Chapter 10

SPECIAL CASES: RELATIONSHIP OF STUPOR TO OTHER REACTIONS

We have described typical cases of benign stupor and isolated certain interrelated symptoms which, when they dominate the clinical picture, we believe establish the diagnosis of stupor, regardless of the severity of the reaction. These symptoms are apathy, inactivity, a thinking disorder and, quite as important as these, an absorbing interest in death. It is typical that the patient contemplates his dissolution with indifference or, at most, with mild or sporadic anxiety. There seems little reason to doubt that when these four symptoms occur alone, we are justified in making a diagnosis of stupor. The next problem is to consider the meaning and classification of cases where these symptoms occur in conjunction with others. This naturally introduces the subject of relationship of stupor to other manic-depressive reactions.

It is probably best to begin with presentation of three such cases.

CASE 16.--_Anna L._ Age: 24. Admitted to the Psychiatric Institute August 21, 1916.

_F. H._ Maternal grandmother temporarily insane during illegitimate pregnancy, thereafter a little odd. Mother high strung and emotional. Father high strung, impulsive and irritable.

_P. H._ As a child she was quick tempered, quite a spitfire and given to tantrums. At the age of 14 she became a vaudeville actress in Cleveland, which was the home of her childhood. When 17 she married a Jew, although she was herself a Catholic. Her husband noted that she was fretful, sensitive, resentful and quick tempered, although apt to recover quickly from her rages. Previously healthy, neurotic symptoms began with marriage, taking the form of stomach trouble and a tendency to fatigue. Shortly after marriage an abortion was induced. After being married for two years she had a quarrel and separated from her husband. They were reconciled later, but in the meantime she had been having relations with another man. When 20 an abdominal operation was performed in the hope of relieving her gastric symptoms, but no improvement occurred. The patient after recovery stated that she continued to be nervous, shaky and dizzy, at times trembling when going to bed at night. Two years later, however, she took up Christian Science and showed objectively some improvement in her health, although according to her later accounts she continued to feel somewhat nervous and fatigable. Her husband stated that at this time she also began to ponder much about such questions as the difference between life and death, what “matter” was, and also studied “grammar” and “etiquette.” According to the patient some five or six months before admission she began to have peculiar sensations following intercourse--a feeling of bulging in the arms, legs and back of the neck. One evening after an automobile ride there were peculiar sensations on her right side like “electricity” or as if she were inhaling an anesthetic. She gasped and thought she was dying. Two months before her admission she went with her husband and his family to a summer resort where she felt increasingly what had always been a trouble to her, namely, the nagging of this family.

Just before her breakdown, because she went daily to the Christian Science rooms in order to avoid the family, they suspected her of immorality and accused her of going to meet other men. Even her husband began to question her motive. Retrospectively the patient herself said that she now felt she was losing her mind and did not wish to talk to any one. At the time she told her husband that she felt confused and as if she were guilty of something and being condemned. Repeatedly she said she knew she was going to get the family into a lot of trouble. Once she spoke of suicide, and for a while felt as if she were dying. Finally she became excited and shouted so much that she was taken to the _Observation Pavilion_, where she was described as being restless and noisy, thinking that she was to be burned up and that she had been in a fire and was afraid to go back.

_On admission_ she looked weary and seemed drowsy. Questions had to be repeated impressively before replies could be obtained, when she would rouse herself out of this drowsy state. She seemed placid and apathetic. She said that nothing was the matter, but soon admitted that she had not been well, first saying that her trouble was physical and then agreeing that it had been mental. When asked whether she was happy or sad, she said “happy,” but gave objectively no evidence of elation. Her orientation was defective. She spoke of being in New York and on Blackwell’s Island, but could not describe what sort of place she was in, saying merely that it was “a good place,” or “a nice country place,” again “a good city.” Once when immediately after her name L. had been spoken and she was asked what the place was, she said “The L.” She knew that she had arrived in the hospital that day but said that she had come from Cleveland, and to further questions, that she had come by train, but she could not tell how she reached the Island. She claimed not to know what the month was and guessed that the season was either spring or autumn (August). She gave the year as 1917, called the doctor “a mentalist,” and the stenographer “a tapper,” or “a mental tapper.” She twice said she was single. When asked directly who took care of her, said “Mr. Marconi,” who she claimed at another time had brought her to the hospital. To the question, who is he? she replied, “Wireless,” and could not be made to explain further. That night she urinated in her bed, and later lay quite limp, again held her legs very tense.

For five days she remained lying quietly in bed for the most part, although once she called out “Come in, I am here,” “Jimmie, Jimmie” (husband’s name). Several times she threw her bed clothes off. Otherwise she made no attempt to speak and took insufficient food unless spoon-fed. At one examination she looked up rather dreamily but did not answer. When shaken she breathed more quickly and seemed about to cry but made no effort to speak. When left to herself she closed her eyes and did not stir when told she could go back to the ward. She was then lifted out of her chair and took a step or two and stopped. Such urging had to be repeated, as she would continue to remain standing, looking about dreamily, although finally when taken hold of she whimpered. When she got to the dining-table she put her hand in the soup and then looked at it. So far there is nothing in this case atypical of what we would call a partial stupor. The cardinal symptoms of apathy, inactivity, with a thinking disorder, are all present and dominate the clinical picture. There is, further, the history of a delusion of death during the onset of the psychosis. Had her condition remained like this, there would be no difficulty in classifying the case, but other symptoms appeared.

