THE LITERATURE OF STUPOR[C]
The cases of benign stupor which we report here are not clinical
curiosities. Taking the symptoms as the products of a reaction type, the
latter is really quite common. One, therefore, asks what other
psychiatrists have done with this material. How have they described
these stupors, how classified them? This chapter, essentially an
appendix, attempts to give a brief answer to this inquiry. No attempt is
made to catalogue all that has been written on or around this subject
but only to mention typical reports and viewpoints.
The French, beginning with Pinel in the 18th Century, were the first to
write extensively of stupor. An excellent paper by Dagonet[13] appeared
in 1872, in which such literature as had appeared up to that time is
discussed. He defines “Stupidity” as a form of insanity in which
“delirious” ideas may or may not be present, which has for its
characteristic symptoms a state of more or less manifest stupor and a
greater or less incapacity to coördinate ideas, to elaborate sensations
experienced and accomplish voluntary acts necessary for adaptation. This
would seem to include our “partial stupor,” as well as the more marked
cases.
He quotes an excellent definition from Louyer Villermay (Dict. des sc.
méd. t. LIII, p. 67). “Stupor is a term applied to stupefaction of the
brain. It is recognizable by the diminution or enfeeblement of internal
sensation and by a greater difficulty in exercising memory, judgment and
imagination. It is accompanied by a general numbness and a weakness of
feeling and movement. The patient, then, has an indefinite and stupid
expression, he understands questions put to him with difficulty, and
answers them with effort or not at all. He seems overwhelmed with sleep,
he forgets to withdraw his tongue after showing it to the doctor, he
complains of no uncomfortable sensation, of no illness, he seems to take
no interest in what goes on about him.... The stupor patient is a fool
who does not speak, in this being more tolerable than the one who speaks
[delightful naiveté!]. One who is dumbfounded by surprise or fright is
also to be called stuporous.”
Dagonet says stupor results from various causes, such as exhaustion, or
emotional and intellectual factors. Clinically it varies in kind and
degree according to the situation in which it develops. When it develops
during normal mental health, it disappears when its cause does. In
insanity it appears in the course of a psychosis of some duration, of
which it seems a part, an exaggeration of some symptom of the general
condition. Evidently he views stupor as a type of reaction: as a more or
less complete suspension of the operation of intellectual faculties, a
more or less sudden subtraction of nervous forces. This reaction can
result from a fright or the memory of it, a brain lesion or trauma, the
action of narcotics, exhausting fevers, excessive grief, the terrors of
alcoholic hallucinations, epileptic seizures, profound anemia and
nervous exhaustion consequent on sexual excess. He is careful to say
that both symptoms and treatment vary with the varied etiologies.
He credits Pinel with being the first to call attention to stupor. This
author claimed that some persons with extreme sensibility could be so
upset by any violent emotion as to have their faculties suspended or
obliterated. He noted, too, that stupors frequently terminated in manic
phases of 20 to 30 days’ duration. Pinel also emphasized the apathy of
these cases. Esquirol called stupor “acute dementia,” a term which
persisted in French literature for a long time. He described an
interesting circular case where alternations between mania and typical
stupor took place. He mentions too the dangerous, impulsive tendencies
of many patients. Georget emphasized the fact which Pinel had also
noted, that retrospectively the stupor patient says his mind was a blank
during the attack. In 1835 Etoc-Demazy published on the subject. He
regarded stupor not as a separate form of insanity but a complication
ensuing on monomania or mania. He recognized the partial as well as
complete stupor. He thought the condition was due to cerebral edema, as
did other writers of that period. Dagonet remarks about this last--a
lesson not learned in fifty years by the profession--that demonstrable
edema does _not_ produce the typical symptoms of stupor. Baillarger in
1843 (Annales Médico-psychologiques) was the first whose ambition to
simplify psychiatric types led to denial of a separate kind of reaction.
He claimed that stupor was not a form of insanity but an extension of a
“délire mélancholique.” As Dagonet remarks, every symptom by which he
characterizes stupor is a psychiatric symptom and insanity can consist
just as well in the diminution as the perversion or exaltation of normal
faculties. Some of Baillarger’s cases had false ideas, some apparently
none at all. Dagonet thinks this justifies two types, one a dream-like
state and another where no ideas are present, although he admits one may
be an exaggeration of the other. Brierre de Boismont (Annales
Médico-psychologique, 1851, p. 442) compares these two kinds of stupors
to deep sleep when intelligence is completely suspended and to sleep
with dreams. (These two types would correspond to our “absorbed mania”
and true deep stupor.) He urges strongly the separation of stupor from
melancholia as an entirely different type of reaction, in this
connection citing the views pro and con of various authors. Of these
Delasiauve is particularly cogent in discriminating stupor from
melancholia on the grounds of the difference of the emotional reactions
and of the intellectual disorder and the real paucity of thought in the
former psychosis.
