CHAPTER II

BENIGN STUPORS

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BENIGN STUPORS

_A STUDY OF

A NEW MANIC-DEPRESSIVE REACTION TYPE_

BY

AUGUST HOCH, M.D.

LATE DIRECTOR OF THE PSYCHIATRIC INSTITUTE OF THE

NEW YORK STATE HOSPITALS, WARD’S ISLAND, NEW

YORK. LATE PROFESSOR OF PSYCHIATRY, CORNELL

UNIVERSITY MEDICAL COLLEGE, NEW YORK

New York

THE MACMILLAN COMPANY

1921

_All rights reserved_

PRINTED IN THE UNITED STATES OF AMERICA

Copyright, 1921,

By THE MACMILLAN COMPANY

Set up and printed. Published July, 1921.

Press of

J. J. Little & Ives Company

New York, U. S. A.

TO

MY FORMER COLLEAGUES

IN THE

NEW YORK STATE HOSPITAL SERVICE

EDITOR’S PREFACE

A word should be said as to the origin and history of this book. When

the late Dr. Hoch became Director of the Psychiatric Institute of the

New York State Hospitals in 1910, he found there an interest in just the

kind of psychiatric research which it was his ambition to further. His

predecessor, Adolf Meyer, had developed the conception that the

psychoses should be looked on as psychobiological reactions rather than

rigid nosological entities and had inculcated the habit of scrupulously

thorough examination and record of what the patient said and did. Meyer

had broken away from the sterile habit of making diagnoses in accordance

with the set terms used to label symptoms; and his work and that of his

assistants thus led to a collection of valuable material which could

serve as a useful starting point for the keen clinical investigation of

Hoch. Specifically, attention had already been fixed on the study of the

so-called functional psychoses, comprising what are generally termed

Dementia Præcox and Manic-Depressive Insanity. An urgent problem in this

field was to separate different reaction types in order to discover

which were recoverable and which chronic or progressive. In order to

understand psychological reactions, interrelation rather than mere

coincidence of symptoms must be studied and, to aid in this, free use

was made of the fundamental principles of unconscious mentation as

exposed in the theories of Freud and his followers.

Almost at the outset it had been discovered that many patients presented

clinical pictures that would not fit into existing diagnostic pigeon

holes. Dr. George H. Kirby, whose skill and industry had made the most

valuable contributions to the archives of the Institute, published in

1913 a brief paper in which he pointed out, not only that many cases

with “catatonic” symptoms recovered, but also that clinically the

behavior of stupor showed it to be related to manic-depressive insanity

as well as dementia præcox. Dr. Hoch took up the problem at this point.

Using Dr. Kirby’s material and adding to it his earlier observations as

well as current cases, he endeavored to work out the essentials of the

stupor reaction. It was his ambition to describe stupor not only in its

psychiatric bearing but also as a life reaction.

The significance of this task is to be realized only when one considers

the general import of the functional psychoses. They are, biologically,

failures of adaptation. The chronic and deteriorating cases give up the

struggle permanently, while the temporary insanities lay bare the soul

of man as he catches a glimpse of unreality but turns back to face the

world as it is. When one realizes that emotional disturbances are

characteristic of the benign psychoses, it is easy to imagine how much

such studies may ultimately illuminate the problems of normal life.

The technical value of this work to psychiatry is more immediate.

Kraepelin laid the foundations for systematic classification with his

dementia præcox and manic-depressive groups. But the rigidity of the

latter, allegedly descriptive, term has confused the problem of

classifying many benign psychoses. It was Hoch’s ambition to prove that,

although elation and depression were the commonest mood anomalies in

this group, they had no more theoretic importance than anxiety,

distressed perplexity or apathy. These other moods, although less

frequent, are just as characteristic of the psychoses in this group. In

other words, the name “Anxiety-Apathy Insanity” would be as appropriate,

theoretically, as Kraepelin’s term. In 1919 Hoch and Kirby published a

report on the perplexity cases. This present book was designed to show

that the symptom complex centering around apathy is as distinct as that

which is recognized by all psychiatrists as mania with its predominant

characteristic of elation.

In 1917 ill health forced Dr. Hoch to resign from his official duties.

He retired to California with the purpose of adding to psychiatric

literature the fruits of his long experience and unrivaled judgment. His

first task was this book. In the midst of this work came a sudden

collapse. As I had been in close touch with his researches, coöperating

in psychological speculations, and was free to devote some time to it,

he asked shortly before his death that I complete the book. This

obligation is incommensurate with the debt I owe for years of

inspiration, tuition and criticism.

The task has been mainly literary. I found the first five chapters

practically completed, while it has not been difficult, as a rule, to

discover from his copious notes what his intentions were as to the

details of the following chapters. I have been greatly aided by the

assistance of Dr. Adolf Meyer and of Dr. Kirby. The latter has been good

enough to read the entire manuscript, making invaluable suggestions and

criticisms.

John T. MacCurdy.

New York.

TABLE OF CONTENTS

CHAPTER PAGE

EDITOR’S PREFACE vii

I. INTRODUCTION AND TYPICAL CASES OF DEEP

STUPOR 1

II. THE PARTIAL STUPOR REACTIONS 34

III. SUICIDAL CASES 50

IV. THE INTERFERENCES WITH THE INTELLECTUAL

PROCESSES 67

V. THE IDEATIONAL CONTENT OF THE STUPOR 82

VI. AFFECT 123

VII. INACTIVITY, NEGATIVISM AND CATALEPSY 132

VIII. SPECIAL CASES: RELATIONSHIP OF STUPOR TO

OTHER REACTIONS 149

IX. THE PHYSICAL MANIFESTATIONS OF STUPOR 174

X. PSYCHOLOGICAL EXPLANATION OF THE STUPOR

REACTION 186

XI. MALIGNANT STUPORS 205

XII. DIAGNOSIS OF STUPOR 223

XIII. TREATMENT OF STUPOR 229

XIV. SUMMARY OF THE STUPOR REACTION 234

XV. THE LITERATURE OF STUPOR 249

INDEX 279

BENIGN STUPORS

CHAPTER I

INTRODUCTION AND TYPICAL CASES OF DEEP STUPOR

The fact that psychiatry lags in development and recognition behind

other branches of medicine is due in part to the crudity of its clinical

methods. The evolution of interest in science is from simple, obvious

and tangible problems to more intricate and impalpable researches.

Refined laboratory work has been done in psychiatric clinics,

particularly along histopathological lines, but clinical studies follow

antiquated methods. The internist does not say, “The patient has sugar

in his urine, therefore he has diabetes and therefore he will die.” He

finds a glycosuria and looks for its cause. If this symptom is found to

be related to others in such a way as to justify the diagnosis of

diabetes, a therapeutic problem arises, that of adjusting the chemistry

of the body. The prognosis depends not on the disease but the

interreaction of the organism and the morbid process. Both in diagnosis

and treatment an individual factor, the patient’s metabolism, is of

prime importance. Now in psychiatry, although the personality is

diseased, this personal factor has been almost entirely neglected.

Text-books furnish us with composite pictures which are called diseases,

not with descriptions of reactions brought about by the interplay of

personal and environmental factors. Educated people are not satisfied

with novels that fail to depict real characters. Clinical psychiatry,

however, has been content with the dime-novel type of character

delineation. This is all the more disappointing, inasmuch as the study

of insanity should contribute largely to our knowledge of everyday life.

This defect can only be remedied by looking on every case as a problem

in which the origin of each symptom is to be studied and its relation

traced to all other symptoms and to the personality as a whole. This is

an ambitious task and we do not pretend to any great achievement, merely

to a beginning.

No better psychoses could be chosen for a preliminary effort than benign

stupors. Every psychiatrist has seen them, although they are wrongly

diagnosed as a rule, and they play no small rôle in the world’s history.

Euripides represents Orestes as having a stupor which is pictured as

accurately as any modern psychiatrist could describe an actual case.[1]

St. Paul is chronicled as falling to the ground, being thereafter blind

and going without food or drink for three days. While apparently

unconscious he had a religious vision. St. Catherine of Siena had

several unquestionable stupors, which are fairly well described. In

fact the mystics in general seem to have had communion with God and the

saints most often when they seemed unconscious to bystanders.[2] The

obsession with death, which seems so intimate a part of the stupor

reaction, is a fundamental theme in poetry, religion and philosophy. The

psychology of this interest is, speaking broadly, the psychology of

stupor. So, from a general standpoint, our problem is related to the

study of one of the most potent ideas which move the soul of man.

Psychiatrically, stupors have long remained an unsolved riddle. In the

century prior to 1872 (See the digest of Dagonet’s publication in

Chapter XV) French psychiatrists wrote some good descriptions of stupor

and offered brilliant, though sketchy generalizations about the

condition. Two years later an English psychiatrist (Newington, See

Chapter XV) improved on the French work. Little light has been thrown on

the subject since then. The researches of the later French School showed

that stupor often occurs in the course of major hysteria, but this left

many of these episodes obviously not hysterical. When serious attempts

were made at classification, this ubiquitous symptom complex was hard to

handle. Wernicke wisely refrained from attempting more than a loose

descriptive grouping. He called all conditions with marked inactivity

and apathy “akinetic psychoses” and said that some recovered, some did

not. Taxonomic zeal began to blind vision when Kahlbaum formulated his

“Catatonia” and included stupor in the symptom complex. The condition

which we call stupor occurs in the course of many different types of

mental disease. It is true that it is frequent in catatonia but is not

exclusively there. Mongols have black hair and straight hair, but one

cannot therefore say that any black and straight haired man is a Mongol.

Fortunately Kahlbaum prevented serious error by leaving the prognosis of

his catatonia open. When Kraepelin included it in his large group of

Dementia præcox, however, it implied that stupor could not be an acute,

recoverable condition.[3] He unquestionably advanced psychiatry greatly

but his scheme was too ambitious to be accurate. Many observers saw

patients, classified as dements according to Kraepelin’s formulæ,

return, apparently normal, to normal life. Finally Kirby[4] published a

series of cases which showed decisively that this classification was too

rigid.

Since his paper is the foundation for this present study, it should be

reviewed carefully. He first points out that Kraepelin’s “Dementia

præcox” includes much more than it should with its inevitably bad

prognosis. He shows how others have found patients with catatonic

symptom complexes proceed to recovery and speaks of these symptoms

occurring in epilepsy and even in frankly organic conditions, such as

brain tumor, general paralysis, trauma and infections. Kirby’s first

claim is that there are probably fundamentally different catatonic

processes, deteriorating and non-deteriorating. Lack of knowledge has

prevented us from understanding the meaning of the symptoms and hence

making the discrimination. He points out that stupor seems to represent

an attitude of defense, similar to feigned death in animals, and that in

a number of his cases it was clear that the stupor symbolized the death

of the patient. Apparent negativism, he found to be often a consciously

assumed attitude of aversion towards an unpleasant emotional situation.

