation for the diversity of opinion. He says that stupor following another psychosis may retain some of its symptoms, so that a mixture obtains, as often in medicine. He then gives excellent descriptions of three types: the deep stupor with paralysis of the faculties, the cases that are absorbed in false ideas, and ecstatic cataleptics.

The remainder of his paper is concerned with cases and discussions about them. He cites examples of stupor following fear or other emotional shocks, following grave injuries such as the loss of a limb, following head trauma and with typhoid fever. As to the last he points out that delirious features are prominent. Many authors have assigned sexual excesses as a cause of stupor. The psychosis, Dagonet says, is not pure but more a mixture of hypochondria and depression. Relationship with mania is next considered. He says that stupor may succeed, alternate with or precede mania. His cases seem mainly to have been what we call absorbed manics or manic stupors. In fact, he uses the last term. The commonest introductory psychosis, he claims, is depression, but from his brief case reports it would seem that most of his patients were not stuporous, in the narrow sense of the term, but severely retarded depressions. In fact, in perusing his case material comprising "stupors" in the course of many types of functional insanity, or as a complication of epilepsy or general paralysis, it is evident that in practice he does not follow the discriminative definitions of the earlier portion of his paper. For him, apparently, patients who are markedly inaccessible to examination from whatever cause are "stuporous." He closes with excellent remarks on physical and psychic treatment. As to prognosis he has nothing to say beyond the opinion that most of the cases recover.

If Dagonet be accepted as summarizing the early French work, we can conclude that their generalizations were on the whole quite sound. These were: that stupor is an abnormal mental reaction, usually psychogenic but often the result of exhaustion, that it consists in a paralysis of emotion, will and intelligence; that the prognosis is usually good; that mental stimulation may produce recovery. What remained to be done after this work was the refinement in detail of these generalizations, particularly in respect to the differentiation of prognostically benign and malignant types. But other Frenchmen did not take up this work, apparently, for the brilliant psychopathologists of the next generations attended to stupor only in so far as it was hysterical.

An Englishman, however, soon took up the task, adding more exactness to his formulations. Newington[14] published his important paper in 1874. A nascent stage of stupor, he thinks, is a common reaction to great exhaustion, "such as hard mental work, prolonged or acute illness, dissipation, etc." Such conditions, like the grave psychotic forms, he regarded as due to physical exhaustion of the brain cells, but, since he thought psychic stress could produce this exhaustion, this "organic" view did not bias his general formulations. He makes a division into two stupors: Anergic Stupor and Delusional Stupor. The former may be primary, being generally caused by a sudden intense shock (Esquirol's "Acute Dementia"), or secondary (a) to convulsions of any kind, (b) to mania in women, (c) to any other prolonged nervous exhaustion. The delusional form results from (a) intense melancholia, (b) from general paralysis in which it may be intercurrent, (c) from epileptic seizures. When one examines his points of difference between these two types, it becomes clear that Newington really gave an excellent differentiation of benign and malignant stupor—in fact, it is the only serious attempt at such discrimination prior to this present work. What is more remarkable is the fact that, although he clearly saw the clinical differences, he failed to see that the two types differed prognostically. His description is given in a table sufficiently concise to justify its quotation in extenso.

ANERGIC STUPOR DELUSIONAL STUPOR

Etiology—Hereditary and Hereditary. individual liability to sudden loss of vis nervosa.

Onset—Rapid. Usually insidious, may be almost instantaneous.

Symptoms—Intellect greatly Conduct shows reasoning power. impaired.

Memory—Seems to be swept Found after recovery to have away as far as possible. been preserved to a great extent.

Emotional Capacity—Nil or Evidence of grief, fear, etc., in almost so. Tears frequent facial expressions and wringing but due to relaxation of and clasping of hands. sphincter muscles. Features Tears rare. Great contraction relaxed, eyes vacant and not of features [grimacing?]. constantly fixed. Eyes fixed on one point, usually upwards or downwards, or else obstinately closed.

Volition—Almost absent. Frequently great stubbornness, refusal to do what is wanted. On the other hand, intense determination in following out own plan.

Motor System—Weak and uncertain. But little interfered with, Patient has to be independently of sheer led about and if placed on a asthenia, produced by seat or in some position does patient's conduct. May stand not move. ("Cataleptoid" behind door or kneel on floor condition.) in constrained position even for days.

Sensory System}—Both dull. Ditto. There seems to be a Reflex System } much greater ability to bear severe pain.

Pupils—Dilated. Tendency to contraction.

Sleep—Generally good. Intense sleeplessness.

General bodily condition— Affected pari passu with Emaciation, sometimes extreme, mental state and seems usually rapid, with governed by it. rapid recovery of flesh. Often not much loss of weight, though whole tone is lowered.

Vascular System—Pulse slow, Pulse weak and often quick sometimes almost imperceptible. and thready. Complexion Cyanotic appearance, edema anemic and sallow. The and iciness of extremities. other appearances may be Great decrease of vitality present but come on later in peripheral structures, and are less marked. as shown by asthenic eruptions and production of vermin.

Digestive System—Tongue Tongue dry, small and furred. clean or if furred it is moist. Refusal of food. Great Appetite apathetic, bowels constipation. Dirtiness of not irregular, but habits habits rare. very dirty.

If one compares these data with those given in the chapter on Malignant Stupors, it is seen that in the main Newington has made the same discrimination as we have. He is certainly wrong in denying "negativism" to his anergic type. Probably, too, he attempts too fine a distinction between the physical symptoms of the two groups. His conclusions are interesting: that in the anergic cases there is an absence of cerebration, while amongst the delusional there is an abnormal presence of intense but perverted cerebration. This is not unlike our own view. He thinks the difference in memory is the most important differential point. Sex is important in determining the nature of the stupor, for he found the anergic type following mania in females only. He observed such an end to manic attacks in 6 out of 36 cases. All his cases were under 30 and he regards the prognosis as good on the whole. As to treatment he emphasizes the necessity for "moral pressure" as a stimulus and cites a case of rapid improvement after a change of scene.

Since 1874 very little advance has been made by British psychiatrists, as seen by a perusal of Clouston's[15] summary in 1904. He regards sex exhaustion as a highly frequent cause, although Dagonet had shown 32 years before that sex abuse does not produce a true stupor. He thinks stupor usually follows depression or mania and says that "the 'Confusional Insanity' of German and American authors is just a lesser degree of stupor." Omitting his stupors in general paralysis and epilepsy he makes three clinical divisions: melancholic or conscious stupor, which is not a product of delusions, although delusions of death or great wickedness may be present, impulsiveness and fits may be observed; anergic or unconscious stupor, which corresponds roughly to our deep, benign stupor; and secondary stupor after acute mental disease, which resembles our partial stupor. He warns against a rash diagnosis of dementia in this last group. His views on the importance of mental causation and the relation to manic-depressive insanity may be gathered from these sentences: "The condition of the mental portion of the convolutions in stupor is probably analogous to the stupidity of a nervous child when terrified or bullied." "Stupor is frequently one of the stages of alternating insanity following the exalted condition. It is more apt to occur in those where the exalted period is acutely maniacal. The stupor is usually melancholic in form." Since he claims that the anergic is a "very curable form of mental disease," while only 50% of the melancholic cases recover, it seems clear that this division is not prognostically final. The "melancholic" is evidently Newington's "delusional" without his more accurate discrimination of symptoms.