Five days after admission she was restless, somewhat distressed, and announced that she wanted to talk to the physician. When examined, the distress, with some whimpering, continued. She asked the doctor not to be harsh to her, frequently said there was something wrong and began to cry. A normal interest appeared only once, when she spontaneously said she wanted to see her relatives. A most interesting feature, however, was a certain perplexity that now appeared. She spoke of this directly: “I do not know what it is all about. I know you are a doctor, that is all. I don’t know whether I passed out and came back again or what--I don’t know what to make of it.” She also felt confused about her marriage--“There is where all the mixup is. I was married when I was 16.” She was reminded that she had said she was single, and replied “I am single.” Then where is your husband? she was asked. “He must be dead.” She recalled the examination on admission and remembered some of the questions that she was asked then, also knew that she had been at the Observation Pavilion and that she had reached this hospital by boat. On the other hand she still claimed that the year was 1917, and in connection with the delusion of having died was quite unclear as to the time. She said that it seemed as if she had died many years ago and that she had come to the hospital years ago. She also spoke of having died at a summer resort the year before. When asked for her age, she said that she must be very old, but on the other hand claimed that she was supposed to die and to come to the hospital when she was 26 (two years more than her actual age).

Her psychosis continued from then on for about ten weeks. She soon began to feed herself, but otherwise for most of this period remained quietly in bed, looking about a good deal, although showing no particular mood reaction until questioned, when she was apt to make repeated statements about her perplexity--that she did not know what it was all about, every one had mixed her up, everything was so strange, “my head is mixed up, I am trying to straighten things up.” She frequently when interviewed became lachrymose and often with her subjective confusion there was considerable anxiety. Another unusual phenomenon for a stupor patient was that she was frightened at a thunder storm. On the whole, however, her apathy and indifference were quite marked. For instance, during the latest phase of her psychosis, when the nurses would sometimes make her dance with them, she did so but without showing any interest and not until immediately before her recovery did she begin to speak spontaneously to any extent whatever. A marked difference from the ordinary stupor was that this apathy was invariably broken into when she was questioned and ideas came to her mind, the nature of which seemed to be essentially connected with her perplexity.

Not only did ideas appear more frequently than one meets them in stupor cases, but they were present in greater variety. The dominant stupor death idea was, it is true, almost constantly present, but it did not come to the direct and unequivocal expression which we are accustomed to see in typical stupor. She did not say “I am dead,” or “I was dead,” but it was always “It seems as if I were dead,” or “I think I must have died,” or some such dubious statement. Other ideas were that her mother was dead and had been put into a box. She frequently gave her maiden name and said that she lived in Cleveland with her mother and that this was Cleveland. At times she thought she was engaged and was going to be married to her husband shortly. Again there were notions that her husband had married somebody else or that some harm was going to come to him. Sometimes she thought that her mother’s name was her own, that is, Mrs. L. The hospital once seemed like a convent to her.

Her subjective and objective confusion seemed quite definitely to be connected with the insecurity and changeability of these ideas. It appeared as if insight and delusion were struggling for mastery in her mind, so that reality and fancy were alternately, even simultaneously, possessing her, and that this gave her the feeling of perplexity from which she suffered. Once when she remarked “It seems as if I had been dead all the time,” she was questioned more about this and replied, “Well, sometimes I thought I was dead, at other times it seemed as if I wasn’t.” In answer to a direct question about her feeling of confusion she said “I don’t know. I know I have lots of good friends, they all want to help me and it seems as if everything got mixed up between the L.’s (her married name) and the G.’s (her maiden name).” This was apparently an elaboration of the wavering ideas she had about her singleness or her married state. Once after referring to her husband as her sweetheart whom she was to marry, and immediately thinking that perhaps he had married somebody else, she added, with a sigh, “The more this goes on, the more mixup.” In short, any question, even on some apparently neutral topic, seemed to start up conflicting ideas in her mind, the inconsistency of which she recognized without being able to control their appearance. Hence, whenever she was spoken to, she became perplexed and distressed.

Her orientation gradually improved so that, although it remained vague, it was no longer glaringly inaccurate. Then quite suddenly she one day came to a nurse and asked how long she had been in the hospital. When told, she remarked that it seemed as if she had spent the whole winter there. She was examined at once and found to be quite clear and at first in good control of her faculties. She remembered a good many of her ideas, in fact was able to elaborate a little from memory on what had already been reported from her utterances during the psychosis. The recovery was not immediately complete, however, for at this examination, when told that she had constantly given her maiden name, she became distressed and said the physician was trying to mix her up and was reluctant for this reason to discuss her ideas. This soon passed, however, and within a few days she was quite normal and had remained so for some months after her discharge from the hospital, when last seen. In fact, according to the husband, she was in better mental and physical health following the psychosis than she had been for years.