After quoting these and other authors, Dagonet offers an explanation for
the diversity of opinion. He says that stupor following another
psychosis may retain some of its symptoms, so that a mixture obtains, as
often in medicine. He then gives excellent descriptions of three types:
the deep stupor with paralysis of the faculties, the cases that are
absorbed in false ideas, and ecstatic cataleptics.
The remainder of his paper is concerned with cases and discussions about
them. He cites examples of stupor following fear or other emotional
shocks, following grave injuries such as the loss of a limb, following
head trauma and with typhoid fever. As to the last he points out that
delirious features are prominent. Many authors have assigned sexual
excesses as a cause of stupor. The psychosis, Dagonet says, is not pure
but more a mixture of hypochondria and depression. Relationship with
mania is next considered. He says that stupor may succeed, alternate
with or precede mania. His cases seem mainly to have been what we call
absorbed manics or manic stupors. In fact, he uses the last term. The
commonest introductory psychosis, he claims, is depression, but from his
brief case reports it would seem that most of his patients were not
stuporous, in the narrow sense of the term, but severely retarded
depressions. In fact, in perusing his case material comprising “stupors”
in the course of many types of functional insanity, or as a complication
of epilepsy or general paralysis, it is evident that in practice he does
not follow the discriminative definitions of the earlier portion of his
paper. For him, apparently, patients who are markedly inaccessible to
examination from whatever cause are “stuporous.” He closes with
excellent remarks on physical and psychic treatment. As to prognosis he
has nothing to say beyond the opinion that most of the cases recover.
If Dagonet be accepted as summarizing the early French work, we can
conclude that their generalizations were on the whole quite sound. These
were: that stupor is an abnormal mental reaction, usually psychogenic
but often the result of exhaustion, that it consists in a paralysis of
emotion, will and intelligence; that the prognosis is usually good; that
mental stimulation may produce recovery. What remained to be done after
this work was the refinement in detail of these generalizations,
particularly in respect to the differentiation of prognostically benign
and malignant types. But other Frenchmen did not take up this work,
apparently, for the brilliant psychopathologists of the next generations
attended to stupor only in so far as it was hysterical.
An Englishman, however, soon took up the task, adding more exactness to
his formulations. Newington[14] published his important paper in 1874.
A nascent stage of stupor, he thinks, is a common reaction to great
exhaustion, “such as hard mental work, prolonged or acute illness,
dissipation, etc.” Such conditions, like the grave psychotic forms, he
regarded as due to physical exhaustion of the brain cells, but, since he
thought psychic stress could produce this exhaustion, this “organic”
view did not bias his general formulations. He makes a division into two
stupors: Anergic Stupor and Delusional Stupor. The former may be
primary, being generally caused by a sudden intense shock (Esquirol’s
“Acute Dementia”), or secondary (a) to convulsions of any kind, (b) to
mania in women, (c) to any other prolonged nervous exhaustion. The
delusional form results from (a) intense melancholia, (b) from general
paralysis in which it may be intercurrent, (c) from epileptic seizures.
When one examines his points of difference between these two types, it
becomes clear that Newington really gave an excellent differentiation of
benign and malignant stupor--in fact, it is the only serious attempt at
such discrimination prior to this present work. What is more remarkable
is the fact that, although he clearly saw the clinical differences, he
failed to see that the two types differed prognostically. His
description is given in a table sufficiently concise to justify its
quotation _in extenso_.
_ANERGIC STUPOR_ _DELUSIONAL STUPOR_
_Etiology_--Hereditary and Hereditary.
individual liability to
sudden loss of _vis nervosa_.
_Onset_--Rapid. Usually insidious, may be almost
instantaneous.
_Symptoms_--Intellect greatly Conduct shows reasoning power.
impaired.
_Memory_--Seems to be swept Found after recovery to have
away as far as possible. been preserved to a great
extent.
_Emotional Capacity_--Nil or Evidence of grief, fear, etc., in
almost so. Tears frequent facial expressions and wringing
but due to relaxation of and clasping of hands.
sphincter muscles. Features Tears rare. Great contraction
relaxed, eyes vacant and not of features [grimacing?].
constantly fixed. Eyes fixed on one
point, usually upwards or
downwards, or else obstinately
closed.
_Volition_--Almost absent. Frequently great stubbornness,
refusal to do what is
wanted. On the other hand,
intense determination in
following out own plan.
_Motor System_--Weak and uncertain. But little interfered with,
Patient has to be independently of sheer
led about and if placed on a asthenia, produced by
seat or in some position does patient’s conduct. May stand
not move. (“Cataleptoid” behind door or kneel on floor
condition.) in constrained position even
for days.
_Sensory System_}--Both dull. Ditto. There seems to be a
_Reflex System_ } much greater ability to bear
severe pain.
_Pupils_--Dilated. Tendency to contraction.
_Sleep_--Generally good. Intense sleeplessness.
_General bodily condition_-- Affected _pari passu_ with
Emaciation, sometimes extreme, mental state and seems
usually rapid, with governed by it.
rapid recovery of flesh.
Often not much loss of
weight, though whole tone is
lowered.