In cases where there had been no prodromal symptoms pointing definitely

to dementia præcox the outcome was almost always good. To discriminate

the cases with good outlook from those with bad, he discerned no

difference in the stupors themselves, but observed that the mental

make-up and initial symptoms differed sufficiently for diagnosis to be

made. His most important point is, perhaps, that these benign stupors

showed a definite relationship to manic-depressive insanity in that some

patients passed directly from stupor to typical manic excitement, while

in others a “catatonic” attack replaced a depression in a circular

psychosis.

Kirby introduces, then, the idea of stupor being a type of reaction

which can occur either in dementia præcox or in manic-depressive

insanity. The matter cannot be left there, in fact it raises new

problems: what constitutes the reaction? how are the various symptoms

interrelated? are they different in deteriorating and acute cases? what

is the teleological significance of the reaction? if it be an integral

part of the manic-depressive group, how does it affect our conceptions

of what manic-depressive insanity is? More than five years have been

spent in endeavors to answer these questions and the results of the

study are now presented.

Naturally the first point to be settled is: what constitutes the stupor

reaction itself. We can say at the outset that it is seen in the purest

form in benign cases, hence they make up the material of this book. To

discover the symptoms of the disorder one cannot do better than to study

them in their most glaring form in deep stupors, where consistently

recurring phenomena may be assumed to be essential to the reaction.

CASE 1.--_Anna G._ Age: 15. Admitted to the Psychiatric

Institute July 25, 1907.

_F. H._ The mother and two brothers were living and said to

be normal. The father died of apoplexy when the patient was

seven.

_P. H._ The patient was sickly up to the age of seven, but

stronger after that. It is stated that she got on well at

school, though she was somewhat slow in her work. She was

inclined to be rather quiet, even when a child, a bit shy,

but she had friends and was well liked by others. After

recovery she made a frank, natural impression. She was

always rather sensitive about her red hair. She began to

work a year before admission and had two positions. The

last one she did not like very well, because, she alleged,

the girls were “too tough.”

Three weeks before admission she came home from work and

said a girl in the shop had made remarks about her red

hair. She wanted to change her position, but she kept on

working until six days before admission. At that time her

mother kept her at home as she seemed so quiet, and when

the mother took her out for a walk she wanted to return,

because “everybody was looking” at her. For the next two

days she cried at times, and repeatedly said, “Oh, I wish I

were dead--nobody likes me--I wish I were dead and with my

father” (dead). She also called to various members of the

family, saying she wanted to tell them something, but when

they came she would only stare blankly. For a day she

followed her mother around, clung to her, said once she

wanted to say something to her, but only stared and said

nothing.

Four days before admission she became quite immobile, lay

in bed, did not speak, eat or drink. She also had some

fever.

The patient herself, when well, described the onset of her

psychosis as follows: She knew of no cause except that her

brother, some time before the onset (not clear how long),

was run over by an automobile and had his foot hurt. She

claimed that while still working she lost her ambition,

lost her appetite, did not feel like talking to any one;

that when she went out with her mother it merely seemed to

her that people stared at her. The day before she went to

the Observation Pavilion her cousin came to see her, and

she thought she saw, standing beside this cousin, the

latter’s dead mother. She also thought there was a fire,

and that her sister was sweeping little babies out of the

room. Then, she claimed, she felt afraid (this still on the

day before going to the Observation Pavilion) because she

had repeated visions of an old woman, a witch. This woman

said, “I am your mother, and I gave you to this woman

(i.e., patient’s real mother) when you were a baby.” She

also was afraid her mother was “going away.”

At the _Observation Pavilion_ she was described as

constrained, staring fixedly into space, mute, requiring to

be dressed and fed.

_Under Observation:_ 1. For five months the patient

presented a marked stupor. She was for the most part very

inactive, totally mute, staring vacantly, often not even

blinking, so that for a time the conjunctivæ were dry. She

did not swallow, but held her saliva; did not react to pin

pricks or feinting motions before her eyes. Sometimes she

retained her urine, again wet and soiled the bed. Often

there was marked catalepsy, and the retention of very

awkward positions. As a rule she was quite stiff, offering

passive resistance towards any interference. She had to be

tube-fed at first. Later she was spoon-fed, and then would

swallow, in spite of the fact that during the interval

between her feeding she would let saliva collect in her

mouth. For a time she had a tendency to hold one leg out of

bed, and when it was put back would stick the other out.

Sometimes she walked of her own accord to the toilet chair,

but on one occasion wet the floor before she got there.

During the first month after admission, this stupor was

interrupted for two short periods by a little freer action:

she walked to a chair, sat down, smiled a little, fanned

herself very naturally when a fan was given to her, though

even then did not speak.

There was, as a rule, no emotional reaction, but after some

months she several times wept when her mother came, though

without speaking. Once when taken to the tub she yelled.

Her _physical condition_ during this stupor was as follows:

She menstruated freely on admission, then not again until

she was well. Several times she had rises of temperature to

102° or 103° with a high pulse and respiration; again a

respiration of 40, with but slight rise of temperature,

though the pulse had a tendency to go to 130 and over. She

was apt to show marked skin hyperæmia wherever touched.

With the fever there was found a leucocytosis of from

11,900 to 15,000, with marked increase of polynuclear

leucocytes (89%). She got very emaciated, so that four

months after admission she weighed 68 lbs. (height 5′ 2″).

2. About five months after admission she was often seen

smiling, and again weeping, and she began to talk a little

to the nurses, though not to the doctors. She also began to

eat excessively of her own accord, and rapidly gained

weight, so that by January she weighed 98½ lbs., a gain

of 30 lbs. in two months. Yet she continued to be sluggish.

3. For two more months she was apathetic and appeared

disinterested, often would not reply, again, at the same

interview, she would do so promptly and with natural voice.

This condition may be illustrated by the summary of a note

made on January 29, 1908, which is representative of that

period. It is stated that she sat about apathetically all

day, appeared sluggish, but was fairly neat about her

appearance and cleanly in her habits. There was at no time

any evidence of affect, except when asked by the examiner

to put out her tongue so that he could stick a pin in it

she blushed and hid her face. When asked whether she

worried about anything, she denied this. When questions

were asked, she sometimes answered promptly and in normal

voice, again simply remained silent in spite of repeated

urging. On the whole, it seemed that simple impersonal

questions were answered promptly; whereas difficult

impersonal questions or questions which referred to her

condition were not answered at all. She proved to be

oriented. Thus she gave the day of the week, month, year,

the name of the hospital, names of the doctors and nurses

promptly. She also counted quickly and did a few simple

multiplications quickly. But she was silent when asked

where the hospital was located, how long she had been here,

whether she was here one or six months, how she felt.

Questions in regard to the condition she had passed

through, or involving difficult calculations, she did not

answer. However, some questions regarding her condition

asked in such a way that they could be answered by “yes” or

“no” were again answered quite promptly. Thus when asked

whether her head felt all right she said, “Yes, sir.” (Is

your memory good?) “Yes.” (Have you been sick?) “No, sir.”

(Are you worried?) “No.”

4. This apathy cleared up too, so that by the middle of

March she was bright, active and smiled freely. With the

nurses she was rather talkative and pleased, though this

was not marked. Towards the physician only was she natural

and free. She then gave the _retrospective account_ of the

onset detailed above. When questioned about her condition

she claimed not to remember the Observation Pavilion,

although recalling vaguely going there in a carriage. She

was almost completely amnesic for a considerable part of

her stay in the Institute. She claimed it was only in

November or December that she began to know where she was

(five months after admission). In harmony with this is the

fact that she did not recall the tube- and spoon-feeding

which had to be resorted to for about four months of this

period. No ideas or visions were remembered. As to her

mutism she said, “I don’t think I could speak,” “I made no

effort,” again “I did not care to speak.” She claimed that

she remembered being pricked with a pin but that she did

not feel it. She remembered yelling when taken to the tub

(towards end of the marked stupor) and claimed she thought

she was to be drowned.

When she went home (March 24, 1908) she got into a more

elated condition. She was talkative, conversed with

strangers on the street, said to her mother that she was

now sixteen years old and wanted “a fellow.” When the

mother would not allow her to go out, she said it would be

better if they both would jump out of the window and kill

themselves. She then was sent back to the hospital. In the

first part of this period after her return, she was

somewhat elated and overtalkative, though she did not

present a flight of ideas, and was well behaved. She soon

got well, however, and was discharged, four months after

her readmission, fully recovered.

After that, it is claimed, she was perfectly well and

worked successfully most of the time with the exception of

a short period in the spring of 1909, when she was slightly

elated.

In 1910 she had a subsequent attack, during which she was

treated at another hospital. From the description this

again seems to have been a typical stupor (immobility,

mutism, tendency to catalepsy, rigidity). According to the

account of the onset sent by that hospital (it was obtained

from the mother), this attack began some months before

admission, with complaints of being out of sorts, not being

able to concentrate and fearing that another attack would

come on. Finally the stupor was said to have been

immediately preceded by a seizure in which the whole body

jerked. She made again an excellent recovery.

The patient was seen about two years after this attack, and

described the development of the psychosis as follows: She

claimed she began to feel “queer,” “nervous,” “depressed,”

got sleepless. Then (this was given spontaneously) she

suddenly thought she was dying and that her father’s

picture was talking to her and calling her. “Then I lost my

speech.” As after the first attack, she claimed not to have

any recollection of what went on during a considerable part

of the stupor but recalled that she began to talk after her

brother visited her. It is not clear how she was during the

period immediately following the stupor.

She made a very natural impression and came willingly to

the hospital in response to a letter and was quite open

about giving information.

CASE 2.--_Caroline DeS._ Age: 21. Admitted to the

Psychiatric Institute June 10, 1909.

_F. H._ The father died of apoplexy when patient was nine.

The mother had diabetes. A paternal uncle was queer,

visionary.

_P. H._ The patient was always considered natural, bright,

had many friends, and was efficient.

Some months before admission the patient’s favorite

brother, who is a Catholic, became engaged to a Protestant

girl, and spoke of changing his religion. The family and

the patient were annoyed at this, and the patient is said

to have worried about it, but was otherwise quite natural

until seven days before admission. Then, at the engagement

dinner of the brother, the psychosis broke out. She refused

to sit down to the table, and then suddenly began to sing

and dance, cry and laugh and talk in a disconnected manner.

