Chapter 15

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.