Essentially, then, this case shows what was at first a typical partial stupor, but soon became complicated by a tendency for questioning to provoke rather a free flow of ideas and a distressed perplexity. This symptom of perplexity soon grew to dominate the clinical picture, so that the psychosis was really a perplexity ushered in by a brief stupor reaction with a background of stupor symptoms running through it. The second case shows similar tendencies but different from the one whose history has just been cited in that the perplexity was never complained of by the patient herself and that her emotional reactions were more marked and varied.

CASE 17.--_Celia C._ Age: 18. Admitted to the Psychiatric Institute May 2, 1914.

_F. H._ Four years after this attack her mother was a patient in the hospital with an atypical manic-depressive psychosis from which she apparently recovered.

_P. H._ The patient herself was described by superficial observers as being bright, sociable, well-informed and very ambitious.

When 18 years of age she was working very hard preparing for some examinations, and worried lest she should fail in them. Some years later the patient accounted for her psychosis by saying she had a quarrel with her sister, immediately after which she began to feel depressed. The anamnesis states that she was slow, complained of not being able to think and feeling as if she had no brain. She was sent to a general hospital, where she was apprehensive, wanted her mother to stay with her and one night called out “Mother.”

The case being recognized after a few days as a psychosis, she was sent to the _Observation Pavilion_, where she was described as jumping about in bed in a jerky, purposeless manner, resistive when anything was done for her, and mute. Her sister reported that when she visited her the patient said “Go away, I am dead.”

_On admission_ she looked dazed, stared vacantly and had a tendency to draw the sheet over her. When put on her feet she let herself fall limply. At times she became agitated, sobbed and cried loudly, especially when attempts were made to examine her physically, or, when she was asked questions, she scarcely spoke.

Her psychosis lasted but a little more than three months under observation and was characterized by the following symptoms: She was usually in bed, staring blankly or appearing otherwise quite indifferent and apathetic, but not infrequently, especially during the first few weeks, she was quite restless, resistive, whined and suddenly appeared startled or distressed with no occasion for this reaction in the environment. Rarely she was suddenly assaultive. When attempts were made to examine her, she was frequently mute or would repeat the question with a rising inflection, not getting anywhere, or would say, “What shall I say,” or “I, I----” never finishing her sentence. After orientation questions she might say “This is--this is--this is----” all this, together with a rather perplexed appearance, gave the impression of considerable bewilderment, but at no time did she complain of autopsychic perplexity. It was difficult to judge of her orientation on account of her failure to answer questions, but it soon appeared that she knew the names of the nurses, for she sometimes called them spontaneously by name. She always ate reluctantly.

During these examinations, however, other symptoms often appeared. When she was talked to, she was apt to indulge in depressive statements and show considerable distress. Such remarks were: “I must confess my guilt,” “I am a bad girl and I have to face my guilt,” or “I have sinned,” or, standing up with a dramatic air, “I must stand up and tell the truth.” Once she said, “It is too late to live now.” She spoke of having lied and usually would not say what about, but once on questioning replied “I said I would not tell what happened here.” She was asked, What do you mean? and answered “I took my oath not to tell anything.” Pressed further she said that the nurses poisoned her. Another time she said she was in prison. To her aunt who visited her she said, “I am a prostitute,” and once she remarked to the doctor, “I have killed my honor,” and on another occasion in the middle of the night she called out, “Chinatown Charlie, come here.” She thought the doctor was her brother.

Most of these statements were associated with painful emotion, but there were a few occasions when an element of elation cropped out. Thus on one occasion she laughed, another time gripped the doctor’s pad and tried to read it. When the nurse laughed, she made a funny grimace at her and said “Why do you laugh?” Again she once sang two songs, but after the first verse got stuck and kept repeating one word.

At the end of three months she improved rather rapidly and was in a condition for discharge as “recovered” a month later. Retrospectively she said that she recalled feeling guilty, thinking that her mother was dead, having been killed by the patient as a result of worrying over the latter’s failure in her examinations and refusal to eat. She remembered, too, that at times she thought the building was burning. Some things like “Chinatown Charlie” she denied remembering, although she had a good recollection for the external facts throughout the psychosis. Her insight was superficially good, but she was reluctant to discuss her psychosis, in fact claimed that she had been made more of a lunatic by coming to the hospital than she was on admission.

Some five years later she had another somewhat similar attack, again following a quarrel, this time with a fellow employee. In this second psychosis, however, manic elements were much more prominent.

Here again, then, we have the symptoms of apparent apathy, inactivity, and similar ideas of death, but the thinking disorder was possibly not very profound, inasmuch as she had a good memory for external events. Her ideas, too, are much more florid than those which we customarily meet with in stupor cases, but the most marked peculiarity was that this “stupor” was liable to constant interruption, either spontaneously or as a result of questioning, which always produced a mood reaction. She was apathetic only so long as she was left alone. In other words, whenever an effort was made to test what seemed to be apathy, the evidences of it disappeared.