Among other things, she said “I hate her,” “I love you,

papa” (father is dead), “Don’t kill me.” She struck her

brother. She was in a few days taken to the Observation

Pavilion.

The patient stated after recovery that what worried her was

that the brother would marry a Protestant and that he would

leave home (favorite brother).

At the _Observation Pavilion_ she was excited, shouted,

screamed, laughed, called out “Don’t kill me,” again

“Brother, brother,” “You are my brother” (to doctor).

_Under Observation:_ 1. On admission, and for two weeks,

the patient presented a marked excitement, during most of

which she was treated in the continuous bath. She tossed

about, threw the sheets off, beat her breasts and abdomen,

put her fingers into her mouth, bit the back of her hands,

waved her arms about, sometimes with peculiar gyration,

etc., at the same time shouting, singing, again praying,

laughing or crying, sometimes fighting the nurses and

resisting them. She also talked quite a little as a rule,

but there were periods when, although excited, she would

not talk or answer questions. She was very little

influenced in her talk by the environment. When on one

occasion asked if she had any trouble, she said: “No--I

don’t want, somebody else gave me a book--all right I love

myself, Uncle Mike too--all right too--all right I am in

Bellevue--I love everybody except the Jews all right, all

right--give me water, give me milk, give me seltzer--white

horse uncle--Holy Father, he is killing me, I want my

mother,” or “Wait a minute, say, that’s a lie--oh no, Holy

water--no I didn’t wash the water away--oh, she forgets, I

am sick--mother why don’t you come--look at the baby, they

knocked my head against the wall--wait a minute, isn’t that

terrible?--I was married--I was so--I forgot--April fool--I

kiss you seven kisses and one more--I love papa and mamma,

I like others too--I am papa’s angel child--yes I confess I

love him, but I don’t want to die myself.” On another

occasion, when asked where she was, she said: “I am at the

ball--I am going to Heaven--don’t shoot me” (affectless).

(Why are you afraid?) “Because you see--high water (in the

tub)--white horse.” (What about the water?) “My name is

Caroline--if you love me, father, tickle me under my feet,”

or, rolling her eyes up, “Oh, isn’t that awful, that ring,

that diamond, that is the key to Heaven.”

2. For about ten days she was somewhat different. She

became quieter and at first lay muttering unintelligibly,

saying some things about being killed, but speaking little,

often restlessly tossing about and tremulous. She had to be

tube-fed. On one day (July 1) she smiled more and talked

more, said to the physician “You have been arrested for

me--you arrested the first man that I ever--New York

State--let me see that book” (note pad). Then she went on:

“Oh, I am all apart--diamonds--they didn’t know--must I

keep them clean?--what is your name?--that is another thing

I would like to know.” But when asked what house she was in

she said: “This is the same Ward’s Island” and then added,

“How long have I been here?--there is my picture up there

(register), who is that? (listening) it’s Ida ...” She

began to sing softly. Then again she whined. “O mamma,

mamma!” When asked how long she had been here, she said:

“Since Decoration Day, when my father went in my sister’s

house, nobody could catch up with me--somebody blackened

her eyes.” When asked whether she was sick, she said “No,

insane.”

Although, as was stated, she said at one time, “This is the

same Ward’s Island,” usually questions regarding

orientation were not answered, as she gave few relevant

replies, but she repeatedly said spontaneously that she was

in “Hoboken or Bellevue,” and called the nurse by the name

of a former teacher. A few days after this state had

developed she had a fever. Once this rose to 104°. The

fever lasted two weeks, coming down gradually. It was

associated with a leucocytosis of 15,000 on June 29 (no

differential count) and with coated tongue. No Widal (two

examinations). No diazo (July 1).

3. Then while the temperature still lasted she developed a

stupor which persisted for about a year. During this time

her temperature rose to 100° without ascertainable cause.

She lay for the most part motionless, changing her position

but rarely; her expression was stolid; she retained and

drooled saliva, wet and soiled herself. She never answered

any questions; showed no interest whatever. At times she

was quite stiff and very resistive but never cataleptic.

Her extremities were cold and cyanotic. She had to be

tube-fed throughout. During this time she lost much hair.

After some months she occasionally gazed about furtively,

or later watched everything when unaware of being observed;

at this time she also smiled occasionally at amusing

things, or perhaps said “yes” or “no” to questions, but

usually was stolid when interrogated.

Then about nine months after admission, while in the

condition just described, she developed a lobar pneumonia.

During it she remained the same. But during convalescence

she began to speak and eat.

4. A period followed lasting six months during which she

was up and about, but sat or stood around a good deal. On

the other hand, she helped the nurses a little when urged.

Her face was often stolid, again she looked about. At times

(even nearly to the end) she drooled and soiled. She said

little. At no time was she resistive. On other occasions

she smiled or laughed, not always on provocation, or she

showed little playful tendencies, such as throwing a pillow

about the room, tearing leaves from the plants, taking the

doctor’s arm and walking down the hall, asking him to kiss

her. At such times she often looked quite bright, keen,

alert and amused. Towards the end she would give at times

playful answers, such as “I came to-day,” or “This is the

Hall of Fame.” This tapered off, so that by December, 1910,

she was perfectly well.

_Retrospectively_, the patient claimed not to remember the

upset at the dinner, or what happened afterward, although

recalling the trip to the Observation Pavilion. She denied

any memory of the journey to the hospital, but could tell

what ward she came to. How well the condition after that

was recalled, was not inquired into, except that she could

or would not explain further the utterances during the

first period. For the stupor period it is stated that she

remembered many external facts, but it is not clear in

which period they occurred.

_Catamnestic Note._ May, 1913: She has worked efficiently,

and is said to have been perfectly well.

CASE 3.--_Mary F._ Age: 21. Admitted to the Psychiatric

Institute June 28, 1902.

_F. H._ The mother died when the patient was five. The

father was living, an alcoholic and reckless man. Four

brothers and sisters died in infancy.

_P. H._ The patient was the only surviving child. She was

brought up in a convent and orphan asylum until 11, when

her father remarried. At 12 she had to go to work, hence

she had but little education. She was bright, efficient,

well liked by her employers (in one position five years).

As to her peculiarities, she was thought to be, perhaps, a

little headstrong, and was also described as always very

exact, rather quick-tempered and inclined to be irritable

when crossed.

She was married six months before admission and had a _baby

three weeks before admission_. The husband stated that when

the father found out she was pregnant, he spoke of killing

him. He frequently upbraided both husband and wife, though

he lived with them. Even after the child was born he

continued to be disagreeable.

The patient was rather low spirited and quieter after her

marriage. She worried over her illegitimate pregnancy and

the scolding from her father. But nothing was thought of

all this, and it did not interfere with her activity. The

birth was normal. She had no flow, no unfavorable symptoms,

and sat up on the twelfth day. She is said to have appeared

natural mentally.

A week before admission the family returned from the

christening, having left the patient apparently well. They

now found her sitting in her chair, limp, with closed eyes,

giving no answer to questions. Only after about twenty

minutes could she be aroused. After her father had given

her milk with whiskey in it, she claimed he had poisoned

her. In the evening she was bright and lively, singing and

dancing with the others, but in the night she woke up her

husband, seemed frightened, said somebody was in the room

and that he should get a priest as she was going to die.

The husband went to sleep again. The next forenoon the

patient claimed she had been frightened all night and

thought her father was going to kill her husband.

On the second day, while sitting at breakfast, she groped

about for the bread plate for some time and then said she

had been blind for a short time. During the day she had

frequent spells in which she would close her eyes, become

perfectly quiet and difficult to rouse. Sometimes at the

beginning of these spells she would say “I am going.” She

was then taken to her aunt and walked there, a distance of

a few blocks. She was there for two days before going to

the Observation Pavilion. In this time she is said to have

been quiet for the most part, often apparently sleeping or

staring. Once she said she was “rather dirty, filthy.” Once

she tried to get out of the window, said it was a door and

that she wanted to get out and take a walk. Above all, she

had, in these two days, repeated peculiar seizures which

the aunt and the husband described as follows: When sitting

on a chair she would close her eyes, clench her fists,

pound the side of the chair, get stiff, slide on the floor,

then thrash her arms and legs about and move the head to

and fro. She frothed at the mouth. After the attack, which

lasted a few minutes, she breathed heavily for a while.

Once she wiped off the froth with a handkerchief and gave

the latter to the aunt, saying “Burn that, it is poison.”

Before the attack she sometimes said that it got dark over

her eyes and that her face felt funny, again that she had a

pain in the stomach which worked towards her right

shoulder. There was no cry in the beginning of the attack,

but once she wet herself.

After recovery the patient herself told the development of

her psychosis thus:

There was trouble between the father and the husband, and

she was afraid of her father. On the day of the christening

she took sick: a queer feeling came over her and she

wondered whether she was going to die, “Then I seemed to

lose myself, and when I came to I found my family standing

around me.” Her father gave her whiskey and she thought it

was poison. “That night I had spells of dancing and

singing, it must have been something I took, perhaps the

liquor.” The same night she was frightened, thought her

father might do some harm, and had a vision of a person in

white standing at her bed. After that she had repeated

spells in which she knew nothing until “I came to again.”

“It was a queer trembling.”

At the _Observation Pavilion_ she was described as in a

state of “intense mental depression,” taking no interest in

things going on about her. She spoke, however; said she

wanted to die, that she had imagined her father had given

her poison, that every one was against her, and that people

were talking about her.

1. _On admission_ the patient had a slightly elevated

temperature, which soon subsided, full breasts but without

inflammation. Sordes were not mentioned.

For a few days she was essentially somewhat restless,

getting out of bed, disarranging her clothes, wandering

about--all in a rather deliberate, aimless way, sometimes

vaguely resistive, again with free movements. She looked,

dazed, sometimes stared straight ahead and looked “dreamy.”

Occasionally there was a tendency to close her eyes. With

the restlessness she looked at times “a little

apprehensive,” or shrank away when approached. She spoke

slowly, with initial difficulty, but answered quite a

number of questions. The mental content of this period was

displayed in the following utterances: She would ask for a

priest, or say “Have I done something?” or “Do people want

something?” or, when asked why she was here, she said “I

have done damage to the city, didn’t I?” (What have you

done?) “I don’t know.” Or she spoke of people watching her.

When asked the day, she said “Judgment Day,” yet she knew

the month. Once when asked what the place was she said,

“This is the hereafter.” When asked what had happened at

home, she said: “Voices told me I was to be killed.” She

was not clearly oriented, called the place Bellevue, asked

“Isn’t this a hospital?” yet again said, “Ward’s Island,

where they work.” On the day of admission she thought she

came “the day before,” but knew she had come in a boat.