_Vascular System_--Pulse slow, Pulse weak and often quick
sometimes almost imperceptible. and thready. Complexion
Cyanotic appearance, edema anemic and sallow. The
and iciness of extremities. other appearances may be
Great decrease of vitality present but come on later
in peripheral structures, and are less marked.
as shown by asthenic
eruptions and production of
vermin.
_Digestive System_--Tongue Tongue dry, small and furred.
clean or if furred it is moist. Refusal of food. Great
Appetite _apathetic_, bowels constipation. Dirtiness of
not irregular, but habits habits rare.
very dirty.
If one compares these data with those given in the chapter on Malignant
Stupors, it is seen that in the main Newington has made the same
discrimination as we have. He is certainly wrong in denying “negativism”
to his anergic type. Probably, too, he attempts too fine a distinction
between the physical symptoms of the two groups. His conclusions are
interesting: that in the anergic cases there is an _absence_ of
cerebration, while amongst the delusional there is an abnormal
_presence_ of intense but perverted cerebration. This is not unlike our
own view. He thinks the difference in memory is the most important
differential point. Sex is important in determining the nature of the
stupor, for he found the anergic type following mania in females only.
He observed such an end to manic attacks in 6 out of 36 cases. All his
cases were under 30 and he regards the prognosis as good on the whole.
As to treatment he emphasizes the necessity for “moral pressure” as a
stimulus and cites a case of rapid improvement after a change of scene.
Since 1874 very little advance has been made by British psychiatrists,
as seen by a perusal of Clouston’s[15] summary in 1904. He regards sex
exhaustion as a highly frequent cause, although Dagonet had shown 32
years before that sex abuse does not produce a true stupor. He thinks
stupor usually follows depression or mania and says that “the
‘Confusional Insanity’ of German and American authors is just a lesser
degree of stupor.” Omitting his stupors in general paralysis and
epilepsy he makes three clinical divisions: _melancholic or conscious
stupor_, which is not a product of delusions, although delusions of
death or great wickedness may be present, impulsiveness and fits may be
observed; _anergic or unconscious stupor_, which corresponds roughly to
our deep, benign stupor; and _secondary stupor_ after acute mental
disease, which resembles our partial stupor. He warns against a rash
diagnosis of dementia in this last group. His views on the importance of
mental causation and the relation to manic-depressive insanity may be
gathered from these sentences: “The condition of the mental portion of
the convolutions in stupor is probably analogous to the stupidity of a
nervous child when terrified or bullied.” “Stupor is frequently one of
the stages of alternating insanity following the exalted condition. It
is more apt to occur in those where the exalted period is acutely
maniacal. The stupor is usually melancholic in form.” Since he claims
that the anergic is a “very curable form of mental disease,” while only
50% of the melancholic cases recover, it seems clear that this division
is not prognostically final. The “melancholic” is evidently Newington’s
“delusional” without his more accurate discrimination of symptoms.
From the standpoint of accurate description the opinion may be ventured
that there is a gap in the literature from the early French writers and
Newington up to the paper by Kirby, which has been discussed in the
first chapter. This gap is filled by literature of the German schools
and their adherents in other countries. German psychiatry has been
concerned mainly with classification or the elaborate examination of
certain symptoms. Inevitably such a program militates against detached
objective clinical description. It is hard to record symptoms that
interfere with classification. German psychiatry has tended to make the
insane patient a type rather than an individual. Hence the gap in the
descriptive literature of stupor.
The necessity of establishing the possibility of some stupors having a
good prognosis has arisen from Kraepelin’s work. He can rightly be
viewed as the father of modern psychiatry because he introduced a
classification based on syndromes and taught us to recognize these
disease groups in their early stages. Inevitably with such an ambitious
scheme as the pigeon-holing of all psychotic phenomena some mistakes
were made. Most of these appear in the border zone between dementia
præcox and manic-depressive insanity. The latter group being narrowly
defined, the former had to be a waste basket containing whatever did not
seem to be a purely emotional reaction. Clinical experience soon proved
that many cases which, according to Kraepelin’s formulæ, were in the
dementia præcox group, recovered. Adolf Meyer was one of the first to
protest and offered categories of “Allied to Manic-Depressive Insanity”
or “Allied to Dementia Præcox,” as tentative diagnostic classifications
to include the doubtful cases.
Difficulties with stupor furnish an excellent example of the confusion
which results from the adoption of rigid terminology. The earlier
psychiatrists were free to regard a patient in stupor as capable of
recovery as well as deterioration. When Kahlbaum included stupor with
“Catatonia,” the situation was not changed, for he did not claim a
hopeless prognosis for this group. But when Kraepelin made catatonia a
subdivision of dementia præcox, all stupors (except obvious phases of
manic-depressive insanity) had to be hysterical or malignant. Faced with
this dilemma psychiatrists have either called recoveries “remissions”
or, like E. Meyer, claimed that one-fifth or one-fourth of catatonics
really get well.
As a matter of fact it seems clear that stupor is a psychobiological
reaction that can occur in settings of quite varied clinical conditions.
