TREATMENT OF STUPOR
In dealing with cases of benign stupor the first duty of physician and
nurse is naturally the physical hygiene of the patient. More is needed
to be done in the bodily care of these persons than for most of the
inmates of our hospitals for the insane. It is perhaps no exaggeration
to claim that a deeply stuporous patient needs as much attention as a
suckling babe. In the first place, the patient must be fed. It is
important for mental recovery that the individual in stupor should be
stimulated to effort as much as possible. Consequently there is an
economy of time in the long run in taking pains to get the patient to
feed himself in so far as that is possible. He should be led to the
table and assisted in handling his own spoon and cup. If this is not
practicable, he should then be spoon-fed, and if this in turn is found
to be out of the question, tube-feeding should be resorted to. But this
last should never be looked on as a permanent necessity, but only as a
method of maintaining the patient’s health until such time as he may be
capable of independent taking of nourishment. In exactly the same way it
is of prime importance to get the patient to attend to the natural
habits of excretion. He should be led to the toilet or to a chair
commode, and efforts to this end should be persistent, just as are those
of a good child’s nurse who has the ambition of making her charge
develop normal habits. Naturally those who retain urine and feces should
be watched to see that this retention does not last long enough to
menace health. The physical aspects of treatment are exhausted with
consideration for cleanliness. On account of the stupor patients’
inactivity and frequent tendency to wetting and soiling, this is a
particularly important consideration. It goes without saying that the
perineal region should be kept scrupulously clean. If any infections are
to be avoided, eyes, nose and mouth should also be cleansed frequently.
A patient who is so indifferent as to keep the eyelids open for such a
long time that the sclera dry and ulcerate is also apt to let flies
settle and produce serious ophthalmic disease.
Less obvious and more important are the measures undertaken for the
mental hygiene of the case. On account of the tendency present in so
many patients for sudden action while in the midst of an apparently deep
and permanent inactivity, it is necessary that these cases be not
isolated but remain under constant observation. This is particularly
true of those who have demonstrated impulsive suicidal explosions.
Not only on the basis of the psychological theory of the stupor process,
but from the observed phenomena of recovery, we gather that mental
stimulation is of first importance if an amelioration of the condition
is to be attempted. If the stupor reaction be a regression, which is
essentially a withdrawal of interest and energy rather than a fixation
on a false object, then excitement is desirable and interest must be
reawakened. The withdrawal is temporary (inasmuch as the psychosis is
benign), but just as a normal person wakes more readily on a clear
sunshiny day than when it rains, so the more cheering the environment
the more rapid the recovery.
Consequently, although trying to those in charge, persistent attention
should be given the patient. Feeding and hygienic measures probably have
considerable value in this work. As soon as it is at all possible the
patients should be got out of bed and dressed. When up, efforts should
be directed towards making them do something, even if it be something as
simple as pushing a floor polisher. On account of their lack of
enthusiasm the stupor cases are often omitted from the list of those
given occupation and amusement. Even if they go through the motions of
work or play with no sign of interest, such exercise should not be
allowed to lapse. Then, too, the environment should be changed when
practicable. A patient may improve on being moved to another building.
Perhaps the most potent stimulus that we have observed is that of family
visits. In most manic-depressive psychoses visits of relations have a
bad effect. The patients become excited, treat the visitors rudely,
perhaps even assault them, and all their symptoms are aggravated. But
the stupor needs excitement, and an habitual emotional interest is more
apt to arouse him than an artificial one. In another point the situation
differs. As a rule manic-depressive patients have delusional ideas or
attitudes in connection with their nearest of kin, so that contact with
these stirs up the trouble. The stupor regression going beneath the
level of such attachments leaves family relationships relatively
undisturbed. Hence, while the visit of a husband is likely to produce
nothing but vituperation or blows from a manic wife, the stuporous woman
may greet him affectionately and regain thereby some contact with the
world.
So many cases begin recovery in this manner that it cannot be mere
chance. One patient’s improvement, for instance, dated definitely from
the day a nurse persuaded her to write a letter home. It is striking,
too, how quickly a patient, while somewhat dull and slow, will brighten
up when allowed to return home. A similar improvement under these
circumstances is often seen in partially recovered cases of involution
melancholia, in whom a psychological regression similar to that of
stupor takes place. Such experiences make one wonder whether perhaps
these alone of all our insane patients would not recover more quickly at
home than in hospitals, provided nursing care could be given them.
This is a mere suggestion. Before treatment can be rational the nature
of any disease process must be known, and we do not pretend to have done
more as yet than outline the probable mental pathology of the benign
stupors. The next step is to put theory into practice and experiment
widely with various means to see if by appropriate stimulation the
average duration of these psychoses cannot be reduced. It is largely
with the hope of inducing other psychiatrists to carry on such work that
this book is written. There is no other manic-depressive psychosis
which, theoretically, offers such hope of simple psychological measures
being of therapeutic value.