When asked her address, she said slowly, “Didn’t I live at,

etc.,” giving the address correctly. To the physician she

said, “Are you my brother?” And on another occasion, “My

God! You are Charlie” (brother). It was difficult to get

her to eat, and she had to be spoon-fed.

2. Then she became more preoccupied, the restlessness was

much less in evidence, it became necessary to tube-feed

her, she retained her urine, answered a few questions, and

when asked where she was, she said, “Calvary, ain’t it?”

(What house?) “Heaven, ain’t it?” She still called the

physician by the name of her brother. After a few days this

gave way to a more marked stupor which lasted nearly two

years. This was characterized most frequently by a complete

inactivity. She usually lay or sat motionless, sometimes

with mouth partly open, letting the flies crawl over her

face, gazing in one direction, soiling, wetting, resisting

moderately or markedly any interference, and had to be

tube-fed. But this was not the invariable state. The most

constant feature was her mutism, but even that was a few

times interrupted. Thus, when after a visit from her uncle

(towards the end of July, 1902) she tried to get out of the

window and was prevented, she swore at the nurse. Or in

August, 1902, when she got into another patient’s bed and

was taken out, she resisted and said promptly: “I think it

is a damned shame I can’t get into my own bed.” But this

was the extent of her talk for a year and a half. Nor was

she always totally inactive. In the middle of July, 1902,

she sometimes tried to get out of bed, wandered about, got

into other patients’ beds. It was on such an occasion that

the above incident happened. In August, 1902, she sometimes

tried to get out when the door was opened, and we have

seen that she tried to get out of the window, but she did

not change her placid expression at such times. Her motive

was not known. On two occasions towards the end of 1902,

when she was taken to a dance and was made to take part,

she waltzed with considerable animation but did not speak.

This was quite striking in that these incidents occurred in

a setting of marked inactivity (i.e., a condition in which

she had to be pushed to the table, pushed to the closet).

She did not soil any more, but she sometimes drooled and

had to be spoon-fed. However, on a third occasion when this

was tried, she had to be dragged around. Finally, though

her facial expression showed at times a preoccupied

staring, she more often looked around, sometimes quite

freely and often looked up promptly enough when accosted.

But there was very little evidence of any affect at any

time. We have seen that twice she swore a little when

opposed. On another occasion she slapped a patient when the

latter helped her. Twice she was seen crying a little

without apparent provocation, but she did not laugh, and

the only suggestion of pleasurable emotion was that at the

two dances mentioned she could be led into a certain

animation. Usually, even when she got less resistive

towards the end, she was essentially apathetic.

Once in January, 1903, she could be made to write her name

but wrote her maiden name. In the end of 1903 she improved

gradually (a condition not well observed), so that by

December she answered some questions in a low tone. Even in

April, 1904, she was still described as apathetic, though

she had begun to do some work.

3. Then she improved markedly and began to work, looked

after herself in a natural way, spoke freely, was entirely

oriented and her mood generally presented nothing striking.

But her mental attitude was still peculiar when she was

questioned. She seemed somewhat inattentive, sulky,

sneering. Thus, when asked why she was here, she said, “You

will have to ask those who brought me here.”

She denied ever having been pregnant, said the nurses on

the ward had spoken of her having had a child and that they

had showed her a child (one was born on that ward about

August, 1903) but that it was not hers. She thought it was

wrong for the nurses to speak on the ward of her having

been pregnant. Again questioned about her marriage, she

first said she had not been married, again that she was

married “a year ago” (was in the hospital then). Again she

spoke of her husband as her “gentleman friend,” claimed she

called herself Mary M. (maiden name) until a girl friend

wrote her a letter addressed to Mrs. F. From then on, she

called herself by her married name. But she thought that

probably they sometimes spoke of her marriage in fun. If

she were Mrs. F. she would be living in Mr. F.’s house.

On June 29, when again asked about her marriage, she said

she was to have been married in December (correct date).

(Were you?) “So they say.” (Do you remember it?) “In a

way.” (When was the baby born?) “You will have to ask

somebody more superior to me, more experienced.” Then, when

further questioned about the age of the baby, she said,

“The baby I saw in the ward was about a year old,” and she

claimed not to remember ever having a baby. When asked why

she had come here she said, “Well, I don’t know, perhaps

you know better, through sickness I guess,” and later:

“Well, don’t you ever get a cold and want doctors to

examine you?” (What kind of a place?) “This is a nice place

for sensible people who have enough knowledge to know and

realize what they come for.” But she knew the name of the

place, the date, the names of persons.

Questioned about the trouble with her father or her

husband’s trouble with him, she denied it, “If he did (sc.

have any trouble), I don’t remember.” About her not

speaking, she said, in answer to questions, “I didn’t know

what I was here for, what was the object in keeping me

here”; and to other questions about her condition, “I don’t

know, those who examined me can tell you more about that.”

Finally, she said in reply to the question, why she came

here, “I don’t remember _unless it was through fire_,” but

would not explain what she meant.

In the beginning of July, she again said that she had no

recollection of her marriage.

She then improved a great deal and finally appeared very

natural, gave the retrospective account noted in the

history, had a clear appreciation of the fact that she was

married and had a child. She claimed that she had

previously forgotten about her marriage and thought she was

still merely keeping company with Mr. F. She claimed not to

remember coming to the hospital, did not know what ward

she came to, who the doctor and nurses were, in fact

claimed that it was about a year before she knew where she

was. But she remembered having been tube-fed. She could not

say why she did not speak. But she appreciated that she had

been ill.

Ten years after discharge the husband, in answer to an

inquiry, stated that she had been perfectly well and had

had no trouble at three successive childbirths.

CASE 4.--_Mary D._ Age: 20. Admitted to the Psychiatric

Institute September 17, 1907.

_F. H._ The grandfather and the father of the patient were

alcoholics. The father died three years before the

patient’s admission; he was killed in an accident. The

mother stated that she herself was nervous, but she made a

normal impression.

_P. H._ The patient was described as bright at school and

efficient in her work as a dressmaker, but she was rather

quiet, inclined to stay at home and had not much

inclination to consort with the other sex. She was rather

proud. As an example of this is stated the fact that she

was always somewhat sensitive, because the family lived in

the basement of the house in which her mother was

janitress. She did not menstruate until 16. It was about

this time that her father was killed in an accident. She

was considerably upset by this, talked a good deal about

the way he was killed, but did not break down. The patient

on recovery stated that it worried her because the father

died without having any chance to get a priest.

Six weeks before admission the patient was given a

vacation, as there was not work enough in the shop, but she

worked at home.

Two or three weeks before admission her appetite failed

somewhat, and ten days before admission, without any

appreciable cause, she began to sleep badly, seemed

somewhat nervous, became a little “fidgety” and said she

worried because her mother had to work so hard. Later she

began to speak about people saying that the ambulance would

come for her and she heard voices saying “You will be

dead.” It is not known in what emotional setting these

remarks were made. Her mother took her to a dispensary. On

the way she asked the mother where she was going and said

“I can’t tell the number and I don’t know where I am going.

I think I am losing my mind.” She also said she could not

understand any more what she read. She was put to bed. She

then talked less, appeared stupid, and was inclined to

refuse food.

Four days before admission she claimed that she could see

her dead father beckoning to her, again she said a certain

young man was God. She was sent to the Observation

Pavilion. On the day she went there she was reported to

have shown a slight jaundice.

The patient, after her recovery, added to the above account

of the mother, that about two weeks before admission, for

no reason which she could state, she began to feel quiet,

and that after that her father’s death began to prey on her

mind, and that later she had a vision of her father. She

claimed that in this period she had no fear but that her

head felt dizzy and her vision seemed dim.

At the _Observation Pavilion_ the patient was described as

constrained, refusing food, mute, resistive of attention,

sometimes muttering to herself and having the appearance of

uneasiness.

_Under Observation:_ 1. On admission the patient had a

slight jaundice, which disappeared in a few days, and the

bile test in the urine was negative on admission. She was

rather thin, but otherwise in good physical condition. Her

temperature was 99.2°.

For three months the patient was very inactive, moving very

little. She had to be dressed and undressed, when taken out

of bed. She often was markedly constrained, either lying

with her head raised from the pillow, or for long periods

of time holding her arms or hands in rather constrained

positions on her body. But there was at no time any

catalepsy when tested by moving her arms. In the beginning,

however, before she lay so persistently with her head

raised, she was found holding it up from the pillow after

her hair had been fixed. Again, she did not correct other,

rather uncomfortable, positions in which she had been left.

There was also at times a slight or occasionally a somewhat

more marked resistance in her arms and neck, but this never

amounted to a pronounced resistance. She sometimes did not

react to pin pricks, sometimes flinched a little, never

warded off the pin, indeed she would put out her tongue

repeatedly when asked to do so in order to have a pin stuck

into it. She very often wet and soiled, once even

immediately after she had been taken to the closet, on

which occasion she did not urinate. Her face was usually

dull, vacant and immobile, but sometimes, when questioned

or when something obtrusive happened, a little puzzled.

Occasionally she looked slowly about or followed people

with her eyes. There was no evidence of any affect as a

rule, but not infrequently she smiled, even quite freely at

times, when the physician came to her or on other

appropriate occasions. For example, once when a nurse came

into the ward whom she had known outside she flushed and

smiled a little. Once when the mother came to see her a few

tears appeared, the only time this occurred.

Although for the most part immobile, when she did move, she

was distinctly slow. When asked to do certain things, she

usually did not comply, but now and then, after urging,

would show her tongue after delay, or merely open her

mouth; or she would bring the hand forward slowly when the

physician offered his hand in greeting. Once she fumbled

with her braids slowly. When out of bed, she stood about

aimlessly or sometimes walked somewhat slowly.

She was almost entirely mute, but a few times she returned

a greeting quite promptly, or on another occasion

(September 23) she said quite promptly, when asked how she

felt, “I feel better. I took off my clothes” (correct--she

had been up and put to bed again). Again she sometimes

answered simple questions by “yes” or “no,” though

sometimes in a contradictory and rather aimless manner, but

promptly enough. Once she said to her mother, “I can’t, I

have to remain here.” There were some other replies which

we shall presently take up. Several times it was possible

to make her write. On these occasions she wrote her name

promptly, or might write only after much delay or stopping

in the middle of a word.