The third case to be considered is somewhat like that of the first, Anna L. (Case 16), in that with the inactivity and apathy there was a coincident subjective perplexity. The apathy, however, was less marked than in the case of Annie L.

CASE 18.--_Catherine M._ Age: 24. Admitted to the Psychiatric Institute November 10, 1913.

_F. H._ Information as to the family is confined to the two parents. The mother, who was frequently seen, seemed to be a natural, sensible woman. The father, on the other hand, had been alcoholic all his life, had had two convulsions while drinking, and had little respect from any member of the family, including the patient.

_P. H._ The patient was said always to have been healthy, from a physical standpoint, although never robust. She got on well at school, and then worked first as a stock girl and later as clerk in a department store, where her work was efficient and she advanced steadily. As a child she played freely with other girls but little with boys. As she grew older she moved about socially a little more, made the acquaintance of men as well as of girls, but never cared much for the former and had no love affairs until she met her husband. She was never demonstrative but always rather quiet and modest. Occasionally she spoke of thinking that people talked about her, but the informant doubted if she brooded over this, because she was not of a worrying disposition. Considering the ideas which appeared in her psychosis, it is striking that in her normal life she was rather antagonistic towards her father on account of his alcoholism and the crudity of his speech and manners.

When she met her husband she liked him from the first, although she at no time became really demonstrative. They were engaged for a year, during which time she agreed to a postponement of three months for the marriage, which was suggested by her mother. For some time before this event she was working harder than usual and seemed a bit worn out. She ceased working a month before marriage and improved physically, although she became rather nervous, that is, she was more easily startled, an accentuation of what had been a characteristic for some years. Her husband stated that at this time she became fearful of the approaching marriage relations and asked him to be kind to her in this respect. She was married a year before admission. For two and a half months she refused intercourse and visited her mother’s home a great deal. She finally submitted. She was quite frigid but became pregnant at once. Her abnormality then became apparent. She kept the fact of her pregnancy to herself for several months and then when she told her mother wanted to have an abortion performed. Neurotic symptoms appeared. She became sensitive with her husband, correcting his grammar, and cried easily. She also began to be anxious about the approaching childbirth, and with this became more religious.

For the first few days after the delivery, she was fussy with the nurse so that two in succession had to be discharged. On the fifth day she woke up and seeing a nurse lying on the couch beside her bed thought the latter was colored. On the seventh day she had a dream in which she thought she “nearly died in childbirth.” Then she began to talk of dying for her baby or of having two babies, of dying herself and rising again after Easter Sunday. She became antagonistic to her husband and with this excited and confused so that she was taken to the Observation Pavilion.

On _admission_ she looked pale and exhausted, had a slight temporary fever and a coated tongue. Her orientation was usually vague but sometimes she gave fair answers. Her verbal productions were rather fragmentary and with the exception of some repetitions there did not seem to be any special topics which dominated her train of thought.

For some days the great weakness and the slight fever continued, and then, as it gradually cleared up, there came a change in her mental condition that settled into the state which characterized the rest of her psychosis. She talked less and was often quite inactive, frequently lying with her eyes closed for long periods, or sat or stood about. Such movements as she made were slow and languid. Her expression was either blank, absorbed, or gave the appearance of peculiar appealing perplexity. This last was not infrequently associated with a rather sheepish smile. She was never resistive and always ate and slept well. With the exception of a few times she did not soil herself. The most interesting feature of her mood reaction was that in a general setting of a slight perplexity there appeared at times and evidently associated with definite ideas, changes in her emotional state. Sometimes this was a matter of distress or of mild ecstasy, sometimes she became markedly blocked. There was at no time any frank elation, but often an appropriate smile, that is, appropriate to the situation and to the thought to which she was giving expression at the time. Then, rarely, there were sudden bursts of peculiar conduct, such as throwing herself on the floor or running down the hall. When questioned as to her motive for these acts, she would flush, look perplexed and apparently be unable to explain them.

Her verbal productions dealt with a rather limited range of topics which can be briefly summarized. As in the other cases, the reader will notice that the bulk of these ideas are of a kind not usually prominent in the typical stupor cases. Many of her thoughts seemed centered around her husband. She always knew him when he visited her, but in her thoughts there was a constant change as to his personality. She persistently confused him with the physicians, with her father, and with God, and one remark is typical, “I thought he was God, priest, doctor, lawyer--well, I wanted to go to Heaven; I thought he would still be my husband; I always hoped that I would be home in Heaven.” Not unnaturally with this confusion there were doubts about her marriage. People said her marriage was wrong and her husband bad. Frequently she thought he was dead, or voices informed her that she was not married to him, or that he was the devil in Hell. In this connection she also said that people called her a whore, or it seemed as if she were accused of not being married.

