THE INTERFERENCES WITH THE INTELLECTUAL PROCESSES
This is one of the most interesting and important of the stupor
symptoms. We are accustomed to think of the functional psychoses having
symptoms to do with emotions and ideas in the main, and, conversely,
that disorientation, etc., observed in such cases is merely the result
of distraction, poor attention or coöperation. But in stupor the deficit
in understanding, incapacity to solve simple problems and failure of
memory seem deep-rooted and fundamental symptoms. So far is this true
that Bleuler[5] looks on “schizophrenic” cases with this symptom of
“Benommenheit” as organic in etiology. It may be said at the outset that
we do not share this view for many reasons. One at least may now be
stated as it seems to be final. In benign stupor purely mental stimuli
may change the whole clinical picture abruptly and with this produce a
change in the intellectual functioning such as we never see in organic
dementias or clouded states. We find it more satisfactory to attempt a
correlation of this with the other symptoms on a purely functional
basis, as will be explained later.
For the study of the interferences with the intellectual processes
during stupor reaction, we have two sources of information: The first is
derived from the account which the patient is able to give in regard to
what he remembers as having taken place around him or in his mind during
the stupor period; the second is the direct observation of partial
stupor reactions.
1. Information Derived from the Patient’s Retrospective Account
We will start with the cases of marked stupor mentioned in Chapter I.
Anna G.’s (Case 1) psychosis commenced at home, and under observation
lasted with great intensity for five months. She remembered only vaguely
the carriage going to the Observation Pavilion, had no recollection of
the latter, nor of her transfer to the Manhattan State Hospital and of
most of the stay at the Institute ward, including the tube- or
spoon-feeding which had to be carried on for four months. She also
claimed that she did not know where she was until four or five months
after admission. She was amnesic for her delusions and hallucinations.
Of Caroline DeS. (Case 2) we have no information. Of Mary F. (Case 3),
whose stupor began at home and under observation lasted two years, we
find that she had no recollection of coming to the hospital, what ward
she came to, who the doctor and nurses were (with whom she became
acquainted later), in fact she claimed that for about a year she did
not know where she was. But she remembered having been tube-fed (this
took place over a long period). Mary D.’s (Case 4) stupor also commenced
at home, and under observation lasted for three months. She had no
recollection of going to the Observation Pavilion, of the transfer to
Manhattan State Hospital, and of a considerable part of her stay here,
including such obtrusive facts as a presentation before a staff meeting,
an extensive physical and a blood examination, and she claimed not to
have known for a long time where she was. Annie K.’s (Case 5) stupor
commenced at home. Although she recalled the last days there and some
ideas and events at the Observation Pavilion, the memory of the journey
to Ward’s Island was vague, as was that of entrance to the ward, and she
claimed not to have known where she was for quite a while. Specific
occurrences, such as the taking of her picture (with open eyes two
months after admission), an examination in a special room, her own
mixed-up writing (end of second week) were not remembered. But it is
quite interesting that an angry outburst of another patient within this
same period, which was evidently not recorded, is clearly remembered.
We shall later show that when the patient comes out of a stupor the
condition may be such that, for a time at least, retrospective accounts
are difficult to obtain. It must also be remembered that not
infrequently the more marked stupors may be followed by milder states,
and it is important, if we wish to determine how much is remembered,
not to confuse the two states or not to let the patient confuse them.
For example, Mary D. (Case 4), who showed two separate phases, while she
claimed not to know of many external facts, also added that she could
not understand the questions which were asked. From observation in other
cases it seems that in marked stupor any such recollection about the
patient’s own mental processes would be quite inconsistent. We have to
assume, therefore, that this remark referred in reality to the second
milder phase, for which, as we shall see, it is indeed quite
characteristic. It is not necessary to burden the reader with other
cases, all of which consistently gave such accounts.
We see, then, that in the marked stupor the intellectual processes are
regularly interfered with, as evidenced by almost complete amnesia for
external events and internal thoughts. In other words, this would
indicate that the minds of these patients were blank. Inasmuch as direct
observation during the stupor adduces little proof of mentation, we may
assume that such mental processes as may exist in deepest stupor are of
a primitive, larval order.