This leads us to her capacity to think, the defect of which

was perhaps most clear in her writing. Thus, though having

been told to write her name, and having written it quickly

enough, when, immediately after it, she was asked to write

her address or the name of the hospital, she had to be

urged much, and then wrote each time merely a repetition of

her name, this time much more slowly. On October 13, when

she was asked to write her name, she wrote it correctly;

then for the address she wrote the house number correctly,

but for 90th street she wrote “90theath”; and, urged again

for the address, she added “Dr. Wyeth.” Again when asked to

write the word “watch” she was slow, and finally put down

“10.” When on October 23 she was asked to write “Manhattan

State Hospital,” she wrote “Manhatt Hhospshosh,” and for

“Ward’s Island” (which she was told), “Ww Iland.” Then she

was asked to write “I wish to go home.” She wrote “I wish

to go home, go West.” Here again the first part was written

promptly.

We now can add some of the other replies which she gave.

Once she was asked “Do you know where you are?” She

promptly said, “Yes.” (Where?) No reply. On another

occasion, at the initial examination, she said she was home

or “in papa’s house.” Once when asked “Do you know me?” she

said “Yes.” (What is my name?) “Miss D.” (her name). On the

occasion on which she had stated that she had taken off her

clothes, she was asked “Where have you taken off your

clothes?” She made the irrelevant reply, “That was the girl

the one I had.”

2. Then she improved somewhat. On January 5 she walked

about a little more, though slowly, and still looked

slightly puzzled when questioned. She spoke more readily,

counted promptly though once stopped in the middle of the

exercise. In calculation she multiplied correctly 3 × 7,

but for 4 × 9 repeated the 21, and when given 9 × 9 she did

not answer. A few days later, though she lay again

motionless with her head raised as before, and, as she had

sometimes done, smiled brightly when accosted, she gave few

replies, but when asked to write down the month she slowly

wrote “December.” Asked to write it the second time, she

did it promptly. She also replied promptly by saying “Yes”

when asked whether Christmas, and again whether New Year’s,

had passed, but did not reply to the questions how long ago

Christmas, or how long ago New Year’s, had occurred. On

January 23 she was decidedly more free and prompt in her

replies, yet she still wet and soiled (in fact this did not

cease until the end of the month, when great improvement

occurred). At this time she gave quite a number of

calculations promptly, about an equal number wrongly. She

knew where she was, knew the names of a number of people

about her, but thought she had been here about two weeks

(four months), and gave the year and the date, the latter

as the 28th of January. When then told that it was

Thursday, January 23, and that she must remember it, and

asked five minutes later what she had been told, she again

said “January 28” and left out Thursday. To some questions

to which she did not know the answers, since she had an

amnesia for the time of their occurrence (the incidents of

coming here), she simply remained silent. Even on February

7, when she was much freer, helped the nurses, and said

herself she was “smarter,” she had difficulty in thinking,

said she was 17 (21), gave the date of her birth correctly,

but the current year as 1909 (1908) and still insisted she

was 17. She then did the calculations on paper, and with

considerable difficulty got correctly “22.” But she could

not straighten out the discrepancy. At that time, also, she

still wrote “Hospitital,” calculated even simple

multiplications with some mistakes, could not get the point

of a story, and to retention tests gave poor results.

Indeed, even seven days later, when she wrote a very

rational letter and appeared quite natural, she made some

omissions in her writing, and a few mistakes in spelling.

However, she now improved rapidly, and by March 31 she made

a very natural impression, was frank, free, had good

insight, calculated well, etc., understood a story,

retention was good.

She then gave the retrospective account embodied in the

history, and in addition told that she had no recollection

of going to the Observation Pavilion, the coming here, or

the first part of her stay, including presentation of the

case at a staff meeting, a physical examination and a blood

examination, and she claimed for a long time not to know

where she was, “I was in a kind of dazed condition.” She

also said she could not understand the questions which were

asked her. This probably refers, however, to the second

part, i.e., the partial stupor lasting for two months. She

did not “feel like talking,” the limbs “felt stiff-like.”

CASE 5.--_Annie K._ Age: 22. Admitted to the Psychiatric

Institute January 7, 1907.

_F. H._ The father was an alcoholic, who died when patient

was a child. A paternal aunt had a nervous breakdown, with

recovery. The mother appeared to be normal.

_P. H._ The mother stated that the patient was a rather

delicate child. She attended school irregularly, never felt

much interest in it, and was always glad to be at home and

help the mother take care of the other children. On the

other hand, she is said to have been quite lively, rather a

tomboy, with a temper. She left school at 14; learned

dressmaking for a year, but did not get along well. Then

she took several other positions, which she held for about

a year, getting on pretty well.

She married at 20. Her husband never supported her well and

often beat her. She had to borrow money to get along and

worried much. During pregnancy she seemed to worry more,

had crying spells, and often seemed absorbed in thought.

Three weeks before admission she gave birth to a child. The

labor was somewhat difficult, but she had no fever. She got

up on the tenth day, and then seemed to lose all interest,

did not attend to the baby, said she was not strong enough.

She sat about, appearing depressed. The mother then took

her and the baby to her house. There she sat or walked

about, said very little. But she repeatedly came to her

mother, said she had something to tell her, or that she had

“done something,” although she could never be induced to

say what. Once she came to her and said, “You are not going

to die.” She often moaned. Finally, she claimed a neighbor

had been saying she was poisoning the baby.

The patient herself gave, after recovery, the onset as

follows: When she married she knew her husband was not what

he should be, but not that he was so bad as he proved to

be. He was a gambler, did not support her, and this caused

her much worry. When she became pregnant, eight months

after marriage, this increased her worry, and throughout

the pregnancy she spoke much to a neighbor about her

worries, and said she did not know how she could manage,

pay the doctor, and the like, but she did not say much

about it to her mother (because the latter would have made

such a fuss about it, or would have said, “It serves you

right”). Then the childbirth came. This further accentuated

her worries. She felt her difficult circumstances, wondered

how she could get the necessary money, “I lay there

worrying.” And she claimed she did not sleep at all. About

her statement, mentioned by the mother, that she had done

something, she said that she thought she had poisoned the

child by giving it fennel tea, and that she thought a

neighbor who visited her said she had poisoned it. She was

then put to bed again, and one night she had a vision of

her father. This frightened her. She thought this meant he

had come for her and she wanted to die.

At the _Observation Pavilion_ she was dull, staring,

resisting attempts at passive motions.

_Under Observation:_ 1. There was nothing noteworthy in her

physical condition, except for a rise of temperature to

100° occasionally during the first month of her admission.

For the first four months she was often found lying in bed

with her head half raised from the pillow, or standing or

sitting about in constrained positions, immobile,

frequently she let saliva collect in her mouth. She usually

wet and sometimes soiled the bed. Sometimes, when sitting

in a constrained position, she let herself gradually slide

on the floor. She often began to feed herself when urged,

but would not finish, and had to be spoon-fed, as a rule.

She was never tube-fed. She was often quite stiff and

showed marked resistance. This was manifested either when

passive motions were tried, at which times she usually

resisted passively, i.e., she became more tense; or when

there broke through a more active aggression and she would

strike. Above all, the opposition showed itself towards the

nurses’ attention; in this she also showed either a

passive, aimless opposition and stiffness, or a more active

one; but even in the latter an open show of angry affect,

or plain irritation, though present at times, was by no

means constant. When it was present, she would strike quite

aimfully; once she struck the nurse and said, “You are the

cause of it all,” and once, when the nurse tried to give

her some milk, she said, in an irritated tone, “I wonder

people would not let me alone some time.” Again, she bit a

patient who tried to hold her. On another occasion she

quickly jumped up and pulled the hair of a patient who

evidently disturbed her by her noisy shouting. As was

stated, she usually wet the bed, resisted being taken to

the toilet, or when taken there, would not urinate or

defecate, but would do so as soon as she was returned to

bed; or she urinated while standing. The same perverse

opposition was seen when she would refuse a glass of milk,

but grab it when it was taken away and then refuse to let

go. She often would grasp the bedclothes or other things

and hold on aimlessly.

She rarely spoke, answered almost no questions, complied,

as a rule, not even with the simplest commands. To pin

pricks she did not react except at times by flushing. But

she did not stare, rather looked about, and was at times

easily attracted by noises or happenings about her, and

would then look in that direction not without some

interest. Often there was then an expression of

bewilderment. Her mood, however, was, as a rule, apathetic,

but at times, as stated, she showed some anger. Once she

wept, and a few times she smiled or snickered. As a rule,

this happened without appreciable cause. But once, when a

cheering remark was made, she smiled; or, when her picture

was taken (to show the peculiar constrained attitude with

the head raised from the pillow), she laughed loudly.

Although she spoke rarely, she made a few utterances in the

first few days. Thus she suddenly said: “I want to see Mr.

N.--what I said to him was not right,” or “Listen! there

are the priests calling,” or “You are all faking--it is me

that done it--they are all dressing up downstairs,” or “I

told you she was not able to nurse the baby,” or “I have

nobody, I am lost--I want to know the truth--my mamma,” or

she called her sister, “They are dead since last night.”

Even during the more stuporous state she could, a few

times, be made to write a little. Then she either wrote

very slowly and not more than a letter, or if she wrote

more, it was remarkably mixed up. Thus when asked to write

the date, she wrote, “Jane (mother’s name) to me to

Chrichst,” or when asked to write her name: “Annie take you

ktusto.”

As to her orientation, nothing could be made out as a rule.

At first, however, a few weeks after admission, she spoke

correctly of the month as January and spoke of the Island.

When at that time she was asked if she had a baby, she

said, in an annoyed tone, “I don’t know.”

2. In the beginning of May, i.e., four months after

entrance, her condition changed somewhat, and for two

months she presented the following state: She stood about,

or walked around slowly, usually with her arms folded. She

had a tendency to stand near the door. She had to be

assisted in dressing, pushed rather than led to her meals,

and urged to eat. For the most part, she would not answer

questions, but would either smile in a sneering way, or

just walk away, or say, “Oh, don’t bother me,” or “I don’t

want to talk,” and generally her attitude was rather sulky.

Nor was this only towards the physicians but towards the

husband, sister and child as well. When on May 17 the

sister came, she would not speak to her but said “Go away.”

The baby she simply pushed away sulkily when it was brought

to her. To the husband she said on May 31, “Go away, you

stink.” In the first part of this period, she presented

some bursts of elation, on one occasion turned somersaults,

indulged in a few pranks with laughter, or once, when a

knock at the door was heard, she called out “Holy gee,

cheese it, the cop.” But these occurred only in the first

part of the period. On June 1 she spoke to the nurse, said,

“What is the matter with these people, they must be crazy,”

asked to go home, and was then by the nurse found to be

oriented, and to know the names of people around her. But

when she was asked about the baby she would not answer, and

questioned whether she was not married, she said “I don’t

know.” Yet when the physician desired to talk to her, she

was just the same as before and remained so for two more

weeks. Another somewhat isolated occurrence was when on

June 18 she spoke a little to the physician, but she sat in

a constrained position when taken into the office and

answered many questions by “I don’t know,” namely, those

regarding her condition and feelings, the questions about

orientation, about her mother’s address, and her child’s

age; but when asked how long she had been married she said

correctly “Two years.”