As prominently as appeared the ideas of the invalidity or impossibility of her marriage, to the same extent did her father assume an important rôle for her. As a rule he appeared in religious guise as God, but often he was the doctor--“I knew my father at home and my father in Heaven; which God do you mean? did you say God or father?” At times she spoke of being in Heaven and that God seemed to be God, doctor or priest. In this connection there were ideas of being under the power of some one, God, devil or father.

As is usually the case where strong interest is expressed in the father, ideas of the mother being dead occurred, although in the frankest form she reported them as dreams; for instance, one night she woke up screaming, said that she had dreamed that her mother was dead and her sister dying. That, in the psychoanalytic sense, this represented a removal of a rival, making union with her father easy, appeared in the statement that her father was dead but that she had dreamed he had come to life again for some one else. When asked what she meant, the question had to be repeated several times, then she said “My mother died, my father and mother had a quarrel.” There is more than a suggestion here of a difference in the significance of death, in so far as it concerned the two parents. The mother dies and remains dead, that is, she is gotten rid of. The father dies but takes on a spiritual existence and comes to life again, a frequent method in psychoses for legitimizing the idea of union with the parent by elimination of the grossly physical.

There were strikingly few allusions to the plainly sexual. She spoke of being married to the doctor, and even went so far as to say that they belonged together in bed. On another occasion she called him “darling.” Once she reported that it was said that she was going to have babies and babies and babies. These references were, however, quite isolated, so that the erotic formed a very small part of her productions.

Delusions of death, we have seen, are the most constant content of true stupors. In this case they were present but distinctly in the background. She spoke quite frequently of being in Heaven. She also talked of being crucified. Once she said “I died but I came back again.” This last utterance was rather significant in that frankly accepted ideas of death were unusual; for instance, she would say sometimes, “I think I am in Heaven, again not. It confuses me, but I know I am in Heaven.”

In general, then, her ideas were, on the whole, not at all typical of stupor but much more like those met with in other manic-depressive conditions. Correlated with this was an unusual mood picture. Quietness and apparent apathy of the patient were interrupted by little bursts of emotion, and throughout the psychosis there was a coloring of perplexity. Not only was this last objectively noticeable, but she spoke very frequently of it and always in connection with the inconsistency of the ideas in her mind which puzzled her. For instance, in speaking to the doctor she said “I think of you as Bill (her husband’s name) sometimes--I get confused thinking of Bill as God, doctor, lawyer, priest.” Again, referring to her husband, she made these curious statements: “They seemed to speak of him as being in the wrong--the right--it seems that the right devil is the wrong one for me--they say he is not the right one for me; they say he went wrong from the time we were married.” Again, she said that she did not know who her father was, and went on: “It puzzles me, this father business, I knew my father at home and my father in Heaven.” Again, “Which God do you mean? Did you say God or father?” A hint as to how this subjective confusion made the environment seem uncertain comes from the statement, “You looked like the devil and yet you were God.”

Distress and anxiety appeared not infrequently and always appropriately. The distress was usually occasioned by an idea of injury to others, as when she cried over the fancied accusation of drowning her husband and mother; or in connection with accusations of herself, such as when she reported “They called me a whore.” As has been stated, there was never any frank elation, but an element of pleasurable expansive emotion was frequently present in connection with her religious utterances. This came particularly when she spoke of union with her father as God. She seemed to swell with ecstatic emotion. It was especially well marked once when she threw herself on the floor and when asked what she was trying to do replied, “I want to do what God wants me to do, drop dead or anything at all.” Perhaps the most unusual affective reaction was a blocking which occurred when certain topics appeared. This is a phenomenon quite unusual for stupor, where speech seems to stimulate and arouse the patient as a rule. One got the impression that ideas tended to come into this patient’s mind which were painful enough to disturb her capacity for connected thought. A good example of this reaction was when she was speaking of her father having died and coming to life again. On being asked what she meant, she became quite blocked and the question had to be repeated several times, when finally the apparently unrelated statements appeared: “I dreamed my mother died--they had a quarrel.” Who had a quarrel? she was asked, and replied “My mother and father.” Apparently her thinking about her father coming to life for some one not her mother stimulated deeply unconscious ideas concerning the separation of her mother and father, and her taking the mother’s place, and these ideas were sufficiently revolutionary to upset her capacity of speech for the time being.

She recovered completely about six and a half months after her admission.

If we consider together the common features of these three cases, we see that they resemble stupors only in the presence of inactivity and apparent apathy. It is true that death appears in the ideational content but not with that prominence, bordering on exclusiveness, which characterizes such delusions in the true stupors. These three patients give one the impression of being absorbed in thoughts that have many variations. It seems as if they had difficulty in grasping the facts of the environment, while feeling at the same time the vividness of the changing internal thoughts, hence a confusion develops which is either subjective, objective, or both. It is probably the introversion of attention which gives rise to the apparent apathy, because normal emotions emerge as part of our contact with reality around us. This lack of contact with the environment leads also to inactivity. If one’s attention and interest is turned inwards, there can be no evidence of mental energy exhibited until the patient is roused to contact with the people or things about him. It is noteworthy that in these cases emotional expression emerged when the patients were stimulated to some productiveness in speech.