Before we examine more carefully the milder grades of stupor, it will be
necessary to say a few words about the retrospective account which the
patient gives of intellectual difficulties during the incubation period
of the psychosis. As a matter of fact, we find that these accounts are
remarkably uniform. While some patients, to be sure, speak of a more or
less sudden lack of interest or ambition which came over them, others of
them speak plainly of a sudden mental loss. Mary. C. (Case 7) claimed
she suddenly got mixed up and lost her memory. Laura A. spoke at any
rate of suddenly having felt dazed and stunned. Mary D. (Case 4) said
she felt she was losing her mind and that she could not understand what
she was reading. Maggie H. (Case 14) began to say that her head was
getting queer. We see from this that the interferences with the
intellectual processes may in the beginning be quite sudden.
In some instances a more detailed retrospective account was taken, which
may throw some light upon the interferences with the intellectual
processes with which we are now concerned. Emma K., whose case need not
be taken up in detail, had a typical marked stupor which lasted for nine
months, preceded by a bewildered, restless, resistive state for five
days. She was in the Institute ward for the first four months, including
the five days above mentioned; later in another ward. When asked what
was the first ward which she remembered, she mentioned the one after the
Institute ward, and when asked who the first physician was, she
mentioned the one in charge of the second ward. However, when taken to
the Institute ward, she said it looked familiar, and was able to point
to the bed in which she lay, though somewhat tentatively. The same
rousing of memory occurred when the first physician, who saw her daily,
was pointed out to her. She remembered having seen him, and then even
recalled the fact that he had thrown a light into her eyes, but
remembered nothing else. This observation would seem to show that with
some often repeated or very marked mental stimuli (throwing electric
light into her eyes) a vague impression may be left, so that it may at
least be possible to bring about a recollection with assistance, whereas
spontaneous memory is impossible. In another instance, the patient was
confronted with a physician who had seen a good deal of her. She said
that he looked familiar to her, but she was unable to say where she had
seen him. Here then again evidence that a certain vague impression was
made by a repeated stimulus.
Another feature should here be mentioned, namely, that isolated facts
may be remembered when the rest is blank. We have seen above that Annie
K. (Case 5), while very vague about most occurrences, recalled a sudden
angry outburst in detail. Another patient, though the period of the
stupor was a blank, recalled some visits of her mother. At these times,
as she claimed, she thought she was to be electrocuted and told her
mother so, “Then it would drop out of my mind again.” These facts are
very interesting. We can scarcely account for such phenomena in any
other way than by assuming that certain influences may temporarily lift
the patient out of the deepest stupor. In spite of the fact that stupors
often last for one or two years almost without change, a fact which
would argue that the stupor reaction is a remarkably set, stable state,
we see in sudden episodes of elation that this is not the case, and
other experiences point in the same direction. A similar observation was
made on a case of typical stupor with marked reduction of activity and
dullness. A rather cumbersome electrical apparatus (for the purpose of
getting a good light for pupil examination) was brought to her bedside.
Whereas before, she had been totally unresponsive, she suddenly wakened
up, asked whether “those things” would blow up the place, and whether
she was to be electrocuted. During this anxious state she responded
promptly to commands, but after a short time relapsed into her totally
inactive condition. We have, of course, similar experiences when we try
to get stuporous patients to eat, who, after much coaxing may, for a
short time, be made to feed themselves, only to relapse into the state
of inactivity.
Such variations are paralleled, as we shall later show, by a suddenly
pronounced deepening of the thinking disorder. We have already seen that
the onset may be quite sudden. All this indicates that, in spite of a
certain stability, sudden changes are not uncommon. Finally, we know
that, in spite of the fact that stupor is an essentially affectless
reaction, certain influences may produce smiles or tears, or, above all,
angry outbursts, which again can hardly be interpreted otherwise than by
assuming that those influences have temporarily produced a change in the
clinical picture, in the sense of lifting the patient out of the depth
of the stupor. All these facts suggest that inconsistencies in
recollection are correlated with changes in the clinical picture.
As is to be expected, the cases with partial stupors remember much more
of what externally and internally happened during their psychoses. Rose
Sch. (Case 6), who had a partial stupor during which she answered
questions but showed a great difficulty in thinking, said
retrospectively that she felt mixed up and could not remember. Although
she recalled with details the Observation Pavilion and her transfer, she
was not clear about their time relations (how long in the Observation
Pavilion, how long in the first ward). Mary C. (Case 7), whose activity
was not entirely interfered with and who showed some thinking disorder,
said retrospectively that she could not take in things. Henrietta H.