It is not necessary to detail publications describing stupors in
hysteria, epilepsy, dementia præcox or in the organic psychoses. It may
be of interest, however, to cite some examples of acute, benign stupors
and the discussion of them which appear in the literature of recent
years.
An important group is that of stupors occurring as prison psychoses.
Stern[16] mentions that acute stupors are found in this group.
Wilmanns[17] examined the records for five years in a prison and
discovered that there were two forms of psychotic reaction, a paranoid
and a stupor type. It is interesting psychologically that the former
appeared largely among prisoners in solitary confinement, while the
stupors developed preponderantly among those who were not isolated. The
stupors recovered more quickly. He describes the psychosis thus: The
prisoner becomes rather suddenly excited, destructive and assaultive;
then soon passes into an inactive state, where he lies in bed, mute,
with open expressionless eyes. He is clean, however; eats spontaneously
and attends to his own hygienic needs. Some cases are roused by
transport from the jail to the hospital but sink into lethargy again
when they reach their beds. Physically, they show disturbances of
sensation which vary from analgesia to hypesthesia. There are a rapid
pulse, positive Romberg sign, exaggerated reflexes, fibrillary twitching
of the tongue and tremor of the hands. Recovery takes place gradually.
They begin to react to physical stimuli and to answer questions,
although still inhibited, until consciousness is quite clear. When
speech begins, it is found that they are usually disoriented for place
and time as the result of an amnesia which sets in sharply with the
excitement. This memory defect gradually improves _pari passu_ with the
other symptoms.
Two attacks in the same prisoner of what seem to have been typical
stupor are reported by Kutner[18] and Chotzen.[19] The patient was a
recidivist of unstable mental make-up. At the age of 34 he was sent to
prison for three years. Shortly after confinement began, he became
stuporous, being mute and negativistic, soiling, refusing food and
showing stereotypy. On being shifted to another institution he appeared
suddenly much better, although he remained apathetic and dull for some
months. A striking feature was a complete amnesia, not merely for the
stupor but also for his trial and entrance to the prison. At the age of
42, he was again incarcerated. A practically identical picture again
developed, with recovery when his environment was changed, and with a
similar amnesia. Recovery seemed to be complete and there were no
hysterical stigmata. The interesting features of this case are that a
typical stupor seems to have been precipitated by imprisonment, while
the retroactive amnesia covering a painful period of the patient’s life
reminds one of hysteria.
A case which is more difficult to interpret is reported briefly by
Seelig.[20] A man of 20 with bad inheritance tried to steal 100 marks.
When sent to jail he became ill shortly before his trial was due and was
sent to a hospital. There he seemed anxious, was shy, and gave slow
answers, with initial lip motions and had to be urged to take hold of
objects. All this sounds more like a pure depression than a stupor. But
he also had paralogia. This might make one think of a Ganser reaction on
the background of depression. S., however, calls it an hysterical
stupor, although he agreed with Moeli that it was hard to differentiate
from a catatonic state.
Löwenstein[21] reports an interesting case of a dégénéré who had had
hysterical attacks. He suddenly developed stupor symptoms, which lasted
with interruptions for nearly two years. After recovery and during the
interruptions the patient explained his mutism, refusal to swallow, his
filthiness and general negativism as all occasioned by delusions. He was
commanded by God to act thus, the attendants were devils, and so on. He
spoke, too, of being under hypnotic influence. In addition there were
other delusions such as that he had killed his brother. The attack came
on with the belief that he was going to die, otherwise none of the ideas
were typical of the stupors we have studied. Another incongruous symptom
was that he did not seem to be really apathetic, he reacted constantly
to the environment. The author comments on the absence of senseless
motor phenomena, such as would be expected in a “catatonic.” His
complete memory of the psychosis also speaks against the usual form of
stupor. It seems possible that this psychosis was neither hysterical nor
a benign stupor in our sense, but, rather, an acute schizophrenic
reaction such as one occasionally sees. From the account which
Löwenstein gives, one gathers that the patient was absorbed in a wealth
of imaginations.
Gregor[22] tells of a stupor which is unusual in that it consisted only
of symptoms connected with inactivity, which did not affect the
intellectual processes. The patient was a rubber worker who suddenly
developed a depression with self-accusation and convulsions. She was
soon admitted to a clinic and then showed mutism and catalepsy. Later
she became totally immobile with no apparent psychic reactions, and
soiled. Gregor studied pulse, respiration and respiratory volume in
their reflex manifestations and found nothing unusual. Next he tried to
discover if there were voluntary alterations in respiration. He
discovered that the respiratory curve could be changed by calling out
words to her, by odors associated with suggestions, menaces, etc. [This
is suggestive of the dissociation of affect, which we have discussed.]
After two months she recovered, _with complete recollection of the
stupor period_. It was then proven that the absence of reactions was not
the same as the lack of perception of stimuli.