At the beginning of July she improved quite rapidly, and on

July 5 appeared fairly free and gave a fair retrospective

account, with some urging, and it was thought that she

smiled somewhat too freely. However, on July 27, she seemed

perfectly well, had normal insight, and then gave the

second retrospective account, which, together with the

first, will now be taken up.

_Retrospectively:_ She claimed to remember things at home,

and at both interviews said she recalled being taken to the

Observation Pavilion. While there she thought she knew

where she was, remembered that she did not talk. She had a

feeling she was going to die and said “I thought I would

die if I kept still.” However, the transfer to this

hospital was vague in her mind, as was the entrance on the

ward, and she claimed not to have known for quite a while

where she was. She added that she used to wonder where she

was, how she had gotten here, and how she could get out,

and thought the questions which were asked were queer.

Individual occurrences, too, specifically inquired into

were not recollected, such as an examination in a special

room. Of the mixed-up writing at the end of the second

week, she had no recollection even when it was shown to

her. She did not recall having her picture taken (with eyes

open) two months after entrance. Yet a sudden angry

outburst ten weeks after admission was remembered. She

stated that she struck the patient because the latter

annoyed her by her shouting. She had a general recollection

of being stiff, having her head raised, and of soiling and

drooling, but could not account for it. She felt stubborn.

She also claimed not to have been hungry and not to have

felt pin pricks.

In regard to ideas which she had, she claimed to be afraid

at first that she would be cut up. She remembered repeated

visions of her father at night, also once of her dead aunt,

who said “Come to me.” She thought she was in a cemetery,

all the family were dead, the baby dead. In the beginning,

too, she sometimes heard a priest whom she had known, say

“Be good and God will look after you.”

In regard to the later period, she recalled that she got up

in May and felt cross. She did not answer because she did

not want to be bothered. She pushed the baby away because

she did not think it belonged to her, the husband because

she did not like him. (She did not think she was not

married.) She evidently remembered the visits, thought she

knew where she was, knew she stood near the door “because I

wanted to go home.” Besides the idea that the baby was not

hers, she recalled none, and thought she had no

hallucinations.

She was discharged perfectly well six months after

admission to the hospital. Soon after that, she left the

husband, once had him arrested in 1908 and sent to the

workhouse. She was again examined in 1913, and was found to

be perfectly well, and she stated she had been well since

the discharge.

These five cases will have to suffice for the present. They were given

in full in spite of the fact that we shall leave out of our present

considerations the history of the cases and certain of the stages, and

confine ourselves to that stage of each case which is best qualified to

give us a good general survey of the essential features of the stupor

reaction.

These phases are: stage 1 of Case 1, lasting five months; stage 3 of

Case 2, lasting one year; stage 2 of Case 3, lasting two years; stage 1

of Case 4, lasting three months; stage 1 of Case 5, lasting four months.

We gather from these descriptions that the essentials of the stupor

reaction are (1) more or less marked interference with activity, often

to the point of complete cessation of spontaneous and reactive motions

and speech; (2) interference with the intellectual processes; (3)

affectlessness; (4) negativism.

_Inactivity:_ There is a complete cessation or more or less marked

diminution of all spontaneous or reactive movements. This includes such

voluntary muscle reflexes as contain a psychic component. For instance,

there is, often, an interference with swallowing (letting saliva collect

and drooling), winking, and even with the inhibitory processes used in

holding urine and feces (soiling and wetting). Often there is no

reaction to pin pricks or feinting motions. The inactivity also often

interferes with the taking of food so that spoon-feeding or tube-feeding

has to be resorted to. The patient may keep his eyes covered or stare

vacantly, the face often presenting a remarkably immobile wooden, or

stolid, expression. Complete mutism is the rule. When activity is not

totally interfered with, those movements which are present may be slow.

The patient may have to be pushed around and be able to take a few

steps, but soon relapses. More often they are of normal rapidity. Speech

then may also be slow and low, but usually shows no change except for

the fact that it is diminished in amount. Sometimes awkward positions

are assumed and retained, and there may be catalepsy.

_Negativism:_ A common symptom is perverse resistiveness. It may consist

in a marked stiffening of the body which is assumed spontaneously or

appears only when attempts at interference are made, or there may be a

more active turning away or even a direct warding off, sometimes with

scowling or anger or even swearing and striking. Retention of urine,

which is seen at times, should, perhaps, be mentioned here. Now and then

we find that a patient is put on the toilet and cannot be induced to

urinate or defecate, while soiling and wetting occur at once on

returning to bed.

_The intellectual processes:_ Little is known about the intellectual

processes from direct observation in these more pronounced cases, except

for the fact that in Case 5 questions or obtrusive occurrences sometimes

produced a somewhat puzzled facial expression. Moreover, the patient

retrospectively stated that she was unable to understand the questions,

which points to marked difficulty in apprehension. We also find that

occasionally there is evidence of an interference with the intellectual

processes which showed itself in what may be called “paragraphic”

writing when the patient could be induced to write. Above all, we see

that retrospectively very little is remembered of what took place during

the stupor, even of such obtrusive events as the moving from one ward to

another, tube-feeding, physical examination, the presentation at a staff

meeting, and the like.

_Affect:_ Complete affectlessness is an integral part of the stupor

reaction. Modification of the statement will later be mentioned. The

patient is indifferent so far as his basic condition is concerned, and

it is only by certain stimuli that at times emotional reactions can be

elicitated, some tears at a visit of a relative, an appropriate smile at

a joke or a comical situation when the stupor is not too deep or an

angry reaction called forth by interference.

_Catalepsy:_ Waxy flexibility or merely a tendency to maintain

artificial positions is a frequent but not an essential symptom.

_Physical Condition:_ Not infrequently we find in the beginning or in

the course of the stupor an elevation of temperature to 101°, 102° or

even 103°. In one case we found a marked cyanosis in the extremities.

Case 2 showed marked loss of hair. Gain in weight is never observed and

marked emaciation is the rule. This we may attribute to the refusal of

food.

A perusal of these cases, then, shows that the dominant (and well-nigh

exclusive) symptoms of the stupor are inactivity, apathy, negativism and

disturbance of the intellectual functions. Benign stupor can be defined

as a recoverable psychosis characterized by these four symptoms. The

meaning of such vague physical manifestations as the low fever is not

clear.

FOOTNOTES:

[1] MacCurdy has discussed the psychological phenomenon of a dramatist

depicting a psychosis correctly in “Concerning Hamlet and Orestes.”

_Journal of Abnormal Psychology_, Vol. XIII, No. 5.

[2] Many of these states seem to be hysterical rather than

manic-depressive stupors, but so far as the unconsciousness goes, there

is probably as much psychological as symptomatic resemblance between the

two types of reaction.

[3] Kraepelin recognizes, of course, the occurrence of stupor symptoms

or states in the course of manic-depressive psychoses. It is stupor as a

clinical entity, as a separate psychosis, that he regards as one form of

the catatonic, and therefore of the dementia præcox, reaction.

[4] Kirby, George H.: “The Catatonic Syndrome and Its Relation to

Manic-Depressive Insanity.” _Jour. of Nervous and Mental Disease_, Vol.

40, No. 11, 1913.

CHAPTER II

THE PARTIAL STUPOR REACTIONS

The cases thus far considered, namely, those of marked stupor, are

fairly well known and have been studied by others. Less well known and

formulated, but even more important from a practical as well as from a

theoretical point of view, are what may be called partial stupors.

The reader has noted that the states of deep stupor described in the

last chapter, did not end abruptly with a sudden return to health or a

sudden change to another type of psychosis. They all gradually passed

away, not by the disappearance of one symptom after another, but by the

attenuation of all. Sometimes a more or less stable condition persisted

for months, in which there was no stupor in a literal, clinical sense

but when apathy, inactivity, interference with the intellectual

functions and negativism all existed. Had these been the only states

observed in these patients, there might have been some ground for doubt

as to the diagnosis. As it was, it was clear that we were dealing with

mild stages of stupor. When a psychiatrist meets with an undeveloped

manic state, he calls it a hypomania and does not hesitate to make this

diagnosis in the absence of complete development into a florid

excitement. This procedure is not questioned, because the manic

_reaction_ as distinguished from a _mania_ is well recognized. We

believe that there is just as distinctive a _stupor reaction_ which may

be exhibited either in deep stupors or what we may term partial stupors.

Theoretically, complete apathy, inactivity, etc., make up the clinical

picture of a deep stupor. When these symptoms appear rather as

tendencies than as perfect states, a partial stupor is the product. That

partial stupors occur as well-defined psychoses, developing and

disappearing without the appearance of deep stupor, we shall attempt to

show in the following three typical cases:

CASE 6.--_Rose Sch._ Age: 30. Admitted to the Psychiatric

Institute August 22, 1907.

_F. H._ Both parents were living (father 74, mother 68), as

were two brothers and two sisters. All were said to be

normal.

_P. H._ Nothing was known of the patient’s early

characteristics, except that she herself said she was slow

at learning in school and did not have much of an

education. But when well she made by no means the

impression of a weak-minded person. The husband had known

her for ten years. He married her eight years before

admission, by civil process, keeping this from his own

family because he was a Jew and she a Christian. He said

that this undoubtedly worried the patient at times and that

she often asked him when he would take her to his family.

The patient herself later also said that this used to worry

her. Finally, one and a half years before admission she

agreed, on account of the children, to accept the Hebrew

faith, and they were then married in the synagogue. But he

still did not take her to his family.

There were four pregnancies: the first child died; of the

survivors one was 8, a second 5 years old. Finally, a year

before admission, she became again pregnant. During the

pregnancy one of the children had whooping cough and she

herself was thought to have caught it. The baby was born

three months before admission. It was a blue baby which

died two days after birth. The patient flowed heavily for

three weeks and was taken to a hospital, where she

continued to flow intermittently for some weeks more.

Finally, three weeks before admission, a hysterectomy was

performed. Several days after this, when the sister-in-law

visited her, the patient begged her to take her home, said

the doctor wished to shoot her and to give her poison.

Later the patient confirmed this, saying that she thought

they wanted to give her saltpeter, and that she heard them

say they wanted to shoot her.

When taken home she refused food; gazed about, was

absorbed, seemed obstinate, and several times tried to jump

out of the window. Retrospectively the patient stated that

she heard children on the street call “Katie.” She thought

they meant her child, heard that it was to be taken away

from her, and a similar idea again came out later in her

psychosis, namely, that somebody was going to harm her

children.