These conditions really constitute a different psychosis in the manic-depressive group, essentially they are perplexity states such as have recently been described by Hoch and Kirby.[7] Not infrequently we see exhibitions of this tendency in what are otherwise typical stupors. For example, Mary F. (Case 3) (the third case to be described in the first chapter), showed for a few days after admission a condition when she was essentially somewhat restless in a deliberate aimless way. At the same time she looked dazed or dreamy. With this restlessness she appeared at times “a little apprehensive.” Although she spoke slowly, with initial difficulty she answered quite a number of questions. Her larval perplexity was evidenced by the doubt expressed in a good many of her utterances, such as, “Have I done something?” “Do people want something?” “I have done damage to the city, didn’t I?” When asked what she had done, she said, “I don’t know.” She asked the physician, “Are you my brother?” and when questioned for her orientation said, “Is not this a hospital?” The atmosphere of perplexity also colored the information which she did recall correctly; for instance, when asked her address, she said, “Didn’t I live at ----?” then giving the address correctly.

As stated in Chapter V dealing with the ideational content of stupor, one has to look on the delusions of patients as symptoms subject to analysis and classification just as truly as the variations in mood or intellectual processes, in fact they should be subject to the same correlation as are the mental anomalies which are usually studied, particularly if we are to understand these psychoses as a whole. Let us, therefore, consider the death ideas in the three cases studied in this chapter. We find that, as in the ordinary stupors, there are delusions of death, also of mutual death (with the father), but there is a tendency to elaboration so that the death is only part of a larger Œdipus drama, the rest of which is usually lacking in stupors. Here it is present. So we have thoughts of the death of the mother or husband, another rival, considerable preoccupation with Heaven, and also erotic fancies.

We find in manic-depressive insanity a tendency for more or less specific ideational contents with different types of the psychoses.[8] For example, there are religious and erotic fancies or ambitious schemes dominating the thoughts of manic patients, fears of aggression and injury met with in anxiety cases, and so on. In stupors, death seems to be a state of non-existence with other meanings lacking or only hinted at occasionally. When it tends to be elaborated, it leads over to formulations suggesting personal attachments and emotional outlet, and then we are apt to find interruptions of the pure stupor picture. For example, Charlotte W. (Case 12), whose case has been described, thought much about being in Heaven and ended with a hypomanic state. Atypical symptoms appear just as constantly in these cases, as do the atypical ideas. In other words, the thought content is definitely correlated with the clinical picture.

As the clinical pictures show the relationship of stupor to other psychoses, so there is also a correlation with varying formulations of the death fancy. We are now in a position to define more narrowly what death means in stupor. It is an accepted fact, a Nirvana state. When death means union with God or appears in other religious guise, manic symptoms tend to develop. When it is unwelcome and appears as “being killed,” we find anxiety symptoms. A patient can conceive of death variously and have various clinical pictures. A knowledge of the metamorphoses of ideas and their relationship to other symptoms enables us to understand such cases, that, without this key, seem confused and lawless jumbles of symptoms. Such theories tend to justify the view of essential unity of the manic-depressive group.

It would be instructive at this point to consider another case which illustrates beautifully how a stupor reaction may crystallize out of other manic-depressive states when attention has become focused on personal death. This patient went through four phases while under observation. First, while showing a perplexed expression but with fair orientation, she gave utterance to erotic and expansive fancies. She was restless, somewhat intractable and gave the impression of brooding over her imaginations rather than luxuriating in them. In other words, her condition seemed to be more that of absorbed than active mania. Second, these same ideas, somewhat reduced, continued in an apathetic state while impulsive symptoms developed: She began to shout like a huckster to be taken to Heaven and made numerous affectless, suicidal attempts. Third, came a true stupor and, fourth, a period of recovery when the stupor symptoms all disappeared but insight into the falsity of her ideas was lacking.

CASE 19.--_Celia H._ Age: 19. Admitted to the Psychiatric Institute October 22, 1913.

_F. H._ The father was living; he always drank, and especially in later years contributed little to the support of the family. The mother was living and said to be normal, while a brother was coincidentally insane, with a recoverable psychosis.

_P. H._ The mother stated that the patient was bright at school, enjoyed company and going out, had a droll wit, was not at all seclusive, no dreamer, helped to support the family and was efficient. She was very much attached to her brother and once said that if anything should ever happen to him she thought she would die. She also cared much for her older sister, with whom she worked, and for her mother.

Three months before the patient’s admission her brother became depressed, mute, seemed worried, cried at times. He was sent to the country. Two months before admission, when the mother and the patient went to bring the brother to town, and while they were at the station, he suddenly tried to throw himself under a train but was restrained just in time. The patient appeared intensely frightened, but did not talk. In fact, she seemed somewhat bewildered and at once became dull. “Her movement and manner were much as at present.”

When the patient was able later to give a retrospective account of the onset, she claimed that for some months before this incident she saw that her brother was losing his mind. She worried about this as well as about her work, and felt worn out. She said that when the brother tried to throw himself under the train she was terrified and could not speak or move, and that her mind got upset at once, “I lost my memory.” The others forgot her and left her alone on the platform. Strangers put her on another train and she knew nothing until she arrived at home.