Froederström[23] reports a case that suggests hysteria, where the stupor
lasted for 32 years. A girl at the age of 14 fell on the ice, had a
headache, went to bed and stayed there for 32 years. She lay there
immobile, occasionally spoke briefly and took nourishment, when it was
put at a definite place at the edge of the bed. At first (according to a
late statement of her brothers) this consisted only of water but was
soon changed to two glasses of milk a day. After being in this state for
ten years she was placed in a hospital for two weeks, where she was
mute, did not react to pin pricks and had to be fed. It seems that at
home she secretly looked after herself, for she kept her hair and nails
in condition. Sometimes she sat up and stared at the ceiling.
After attending to the patient for 30 years, her mother died. The
patient cried for several days when told of it, and after this she took
nourishment of her own accord. Two years later a brother died. Again she
cried on hearing the news. Her father, who looked after her when the
mother was dead, also died. Then a governess came into the home, who
noticed that furniture was moved about when she was alone.
At the age of 46 she suddenly woke up and asked at once for her mother.
She claimed total amnesia for the period of her stupor, including the
stay at the hospital. She could summon memories of her childhood,
however. Her brothers she did not recognize and said, “They must be
small.” She recalled the fall on the ice and coming home with headache,
toothache and pain in the back. Her general knowledge was limited but
she could read and write. Her expression and appearance was that of a
young person, only her atrophic breasts and the fat on her buttocks
betraying her age. She had been well for four years at the time the
report was made.
He thinks that a certain tendency to exaggeration and simulation speak
for hysteria. We would be more inclined to view the fact that she looked
after herself in spite of complete amnesia as evidence of hysteria.
Another protracted case suggestive of hysteria is that reported by
Gadelius.[24] The patient was a tailor, 32 years old, who had always
been rather taciturn and slow. A year before admission he began to have
ideas of persecution and to shun people. Then he developed a stereotyped
response, “It is nice weather,” whenever he was addressed. A month
before admission inactivity set in. He would sit immobile in his chair
with closed eyes and relaxed face; he resisted when an attempt was made
to put him to bed. His color was pale.
He was taken to hospital on November 1, 1882, where he was observed to
be immobile and to have little reaction to pin pricks. When a limb was
raised, it fell limply. However, he would leave bed to go to the toilet.
Tube-feeding became necessary, but when the tube was inserted in his
nose, he woke up. He then showed an amnesia not merely for his illness
but for his whole life: he did not know his father, that he was married
or that he had a mother. Towards the end of November, he became limp
again and answered, “I don’t know” to most questions. In December,
however, he improved again and for a few months these variations
occurred. From April, 1883, to May, 1886, he was in deep stupor, almost
absolutely immobile and close to being completely anesthetic even with
strong Faradic currents. Towards the end of this period he walked about
_whenever he thought he was not watched_. He was very cautious about
this and became motionless any time he became aware of observation.
(Gadelius thinks this was not simulation but the expression of an
automatism on the basis of a vague fixed idea.)
This condition persisted apparently for five years more, by the end of
which time the anesthesia had turned into a hyperesthesia. A year later
he began to eat. It was now found that he had an amnesia for his illness
and former life, so that he did not even recognize a needle or pair of
scissors. He knew that he was born in the month of February and retained
some facility in calculation, in speech, walking and usual motions. Then
he regained all his memories and resumed his trade as tailor. He was
discharged in June, 1893, nearly eleven years after admission.
It seems safe to say that elements at least of hysteria appear in this
history, such as the profound retroactive amnesia and appearance of
simulation in the conduct of the patient. Accurate and rapid grasp of
the environment is necessary for such a watch as he kept on the eye of
his attendants. Mental acuity of this grade combined with amnesia looks
more like an hysterical than a manic-depressive process.
Leroy[25] describes a case much like ours which is interesting from a
therapeutic standpoint. The patient was a woman who passed from a severe
depression with hallucinations and anxiety into a long stupor, from
which she recovered completely. There was no negativism and no affect,
although the latter appeared so soon as contact began to be established.
When well she had a complete amnesia for the onset of the psychosis.
Leroy attributed the recovery, in part at least, to the thorough
attention given the patient. Kraepelinian rigidity is seen, however, in
the author’s refusal to regard the case as “circular” because of the
lack of all cyclic symptoms. He takes refuge in the meaningless label
“Mental Confusion.”