At the _Observation Pavilion_ she appeared stupid, rather

immobile, her attention difficult to attract.

_Under Observation:_ On admission the patient appeared

sober, impassive, moved very little, was markedly

cataleptic, though not resistive. On the other hand, her

eyes were wide open and she looked about freely, following

the movements of those around her not unnaturally. When

questioned, she looked at the questioner rather intently,

and was apt to breathe a little more rapidly, and made some

ineffectual lip motions but no reply. To simple commands

she made slow and inadequate responses. She flinched when

pricked with a pin, but made no attempt at protecting

herself. She had to be spoon-fed. The catalepsy persisted

only for two days.

After this she continued to show a marked reduction of

activity, moved very little, said nothing spontaneously,

had at first to be spoon-fed (later ate naturally enough).

But she never soiled herself and went to the closet of her

own accord.

Emotionally she seemed dormant for the most part, though

for the first few days she appeared somewhat puzzled, and

one night when a patient screamed she seemed afraid and

did not sleep, whereas other nights she slept well. She

answered only after repeated questions and in a low tone.

Very often, though her attention was attracted easily

enough, her answers were remarkably shallow and also showed

a striking off-hand profession of incapacity or lack of

knowledge. This was often without any admission of

depression or concern about her incapacity. She would

usually say “What?” or “Hm?” or repeat the question, but

most often would say, “I don’t know,” this even to very

simple questions. For instance, when asked, “What is your

name?” she answered, “My name? I don’t know myself” (but

she did give her husband’s name), or when asked to write

her name, she said, “I don’t know how to write,” or “Call

Annie, she will write my name.” When requested to read or

write (even when asked for single letters), she would make

such statements as “I can’t read.” However, she finally

named some objects in pictures. This condition was

characteristic of her for two weeks.

Then her condition changed a little. She spoke a little

more freely but was similarly vague. The following

interview of September 9, is characteristic: When asked how

she was, she said, “Belle.” (Are you sick?) “No.” (Is your

head all right?) “Yes.” (Is your memory all right?) “Yes.”

(Do you know everything?) “Yes.” (Understand everything?)

“Yes.” (Are you mixed up?) “No.” (Do you feel sick?) “No.”

But when asked where she was, how long she had been here,

what the name of the place was, what was the occupation of

those about her, she said, “I don’t know.” (How did you

come here?) “I couldn’t tell how I came up here.” (What are

you here for?) “I am walking around and sitting on

benches,” but finally, when again asked what she was here

for, she said, “To get cured.” She now gave and wrote her

name and address correctly when requested, also gave the

names of her children. Yet when asked about the age of the

girl, said, “I don’t know, my head is upside down.” When an

attempt was made to make her repeat the name of the

hospital, or the date, or the name of the examiner, she did

so all right, but even if this was done repeatedly and she

was asked a few minutes later, she would say “I couldn’t

say,” or “I forget things,” or “I have a short memory,” or

she would give it very imperfectly, as “Manhattan Island,”

or “Rhode Island” for “Manhattan State Hospital, Ward’s

Island.” (How is your memory?) “All right.” But when at

this point the difficulty was pointed out, she cried.

(Why?) “Because I forget so easily.” All this was while her

general activity was much reduced, and she seemed to take

very little interest in her surroundings.

Then she improved somewhat, asked the husband some

questions about home, and on one occasion cried much and

clung to him and did not want to let him go without taking

her. She also began to work quite well, but still said very

little spontaneously. During this period when asked

questions, she spoke freely enough, but seemed somewhat

embarrassed. What was still quite marked were striking

discrepancies in giving dates, and her utter inability to

straighten them out when attention was called to them, as

well as to her inability to supply such simple data as the

ages of her children. Her capacity was later not gone into

fully but it was certainly less defective on recovery than

at this time. She was rather shallow in giving a

retrospective account during this period. Even later, when

she had developed a clear insight and made, in respect to

her activity and behavior, a natural impression, she was

not able to give much information about her psychosis,

although she apparently tried to do so.

She was discharged recovered four months after admission,

her weight having risen from 93 lbs. on admission to 133

lbs. on discharge. For the first two weeks of her stay in

the hospital, her temperature varied between 99° and 100°.

_Retrospectively:_ She said in answer to questions about

her inactivity and difficulty in answering that she did not

feel like talking, felt mixed up, could not remember well,

did not want to write.

Before she was quite well she knew of her entrance to the

Observation Pavilion and her transfer to Ward’s Island, of

which she could give some details, but thought she had been

in the Observation Pavilion two weeks instead of three days

and in the admission ward one month instead of a few hours.

As to the precipitating cause of the attack, she spoke of

her flowing so much after childbirth and of her operation.

She was seen again in March, 1913, when she seemed quite

normal mentally and claimed that she had been well ever

since leaving the hospital.

With the exception of negativism, which appears only in the anamnesis,

all the cardinal stupor symptoms are found in this history. Particularly

noteworthy is her intellectual deficiency which seemed to be made up of

a real incapacity plus a remarkable disinclination for any mental effort

whatever. It is important to note that her attitude towards this

disability was usually one of indifference and that, in general, there

was no show of affect whatever. Freedom of speech was the last thing for

her to regain.

CASE 7.--_Mary C._ Age 26. Single. Admitted to the

Psychiatric Institute April 7, 1907.

_F. H._ The father had repeated attacks of insanity, from

which he recovered, but he died in an attack at the age of

60. A sister also had a psychosis, from which she

recovered.

_P. H._ The patient was rather quiet and easily worried.

When 14 she had some dizzy spells, with momentary loss of

consciousness. After that time she had no such attacks,

except after a tooth extraction when about 24.

The patient came to the United States six months before

admission. She went to live with a cousin who died a week

after she arrived at his house. She worried and said that

she brought bad luck. Then she took a position, where she

was well liked, but she was not particularly efficient. In

this situation she often felt homesick and lonely.

Two weeks before admission an uncle died, which affected

her considerably. She spoke of his leaving three children,

and would not go to the funeral. Then she thought she was

going to die. She felt dizzy, weak, walked with a stooped

position, was sleepless. In the midst of this she suddenly

felt frightened and walked into her mistress’ room, to

whom she complained that some one was talking outside but

could not tell what was said. She heard shooting.

Retrospectively, after recovery the patient said that at

that time she suddenly got “mixed up,” and that her “memory

got bad.”

She was taken to a general hospital, where she thought

there was a fire, and screamed “Fire!” She was soon

transferred to the _Observation Pavilion_, where she

appeared dazed, moving slowly, yet showing a certain

restlessness. She spoke of “the boat” being shut up so that

no one could go out. Again, she said “The boat went down

and all the people keep turning up.” Retrospectively the

patient stated about this condition that she remembered

going to the general hospital but not her stay at the

Observation Pavilion. (The trip to the Manhattan State

Hospital was again clearer to her.) About the ideas she had

at the time, she remembered only that the room seemed to go

around, and that after she had come to the Manhattan State

Hospital and was clearer, she thought she was in Belfast,

was on a ship, and that people were drowning.

_Under Observation:_ On admission she had a temperature of

100°, a coated tongue, suffused conjunctivæ. There were

herpes of the lower lip, a general appearance of weariness

and exhaustion, a flushed face, trace of albumen in the

urine, which was absent on the third day, no leucocytosis,

but 41 per cent. lymphocytes.

Then and henceforth she was inactive and very slow in all

her movements; she never stirred spontaneously, and had to

be pushed to the toilet and to the table; she ate slowly.

She did not speak spontaneously, and her replies were very

slow in coming. She had to be urged considerably before she

would speak and, as a rule, she did not answer. On one

occasion she was for a day totally inactive and looked

duller. That day and on a few other occasions she wet the

bed. There was at times an appearance of dull bewilderment.

When, soon after admission, asked whether she felt cheerful

or downhearted, she said “downhearted,” but this was the

only time. Often she answered “I don’t know,” when asked

whether she was worried, and she could never say what she

was worried about. Again she directly denied worry.

Sometimes she smiled appropriately, and repeatedly, when

asked how she felt, said, “I feel better.” In answer to

questions as to how her head was, she replied several

times, “My memory is gone,” also “I can’t take in my

surroundings,” or “I don’t know where I am,” or “I cannot

realize where I am.” Again, she spoke of being dizzy and

once said it was as though the room went round. Sometimes

she knew where she was or knew names, again said “I

forget,” but she always was approximately oriented as to

time. There were no special ideas expressed and no

hallucinations, except in the very beginning when she still

thought at night, when she heard the boats on the East

River, that people were being drowned. She later, as stated

above, said she thought she was on a boat and people were

being drowned.

By June, i.e., two months after admission, she began

rhythmical swaying of the body, twisting of the fingers, or

pulling out some of her hair. She ascribed this behavior

simply to “nervousness.”

On July 16, after a visit from her cousin, who said to her

that if she worked she would soon get better, she began

spontaneously to occupy herself somewhat. She became more

active, said she felt stronger and brighter, and that her

memory was better. By the beginning of August she was

fairly free, but still spoke in a rather low voice,

although answering well. Her capacity to calculate also

remained poor. When asked about the more inactive state,

she said she had been afraid to stir. (What afraid of?) “I

didn’t know where to go or what to do.” Further, she

recalled that she had had a numb feeling in her tongue,

could not speak quickly, and that her mind had felt

confused and “she could not take in things.” Further review

with her of the earlier period of her psychosis showed that

there was a blank for external events and most of the

internal events during this time.

She made a perfect recovery and was discharged August 7,

1907, four months after admission.

This case, although very like the last, differs from it in two

particulars. For one day her symptoms were sufficiently marked to

suggest a deep stupor. Secondly, her intellectual incapacity was not so

marked (always approximately oriented for time) and with this there was

some subjective appreciation of her defect. Apparently, however, this

insight did not cause her any worry. The affectlessness was equally

prominent in both of the foregoing cases, the fact that Mary C. (Case 7)

once admitted feeling downhearted in response to leading questions,

having little significance in the face of her expression, actions and

usual denial of worry. It is interesting to note that, during the bulk

of her psychosis, her only complaints were of mental hebetude and

dizziness. Possibly the latter was merely an expression of her

subjective confusion.

CASE 8.--_Henrietta H._ Age: 22. Admitted to the

Psychiatric Institute March 6, 1903.

_F. H._ The father stated that both parents were living and

well, also eight brothers and sisters.

_P. H._ The patient came to this country when she was a

baby. She was bright at school and industrious. From the

age of 17 on, she worked in a drygoods store and gave

satisfaction. About her mental make-up no data were

available, except for the statement that she always made a

natural impression.