The mother added that at the time when the incident with the brother happened, the patient was menstruating and that this ceased at once.

At home she sat about inactive and did not seem even to worry. Whenever any one asked her about her brother she replied that he was dead. For two weeks before admission she said she was rich, that she owned all the property around. She also said she was married to Mattie S. In this connection the mother says that a foolish neighborwoman, the mother of Mattie S., told the patient since her sickness, by way of encouragement, that she should marry her son (the man mentioned). Finally, the patient also expressed the idea that her mother was a stranger, that her real mother was dead.

At the _Observation Pavilion_ she was described as wandering about in a perplexed manner, restless, resistive, answering few questions and in a low tone. She said things were “changed,” also that she was married to S.

_Under Observation:_ 1. For about ten days the patient’s condition may be described as follows: The most striking feature was a certain restlessness with insistence on going out, with complaints that this and that had been done to her and with senseless struggling when interfered with. But all the motions were slow, the whole restlessness aimless and impulsive. Although the facial expression was somewhat perplexed, it changed remarkably little, and whenever asked whether she felt worried or anxious she denied it, and, indeed, there was only a suggestion of perplexity in her face.

The ideas which she expressed during this time referred to a few topics only, namely, marriage, wealth, and State prison. The remarkable fact was that all the ideas about marriage and wealth were spoken of, often immediately, again after some interval, now in the positive and again in the negative sense. Thus she said she was “Mrs. S.,” again “You kept me from marrying Mattie S.,” or “I am not supposed to be here--I am a married person,” but also “You kept me from getting married.” Or, “Take off that black dress, I am a bride,” again “You have taken my bridal crown off my head,” “The steamboats (seen from the window) are mine--I own the ships, the oceans, the land and everything,” or again, she said she owned a kingdom, was Sh.’s wife, a wealthy woman, had millions. Sometimes she connected the millions with Sh. “Sh. has millions.” On the other hand, she said: “I owned all this before I came. I have nothing now,” or “You have taken the regal crown from me,” “You have made a pauper of me,” “They did it again, they took my millions away,” or “Let me out, they are taking my millions.”

Other ideas throughout this period were that this was a State prison, that “bums” were around. On one occasion she said “You can’t put down all these things and make me out a lunatic.” At another time she pulled a patient’s hair and then said without fun: “I fixed the leading lady of the dump--she knows a lot, but she does not know enough to keep her soup cool.” When questioned about this woman (who at the time while cleaning had moved the furniture), she said: “I don’t know where I am at.”

The orientation during these days was not markedly disordered, when one got down to it. Although she spoke of State prison, it was always found she knew the name and the location of the hospital, the names of people around her, even the date approximately, though she was apt to say it was February 19, 1492, or October 19, 1492, or when the year was not given as 1492 she said it was “1900 or 1901, or 1911 or 1912.” Frequently, however, it was hard to hold her attention.

Finally, it should be mentioned that she very often wet herself in bed or when standing, even when standing in the examining room.

2. The period following and lasting for two months may be given in the form of abstracts of each note.

_November 7:_ Yesterday quiet, though struggling. Says without change of expression, “I saw four people killed--my mother, my brother, a priest, and my dear sister--we were all killed.” Again, “I don’t know where I am,” “I am an orphan, my people died” (without affect).

_November 20:_ More quiet recently, says little, but tries to get out when brought to the examining room, but when not prevented walks slowly about as before, says she wants to go home. Looks peculiarly blank.

_November 23:_ Has remained quiet, says she is Dr. M.’s wife. But when told she is not married, she agrees. Her attitude towards the doctor is not changed, but when the nurses talk to him, she has tried to prevent it.

_December 6:_ Has remained quietly in bed, gazing about. Slow in motion. She has spoken of being Dr. M.’s wife, again President Wilson’s wife, again “Vincent (brother) is the ruler of the world.”

At interview says little, seems abstracted, answers briefly in low tone. (Does anything bother you?) “No.” (Are you natural?) “Yes.” (Who are you?) “C. H.” (correct). (You said you were the President’s wife?) “No.” (Are you married?) “No.” (You talked about the kingdom?) “I own the kingdom” (affectlessly). (Where is Vincent?) “Here.” (Have you heard him?) “Yes.” (What did he say?) “Nothing.” (Is he all right?) “Yes.” (Where is your mother?) “Home.” (Why don’t you go home?) “I can’t.” (Why not?) “I can’t.” (Why not?) “The family tree is broken, the Cardinal.” (What about him?) “Nothing.” (Retrospectively she said later she thought her brother was a cardinal.)

_December 8:_ When her mother visited her she said “It is about time you come--I thought you were dead.” Has walked down the hall “looking” for her dead cousin. When asked if she wanted to see her brother, said, “Ain’t he dead?”

_December 12:_ Cries out in an affectless tone like a huckster, “Father MacN., take me to Heaven,” repeating this over and over.