An important group of cases is that of the stupors occurring during
warfare. Considering stupor as a withdrawal reaction, it is surprising
there were so few of them, although partial stupor reactions as
functional perpetuation of concussion were very common. The editor saw
several typical cases in young children in London who passed into long
“sleeps” apparently as a result of the air raids. Myers[26] has given
us the best account of stupors in actual warfare. A typical case was
that of a man who was found in a dazed condition and difficult to
arouse. He could give little information about himself, could neither
read nor write and never spoke voluntarily. A week later his speech was
still limited and labored and no account of recent events could be
obtained from him. Under hypnosis he was induced to talk of the accident
which had precipitated this disorder. He became excited in telling his
story, evidently visualizing many of the events. In several successive
séances, more data were obtained and a cure effected. Myers points out
that in all his cases there was a mental condition which varied from
slight depression to actual stupor, all had amnesias of variable extent
and all had headaches. The mental content seemed to be confined to
thoughts of bombardment, with a tendency for the mind always to wander
to this topic. The author thinks that pain is a guardian protecting the
patient from too distressing thoughts. An effort to speak would cause
pain in the throat of a case of mutism and, sometimes, when a
distressing memory was sought after under hypnosis, physical pain would
wake the sleeper. His view is that pains tend to preserve the mutism and
amnesia, so that there are “inhibitory processes” causing the stupor,
which prevent the patient from further suffering. He does not find
either in theory or experience reason to believe that these conditions
are the result of either suggestion or “fixed ideas.” He thinks it
natural that the last symptom of the stupor to disappear should be
mutism, as speech and vision are the prime factors in communicating with
environment. [As has been noted frequently in this book, mutism is a
common residual symptom of the benign stupor.] Myers believes that in
nearly every instance mutism follows stupor and is merely an attenuation
of the latter process. When deafness is associated with mutism, he
thinks it is often due merely to the inattention of the stuporous state.
In this connection we should mention that Gucci[27] points out that
stupor patients with mutism of long duration may, when requested, read
fluently and then relapse again into complete unreactiveness towards
auditory impressions. This, we would say, is probably an example of a
more or less automatic intellectual operation occurring when the patient
is sufficiently stimulated, although he cannot be raised to the point of
spontaneous verbal productivity.
As these scattered reports about benign stupors are so unsatisfactory,
one naturally turns to text-books. Little more appears in them.
Kraepelin treats stupors occurring in manic-depressive insanity as
falling into two groups, the depressive and manic. The former seems to
be nearer to our cases, judging by the statements in his rather sketchy
account. He regards stupor as being the most extreme degree of
depressive retardation. [This possibility has been discussed in the
chapter on Affect.] His description seems perhaps to include cases which
we would regard as perplexity states or absorbed manias. Activity is
reduced, they lie in bed mute, do not answer, may retract shyly at any
approach, but on the other hand may not ward off pin pricks. Sometimes
there is catalepsy and lack of will, again there may be aimless
resistance to external interference. They hold anything put into their
hands, turning it slowly as if ignorant of how to get rid of it. They
may sit helpless before food or may allow spoon-feeding. Not rarely they
are unclean. As to the mental content, he says they sometimes utter a
few words, which give an insight into confused delusions that they are
out of the world, that their brains are split, that they are talked
about, or that something is going on in the lower part of the body. The
affect is indefinite except for a certain bewilderment about their
thoughts and an anxious uncertainty towards external interference.
Intellectual processes suffer. They are disoriented and do not seem to
understand the questions put to them. An answer “That is too
complicated” may be made to some simple command. Kraepelin thinks that
the disorder is sometimes more in the realm of the will than of
thinking, for one patient could do a complicated calculation in the same
time as a simple addition. After recovery the memory for the period of
the psychosis is poor and quite gone for parts of it. Occasionally there
may be bursts of excitement, when they leave the bed; they may scold in
a confused way or sing a popular song.
His manic stupor is a “mixed condition,” a combination of retardation
with elated mood. The condition is different from the depressive stupor
in that activity is more frequent, either in constant fumbling with the
bed clothes or in spasmodic scolding, joking, playing of pranks,
assaultiveness, erotic behavior or decoration. The affect is usually
apparent in surly expression or happy, or erotic, demeanor. They are
usually fairly clear and oriented and often with good memory for the
attack but with evasive explanations for their symptoms. One cannot make
any classification of the ideas he quotes, but it is apparent from all
his description that the minds of these “manic stupors” are not a blank
but rather that there is a fairly full mental content.
Wernicke, unhampered by classifications of catatonia and
manic-depressive insanity with inelastic boundaries, calls all stupor
reactions akinetic psychoses with varying prognosis. He does not make
Kraepelin’s mistake of confusing the apathy of stupor with the
retardation of depression, stating distinctly that the processes are
different.
Bleuler also has grasped this discrimination. He points out that the
thinking disorder in what he terms “Benommenheit” (dullness)
differentiates such conditions from affectful depression with
retardation. He writes, of course, mainly of dementia præcox,[28] but
makes some remarks germane to our problem. In the first place he denies
the existence of stupor as a clinical entity, except perhaps as the
quintessence of “Benommenheit”, it is the result of total blocking of
mental processes. Consequently, he says, one can observe the external
features of stupor in all akinetic catatonics, in marked depressive
retardation, when there is a lack of interest, affect or will, in
autism, with twilight states, as a result of negativism or, finally,
when numerous hallucinations distract the patient’s attention into a
world of fancy. He notes that in all stupors (with the exception,
perhaps, of “Benommenheit”) the symptoms may disappear with appropriate
psychic stimulation or that some reaction, no matter how larval, may be
observed. He speaks, for instance, of the visits of relatives waking the
patient up.