When 21 (February, 1902), without known cause, she broke

down and was sent to the Manhattan State Hospital, but was

not observed in the Institute ward. She remained in the

hospital for three months. It was claimed that the attack

came on suddenly two days before she was sent away. She

suddenly appeared anxious, said something had happened and

became excited. This lasted for about a week, and then she

was, as the description says, “depressed and cataleptic.”

She remained in this condition for about a month, during

which time there was a slight rise of temperature. Then she

improved gradually and was discharged three months after

admission. After recovery from the present attack the

patient stated that during the first sickness she had

visions of dead friends.

She was perfectly well in the interval.

Six days before admission she suddenly became excited,

refused to eat, and began to talk, repeating phrases over

and over. Then she became elated and excited.

After recovery the patient described the onset of her

psychosis as follows: Six days before admission, after

having been perfectly well and without any known cause, she

was feverish and vomited, but slept well. Next day she felt

nervous, and her thoughts were clear. She constantly

thought of dead friends, heard them talking, when she tried

to do anything the voices said, “Don’t do that.” She also

thought somebody wanted to harm her people. Soon she

started singing and felt happy.

Then she was sent to the _Observation Pavilion_, where she

appeared to be in the same condition which was observed in

the Institute.

_Under Observation:_ 1. On admission she was in good

physical condition, except for her skin seeming greasy. She

presented for nine days the following picture: She was

essentially elated, laughing, singing, jumping out of bed,

good-natured and tractable, and very talkative. Her

productions showed a good deal of sameness and a certain

lack of progression. She spoke at times in a rather

monotonous voice, but again often in very theatrical tones,

with much, rather slow, gesturing. The following are very

representative samples:

“I have been suffering from my own blood, my own blood sent

all away from home. I just came from Bellevue. I left here

last May (correct) a healthy girl. A sister is a sister--I

wonder why shorthand is shorthand, a stenographer is a

stenographer (seeing stenographer write)--a kind brother,

Bill H.--why H. his wife is a sister-in-law to us, she has

four children--four beautiful children--sister-in-laws and

brother-in-laws--telephone ringing (telephone did

ring)--dear Lord, such a remembrance--remembrance was

remembrance, truth was truth--honesty is honesty--policy is

policy--if she married him, she is my sister-in-law and he

is my brother-in-law--Max knows me--she changed her name to

Mrs. R.--two children who are Rosie and Maud, if names were

given, names should not be mistaken--they are Julia,

Lillian--Rosie and Maud--why should wonders wonder and

wonders cease to wonder, why should blunders blunder and

blunders still blunder; sleep is one dream and dream means

sleep--if move is moving, why not move?” When she

accidentally heard the word wine, she said “Guilty wine is

not in our house--wine is red and women are women, and

women and wine and wine and women and wine and song.”

Again, “You are not Mr. Kratzberger, Mr. Steinberger, Mr.

Einberger--you are not Mr. Horrid or Mr. Storrid--perhaps

you are Mr. Johnson or Mr. Thompson--no, you are Dr. C.”

(correct).

She was quite clear about her environment.

Although the mood was throughout one of elation, on the

ninth day in the forenoon she cried at times, wanted to see

her mother, and spoke in a depressed strain (content not

known). A few hours after that she suddenly became quiet.

2. Then for four days (March 14-17) she was markedly

inactive, though at times got out of bed. She looked about

in a bewildered manner, did not speak spontaneously, but

could with urging be induced to make some replies. She did

this now fairly promptly, now quite slowly. Questions were

apt to bring on the bewilderment. Thus, when asked where

she was, she merely looked more bewildered, finally said

“Bellevue--I don’t know,” and questioned who the doctor was

whom she had called by name in her manic state, she said,

with some bewilderment, “Your face looks familiar.” (Where

have you seen me?) “In New York.” She claimed to feel all

right. There was no real affect. She made the statement

that at home she heard voices saying “You will be killed.”

3. Henceforth this bewilderment ceased, and for 16 or 17

days she was essentially inactive for the most part, for a

short time with a tendency to catalepsy and some

resistiveness, and at that time lying with eyes partly

closed. As a rule she said nothing spontaneously, but

replied to some questions, usually with marked retardation,

again more promptly. She constantly denied feeling sad or

worried, repeatedly said she felt “better,” only on one

occasion did she cry a little. When asked to calculate she

sometimes did it very slowly, again fairly promptly. The

simple calculations were usually done without error, the

others with some mistakes. As to her orientation the few

answers obtained showed that at times she knew the name of

the place and the day, again she gave wrong answers

(Bellevue). Once asked on March 23 for the day, she said

April. She wrote her name promptly on one occasion, again

a sentence slowly but without mistakes. Once during the

period she sang at night. Once she suddenly ran down the

hall but quickly lapsed into the dull condition.

On April 4, at the end of this period, she suddenly

laughed, again ran down the hall, said she had done nothing

to be kept on Ward’s Island. But she quickly lapsed again

into the dull state. Later, on the same day, when the

doctor was near, she said, in a natural tone, “Thank God,

the truth is coming out.” (What do you mean?) “That I have

been trusting in a false name and that Miss S. (the nurse)

should not nurse me.” Then she got suddenly duller,

calculated slowly and with some mistakes, 3×17=41, 4×19=56,

and when asked to write Manhattan State Hospital she wrote

(not very slowly) “Mannahaton Hotspalne.”

4. Next day it was noted that she was more stuporous, and

she remained so for two weeks, now showing a decided

tendency to catalepsy and more resistance than before,

though not marked, except in the jaw. She lay often with

head raised, sometimes with eyes partly open, or staring in

a dull, dreamy way, neither soiling nor drooling, however;

a few times she looked up when spoken to sharply. There was

no spontaneous speech. Usually she did not answer at all,

but a few times a short low response was obtained. Once she

wrote slowly a simple addition, put down on paper. When, on

one occasion, asked how she felt, she, as before, said, “I

feel better.”

5. Then, with the exception of a day at the end of the

month, when the more stuporous state was again in evidence,

she returned to her former condition without catalepsy or

resistiveness and without staring, but essentially with

inactivity or slowness. She now even dressed herself,

answered slowly though not consistently, but she again

denied feeling troubled or sad, “I feel better.”

On July 7 she got brighter but was still rather slow. She

then even began to do some work. She again denied feeling

sad.

In a few weeks, while having a temperature of 102° with

vomiting and diarrhea, she suddenly got freer. She then

said, in answer to questions, that she did not speak

because she was not sure whether it would be right, again

because she seemed to lose her speech. She did not move

because she was tired, had a numb feeling. She said she

had not been sad, “but I had different thoughts,” “saw

shadows on the walls of animals, living people and dead

people.” She was not frightened, “I just looked at them.”

People moved so quickly that she thought everything was

moved by electricity. She thought her head had been all

right.

After a few days she relapsed into a duller state again,

but then got quite free and natural in her behavior. On

August 28 she gave a _retrospective_ account of her

psychosis, a part of which has been embodied in the

history. She had insight in so far as she knew she had been

mentally ill. She claimed to remember the Observation

Pavilion and her coming to the hospital, also the incidents

during the manic state, when she heard cannon and thought a

war was on, and voices she could not recognize nor

understand. Then she became stupid, although neither sad

nor happy.

Then, she claimed, she got stupid, but neither sad nor

happy. She claimed to have known all along where she was,

but felt mixed up at times, her thoughts wandered and she

felt confused about the people. She thought she was in

everybody’s way, thought others wanted to get ahead of her,

did not speak because she did not know if it were right or

wrong, felt she might cause disturbance if she answered.

(It is not clear whether she had complete insight into the

morbid nature of these statements.) She also claimed again

that all along she “saw shadows on the wall,” “scenes from

Heaven and Earth,” “shadows of dead friends laid out for

burial.” She had insight into the hallucinatory nature of

these visions. Sometimes she thought she was dead also. She

claimed that she began to feel better when these shadows

stopped appearing in June (the actual time of her

improvement).

She was discharged recovered a month later, after having

been sent to another ward.

In this case, then, we find that the two months of stupor were ushered

in by a brief state in which, in addition to the usual inactivity, there

was a certain bewilderment, increased by questions, while the

orientation which in the preceding manic state had been good became

seriously interfered with. The psychosis bordered on deep stupor for

brief periods when the inactivity seemed to be complete or she lay in

bed with her head raised from the pillow. On the other hand, there were

occasional sudden spells of free activity even with a certain elation.

She could often be persuaded to answer questions or to write, the

slowness of this spoken or written speech varying considerably. Her

replies revealed the fact that she was essentially affectless and that

her intellectual processes were interfered with, even to the extent of

paragraphic writing. We have, therefore, here again features similar to

those of the preceding cases. In addition we must add as important that

this patient said retrospectively that she thought she was dead, that

she saw “shadows from Heaven and Earth,” “shadows of dead friends laid

out for burial,” all this without any fear. We shall see later that this

is a typical stupor content.

We will here include state 3 of Anna G. (See Chapter I, Case 1) who

after the pronounced stupor was for two months merely dull, somewhat

slowed and markedly apathetic. Although her orientation was not

seriously affected, there was considerable interference with her

intellectual processes, as shown in her wrong answers or her lack of

answers when more difficult questions were asked.

A similar picture was presented in state 2 of Mary D. (See Chapter I,

Case 4.) Here, to be sure, there were more marked stupor features in

that the patient wet and soiled, in addition to occasional spells when

she lay with her head raised. But she spoke and acted fairly freely

(even while soiling). By her replies she showed a considerable

intellectual inefficiency, although, like Anna G., her orientation was

not seriously disturbed. Here again there was complete affectlessness.

This gives us, therefore, five states which may be analyzed for the

symptoms of partial stupor. The pictures of all five are unusually

consistent. There is inactivity, marked but not complete; poverty of

affect without perfect apathy; and a marked interference with the

intellectual processes. The last can be studied better than in the deep

stupors because these partial cases are more or less accessible to

examination. There is a tendency for the patient to think much of death

either in the onset or during the psychosis. Negativism seems much less

prominent than in the deep stupors.

A natural criticism is that these cases merely had retarded depressions.

Although this topic will be discussed fully in a later chapter, two

differential characteristics should be mentioned now. First, depression

is a highly emotional state in which the sadness of the patient is as

evident from his facial and vocal expression as from what he says, while

these stupor reactions are by observation and confession states of

indifference. Secondly, there is no such disturbance of the intellectual

processes in depression as is here chronicled. Let the retardation once

be overcome so that the will is exercised and no real defect is

demonstrable. In our experience the cases of apparent depression with

intellectual incapacity are found on closer study to be really stupors

as other symptoms show.