(Case 8), who had a partial stupor, claimed to have known all along
where she was, but that she felt mixed up, that her thoughts wandered
and that she felt confused about people. In the cases where a partial
stupor was preceded by a marked one, such as in phase 2 of Anna G. (Case
1) and phase 2 of Mary D. (Case 4), we have no retrospective account
regarding the partial stupor, because emphasis in the analysis was
naturally laid on the period comprising the most marked disorder.
However, we can gather from the few cases at our disposal that the
patients retrospectively lay stress chiefly on their inability to
understand the situation.
We finally have to consider the group of suicidal cases. We have
information only in regard to two cases, namely, Margaret C. (Case 10)
and Pearl F. (Case 9). In both of these, we find that a good many things
that happened during the period under consideration were remembered, as
were also the patients’ own actions. In Rosie K. (Case 11) we have at
least the evidence that she remembered her own impulses, namely, that
she refused food because she wanted to die. In other words, in these
partial stupors with impulsive suicidal tendencies the interference with
the intellectual processes seems to be moderate, and memory for external
events not markedly affected.
2. Information Derived from Direct Observation
The evidence can best be presented by considering the details of some
cases.
Rose Sch. (Case 6) was remarkable, in connection with the present
problem, in her unusually poor answers. She either merely repeated the
questions, or made irrelevant superficial replies, or said she did not
know, this even with very simple questions. When better, too, though not
quite well, she showed striking discrepancies in time relations and
incapacity to correct them. It would seem that in this case there was
something more than an acute interference with the intellectual
processes, such as we are here discussing. As a matter of fact, we have
the statement in the history that the patient herself said she was slow
at learning in school and had not much of an education. A congenital
intellectual defect and the attitude which it creates may, however, as
my experience has repeatedly shown me, very greatly exaggerate an acute
thinking disorder. The case, therefore, while it shows us an
unquestionably acute interference with the intellectual processes, does
not give us useful information about its nature. More information can be
gathered from Mary D. (Case 4). Even toward the end of her marked stupor
some replies were obtained chiefly by making her write. When asked to
write Manhattan State Hospital, she wrote Manhatt Hhospshosh, and for
Ward’s Island, Ww. Iland. Again, instead of writing 90th Street, she
wrote 90theath Street. These are plainly reactions of the path of least
resistance or, in these instances, of perseveration. Of the same nature
are some of her other replies in writing or speaking. After she had been
asked to write her name, she was requested to add her address, or the
name of the hospital; she merely repeated the name. Similarly, when
asked whether she knew the examiner, she said “Yes,” but when urged to
give his name, she gave her own. In the partial stupor at a time when
she knew where she was, knew the names of some people about her, the
year and approximately the date, she made mistakes in calculation and
could not get the point of a test story. Moreover, she failed in
retention tests without there being any evidence of anything like a
marked fundamental retention disorder, such as we find in Korsakoff
psychosis. It seems that these results are best termed defects in
attention, which chiefly interfere with the apprehension of more
difficult tasks. As we shall see later, this seems to be rather
characteristic of these cases. Another point which should be mentioned
is the fact that her reaction to questions which she was unable to
answer (such as matters which referred to her amnesic periods) was
peculiar, inasmuch as she did not only not try to think them out, but
seemed indifferent to her incapacity, simply leaving the question
unanswered. This too, as we shall see later, is characteristic. Laura
A., at a time when she could be made to reply, merely repeated the
question, again a reaction of least resistance. The same patient
sometimes asked, “Where am I?” Mary C. (Case 7) made similar queries.
Although she was at times approximately oriented, she would say, “I
don’t know where I am,” or “I can’t realize where I am,” or more
pointedly, “I can’t take in my surroundings.” She often did not answer
and sometimes seemed bewildered by the questions. Henrietta H. (Case 8)
again showed some defect of orientation and mistakes in calculation, and
above all, marked mistakes in writing (for Manhattan State
Hospital--Manhaton Hotspal). A special feature here is that this
occurred immediately after she had been quite talkative, but suddenly
had relapsed into a dull state. Anna G. (Case 1), during the third phase
of her psychosis, showed the following: Although she was approximately
oriented and answered promptly simple questions; e.g., about orientation
or simple calculation, she, like these other patients, simply remained
silent when more difficult intellectual tasks were required of her
(more difficult calculations); or when she was asked how long she had
been here (which involved data that could not be available to her, owing
to her amnesia); or when questions were put to her regarding her
feelings or the condition she had passed through. On the other hand, she
sometimes gave appropriate replies in the words “yes” or “no,” but it
was difficult to say whether these answers did not also represent the
path of least resistance.