His only real group is “Benommenheit,” which he separates out as a true
clinical entity. This seems to correspond roughly with our “Partial
Stupors.” It is essentially an affectless, thinking disorder, usually
acute, sometimes chronic, occurring among schizophrenics. He believes
that it is the result of some organic process (intracranial pressure or
toxin). Activity is much reduced or absent; they have poor
understanding, answer slowly or confusedly; their actions are sometimes
as ridiculous as those of people in panic (e.g., throwing a watch out
of the window when the house is on fire); the defect is best seen in
writing, for large elisions are found in sentences. He was able to
analyze only one case and she retained her affect; it was even labile
and marked. One suspects that such a case might, perhaps, not really
find a place in the “Benommenheit” group even as Bleuler himself
describes it.
With the exception of Kirby, whose work has already been discussed in
the introduction, we have been able to find only one author who has
attempted any symptomatic discrimination of the recoverable and
malignant catatonic states. Raecke[29] made a statistical study and
found that 15.8% recovered, 10.8% improved, 54.4% remained in
institutions, while 30% died. With the etiology mainly exogenous 20%
recovered and 14.3% improved. A good outcome was seen in 30.2% of
hereditary cases, while only 22.7% did well in the non-hereditary group.
His most important contribution is in his formulation of good and bad
symptoms. He thinks that dull, apathetic behavior with uncleanliness and
loss of shame are not so unfavorable as has been thought. Malignant
symptoms are grimacing with prolonged negativism but without essential
affect anomaly, decided echopraxia and echolalia and protracted
catalepsy. We would agree with this, although command automatisms have
not been prominent either in our benign or malignant stupors.
Two writers have made special observations that should be confirmed and
amplified before their significance can be established. Whitwell[30]
thinks that in addition to a diminished activity of the heart there
exists a pathological tension. Ziehen says that he also has frequently
seen angiospastic pulse-curves in exhaustion stupor or acute dementia,
but that other pulse pictures may be seen as well. Any such studies
should be correlated rigorously with the clinical states before they can
have any meaning. Wetzel[31] tested the psychogalvanic reflex in stupors
and in normal persons who simulated stupors. He found them different.
Only one publication has come to our attention in which an attempt is
made at psychological interpretation of various symptoms in stupor.
Vogt[32] derives much from a restriction of the field of consciousness.
Only one idea is present at a time, hence there is no inhibition and
impulsiveness occurs. Similarly, if the idea appear from without, it,
too, is not inhibited, which produces the suggestibility that in turn
accounts for catalepsy. Stereotypy and perseveration are other evidences
of this narrowness of thought content. Negativism is a state, he says,
of perseverated muscular tension. [This would apply only to muscular
rigidity.] So far as it goes, this view seems sound. Of course it
leaves the problem at that interesting point, Why the restriction of
consciousness?
If stupor be a psychobiological reaction, it should occur, occasionally,
in organic conditions just as the deliria of typhoid fever may contain
many psychogenic elements. Gnauck[33] reports such a case. The patient,
a woman, was poisoned by carbon dioxide. At first there was
unconsciousness. Then, as she became clearer, it was apparent that she
was clouded and confused. She soiled. Neurological symptoms were
indefinite; enlargement of the left pupil, difficult gait and
exaggerated tendon reflexes. Months later she was still apathetic,
although her inactivity was sometimes interrupted by such silly acts as
cutting up her shoes. After five months she recovered with only
scattered memories of the early part of her psychosis. What seems like a
typical stupor content was recalled, however. She thought she was
standing in water and heard bells ringing.
Stupor-like reactions are not infrequent in connection with or following
fevers. Bonhoeffer[34] describes a type that follows a febrile
Daemmerzustand of a few hours or a day at most. The affect suddenly
goes, disorientation sets in. Although outbreaks of anxiety may be
intercurrent, the dominant picture is of stupor. Reactions are slowed,
often there is catalepsy. Sometimes there is a retention defect and
confabulation to account for the recent past. Again the retention may be
good. In the foreground stands a strong tendency to perseveration. This
may affect speech to the point of an apparent aphasia or produce
paragraphia. Plainly organic aphasia and focal neurological symptoms are
sometimes seen.
As Knauer[35] has gone thoroughly into the question of the febrile
stupors, the reader is referred to his paper for a digest of the
literature on this topic. Mention has already been made in Chapter IX to
this publication, where the close resemblance of these rheumatic, to our
benign functional, stupors has been noted. Discrimination seems to be
possible only on the basis of delirium-like features being added in the
organic group.
FOOTNOTES:
[C] This chapter has been written mainly from material in Dr. Hoch’s
notes which was manifestly incomplete. No claim is made for its
exhaustiveness.
_The Editor._
[13] Dagonet, M. H.: “De la Stupeur dans les Maladies Mentales et de
l’Affection mentale désignée sous le Nom de Stupidité.” _Annales
Medico-Psychologiques_, T. VII, 5e Serie, 1872.