_December 15:_ Quiet as a rule, then for a time at the door, pulling at it and with whining voice but affectlessly saying “Give me the key--I want to go to the river--you can’t keep me from Heaven--it is either Heaven or the river, give me the keys, give me the keys, open the door,” “The niggers are taking possession.” To the physician to whom she had claimed to be married, often repeats “You don’t belong to me, I don’t belong to you.” (What about the niggers?) “A band of niggers, that is all they are.” (Are the nurses niggers?) “That is all they are.” Asked about her people, she says “They are in Heaven.” (Where are you?) “I am in Heaven” (without change of expression). Again, when asked where her people are, says “At home.” Then she went willingly back to bed and was quiet. In the afternoon she again went to the door and tried to get out. When questioned, she said “I don’t want to be an animal,” “Everybody is making an animal of me” (pointing to an animal picture). Then again, while trying the door, repeats in the same affectless manner that she wants to go “to the river,” “to the bottom of the river,” “to Heaven to see my mother.” This last was said in a whining tone, with some tears. She kept turning the knob, tried to get the keys, and struggled impulsively when prevented.

_December 23:_ Though quiet on the whole, when a visitor came yesterday, she ran after this woman saying “I want my generations,” and clung to her, and to-day at intervals keeps talking about wanting to see her generations but is often quiet. (Retrospectively she said she wanted to see all her ancestors from the beginning of time.)

_December 27:_ Of late often talks affectlessly about wanting to die or wanting to go to Heaven, struggling impulsively to get medicine away from the nurses, asking for poison, trying to drink her own urine, or even the fluid in the bed pan after she had been given an enema, all evidently with suicidal intent.

_December 28:_ Still constant, impulsive and apparently affectless attempts at suicide, tries to get medicine away from nurses, to get the fire extinguisher bottles, a bottle of ink, etc., struggling when prevented.

But when examined quiet, even smiles at a joke. When questioned, denies feeling either worried or depressed. She said she wanted to go home. She gave poor attention to the questions. Later she threw a wet sheet over a patient and laughed (this is rare). Later she slapped another patient. Again she began to talk about wishing to go to the grave. Calls Dr. M. “Uncle John.”

_December 30:_ Talks either about wanting to die, or wanting to go to Heaven, or wanting to go to Ireland, all this as usual in an affectless way. Calls Dr. M. “Uncle John.” Keeps shouting “Take me to Ireland.”

_January 9, 1914:_ Often quiet in bed, again goes to door, talks about wanting to go “to Heaven” or “to Ireland.” On the whole, says little.

It seems, then, that the transition was not abrupt, that many traits of the first period remained, but that she was on the whole much quieter, with the exception of some spells when she insisted on going out or killing herself. At such times she showed an affectless, impulsive excitement. Whether there was an element of perplexity then is not clear from the notes. The topics of which she spoke also changed. The idea of wealth was rarely expressed, also the idea of marriage was much in the background, but prominent ideas were those of death, Heaven, killing herself, going to Ireland--all of which she produced in an affectless way. It should be added that she persistently wet and soiled during this, as well as in the first period.

3. Then followed three months of greater inactivity. She lay in bed gazing, moving very little, not even when her meals were brought. She answered but little and consistently wet and soiled. This state lasted from about the middle of February until the beginning of April.

4. From this stuporous state she emerged during the next four weeks, the awakening being associated with persistent efforts to arouse her. She then was, for six or seven weeks, nearly normal, so far as her mood went, but had a tendency to cling to some of her ideas and was overtalkative. Her memory for the earlier phases of the psychosis was good, as she recalled not only many external events but most of her false ideas. She said, however, that her mind had been a blank for the third stage and she remembered nothing of it. At the end of this time she cleared up entirely and was discharged as “recovered.” She continued well for some months, during which she was occasionally examined.

This case gives an excellent example of the relationship of stupor to other manic-depressive reactions. She begins with an absorbed state, showing elements of perplexity and mania. With this there are expansive ideas but, also, statements about losing everything and being in prison, which suggest abandonment of life. Next, with increasing apathy, she begins to speak of death and soon makes impulsive suicidal attempts. Evidently her mind was becoming more and more focused on death and with this there was an appropriate emotional change. She was either apathetic or the affect exhibited itself in pure impulsiveness. Then comes the stupor, when all ideas disappear and mentation is reduced or absent. When the stupor lifts, the original ideas appear not only in memory but occasion a wavering insight. It is appropriate that she recalled all of her psychosis fairly well with the exception of the pure stupor, which she remembered only as a time when her mind was a blank.

FOOTNOTES:

[7] Hoch, August, and Kirby, George H.: “A Clinical Study of Psychoses Characterized by Distressed Perplexity.” _Archives of Neurology and Psychiatry_, April, 1919, Vol. I, pp. 415-458.

[8] Hoch, August: “A Study of the Benign Psychoses.” _Johns Hopkins Hospital Bulletin_, May, 1915, XXVI, 165.

A book on “the psychology of manic-depressive insanity” will shortly appear by the editor.