We will finally take up the last phase of Margaret C. (Case 10).
Although she was entirely oriented, there was a certain vagueness about
her answers which is difficult to formulate. She was telling about the
onset of her sickness and said that at that time her mind was taken up
with prayers about the salvation of her relatives. She was asked exactly
when it was that she thought of this and she answered “Now?” (What
period are we talking about?) “The present.” (What did I ask you?)
“About this period of my sickness.” (Which one?) “What sickness?” She
said herself at this point, “I am rather stupid.” Again when asked how
her mind worked, she said, “Pretty quickly sometimes--I don’t know.” (As
good as it used to?) “No, I don’t think so.” (What is the difference?)
“There is no difference.” (What did I ask you?) “The difference.” (The
difference between what?) “You did not say.” In this the shallowness of
her comprehension and thinking is well shown, and it seems here again
perhaps justifiable to formulate the main defect as one of attention,
which prevents completion of a complicated process of comprehension. A
feature of further interest in this case is that automatic intellectual
processes, such as those necessary for the writing of a long poem from
memory, were not interfered with.
Summary
In the most pronounced stupor we have evidently a more or less complete
standstill in thinking processes. Practically no impressions are
registered and consequently nothing is remembered except events that
occurred in some short periods when some affective stimulus, or a brief
burst of elation, lifts the patient temporarily out of the deep stupor.
It is impossible to say whether the statement of a complete standstill
has to be qualified. In some stupors repeated environmental stimuli
sometimes make at least a vague impression, so that while spontaneous
recollection is impossible a feeling of familiarity is present when the
patient is again confronted with this environment. This might be an
exception to the dictum of complete mental vacuity, or it may be that
there are somewhat less pronounced stupor reactions. When more is
perceived, there is often a retrospective statement of having felt mixed
up, being unable to take in things, or, directly under observation, the
patient may say, “I cannot realize where I am,” “I cannot take in my
surroundings.” In harmony with this is the fact that questions often
produce a certain bewilderment. In quite pronounced states in which
some replies can still be obtained, we find that the intellectual
processes may be interfered with to the extent of a paragraphia, i.e., a
remarkably mixed-up writing in which perseveration (one form of
following the path of least resistance) plays a prominent part. This
same principle is also seen in such reactions as the repetition of the
question or the senseless repetition of a former answer. These phenomena
remind us of what we see in epileptic confusions, in epileptic
deterioration and in arteriosclerotic dementia.
In milder cases difficulties in orientation may be more or less marked;
or there may be incapacity to think out problems, although the
orientation is perfect. The more automatic mental processes may run
smoothly (memory and calculation may be excellent) and there may yet be
a certain shallowness in thinking, a defect of attention (a purely
descriptive term) which is most obvious in the patient’s inability to
grasp clearly the drift of what is going on or the meaning of
complicated questions. I am inclined to think that poor results in
retention tests are entirely due to this attention disorder, for we have
no evidence of any fundamental retention defect such as we find in the
totally different organic stupors. From a practical point of view it is
important at this place to call attention to the fact that such mild
changes are particularly seen in end stages. Even when pronounced
negativistic tendencies do not play a prominent rôle, the patient is
then apt to be silent chiefly as a result of the residual disorder in
the intellectual processes. Still more striking are the conditions which
are on a somewhat higher level and in which the shallowness of the
responses, due to the residual disorder of attention, together with the
last traces of the affectlessness, are apt to create the impression of a
dementia. In such cases the opinion is often held that the patient has
reached a defect stage from which recovery is impossible, whereas a
thorough knowledge of these end stages teaches us that they are not only
recoverable but quite typical for the terminal phases of stupor.
Considering these data, especially those gathered in the end stages, it
would appear that there is no tendency in this intellectual disorder
associated with the stupor reaction for any special side of mental
activity to be most prominently affected. It looks rather as if it were
a question of a general diminution of the capacity to make a mental
effort which in its different intensities accounts for the symptoms.
FOOTNOTES:
[5] See Chapter XV.