[14] Newington, H. Hayes: “Some Observations on Different Forms of
Stupor, and on Its Occurrence after Acute Mania in Females.” _Journal of
Mental Science_, Vol. XX, 1874, p. 372.
[15] Clouston: “Mental Diseases.” J. & A. Churchill, 1904.
[16] Stern: “Ueber die akuten Situations-psychosen der Kriminellen.”
Abstracted, _Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate Bd.
V, S. 554.
[17] Wilmanns, K.: “Statische Untersuchungen über Gefängnisspsychosen.”
_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 847.
[18] Kutner: “Ueber katatonischer Zustandsbilder bei Degenerierten.”
_Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 375.
[19] Chotzen: “Fall von degenerativem Stupor.” Abstracted, _Zeitschr. f.
d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 1077.
[20] Seelig: “Psychiatrischer Verein in Berlin, 1904.” _Neurol.
Centralbl._, 1904, S. 421.
[21] Löwenstein: “Beitrag zur Differentialdiagnose des katatonische u.
hysterische Stupors.” _Allg. Zeitschr. f. Psychiatrie_, Bd. LXV.
[22] Gregor: “Über die Diagnose psychischer Prozesse im Stupor.” Leipzig
Meeting, 1907. Reported in _Neurol. Centralbl._, 1907. S. 1083.
[23] Froederström: “La Dormeuse d’Okno. 32 ans de Stupeur, Guérison
complète. Nouvelles Iconographies de la Salpétrière,” 1912, No. 3.
Reviewed by E. Bloch, _Neur. Centralbl._, 1913, S. 852, and by Forster,
_Zeitschr. f. d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 510.
[24] Gadelius: “Ett ovanligt fall af stupor med nära 9-arig oafbruten
tvangsmatning; uppvaknande; total amnesi; helsa” (_Hygiea_, 1894, LVI.,
Part 2, No. 10, p. 355). Abstracted by Walker Berger, _Neurol.
Centralbl._, 1895, S. 186.
[25] Leroy: “Un cas de stupeur, guéri au bout de deux ans et demi.”
_Bull. de la Soc. Clin. de Méd. Ment._, III, 276, 1910. Abstracted in
_Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate, Bd. II, S. 495.
[26] Myers, Charles S.: “Contributions to the Study of Shell Shock.”
_Lancet_, January 8, 1916, pp. 65-69. _Lancet_, September 6, 1916, pp.
461-467.
[27] Gucci, R.: “Sopra una particolarità del mutismo per stupore
communicazione preventive.” _Archivio italiano per le malattie nervose_,
1889, XXVI, 69-108. Reviewed in _Neurol. Centralbl._, 1889, S. 659.
[28] “Dementia Præcox oder Gruppe der Schizophrenie” Aschaffenburg’s
“Handbuch der Psychiatrie.”
[29] Raecke: “Zur Prognose der Katatonie.” _Arch. f. Psychiatrie_, Bd.
XLVII, 1, 1910.
[30] Whitwell: “A Study of the Pulse in Stupor.” _Lancet_, Oct. 17,
1891. Reviewed by Ziehen, _Neurol. Centralbl._, 1892, S. 290.
[31] Wetzel: “Die Diagnose von Stuporen.” Baden-Baden Meeting of May,
1911. Reported in _Neurol. Centralbl._, 1911, S. 886.
[32] Vogt, Ragner: “Zur Psychologie der Katatonischen Symptome.”
_Centralbl. für Nervenheilkunde_, 1902, S. 433.
[33] Gnauck, R.: “Stupor nach Kohlenoxydvergiftung” (_Charité-Annalen_,
1883, p. 409). Reviewed by Moeli, _Neurol. Centralbl._, 1883, S. 237.
[34] Bonhoeffer: “Die Symptomatischen Psychosen,” 1910.
[35] Knauer, A.: “Die im Gefolge des akuten Gelenkrheumatismus
auftretenden psychischen Storungen.” _Zeitschr. f. d. ges. Neurol. u.
Psychiatrie_, Bd. XXI, S. 491-559.
INDEX
absorption, 163
activity, reduction of, 36, 100, 120
acute dementia, 251
adaptation, 107, 192
adrenalin, 180
affect, 9, 22, 32, 44, 113, 116, 117, _123_, 170
affect, dissociation of, 128, 201, 205, 237
affect, inappropriate, 216, 237
affect, poverty of, 234
affect, shallow, 127
affectlessness, 171, 172
affects, combination of, 245
agitation, 156
akinesis, 121
akinetic psychoses, 4, 274
albuminuria, 40
allied to dementia præcox, 236, 260
allied to manic-depressive, 236, 260
allopsychic, 135
ambivalence, 147
amnesia, 9, 24, 68, 70, 267, 269
anergic or unconscious stupor, 258
anergic stupor, 255, 256
anesthesia, 196, 212, 268
anger, 118, 139
angiospastic, 276
animal, turning into, 171
Antæus, 190
apathy, 36, 48, 112, 122, 123, 151, 152, 163, 181, 195, 225, 237
apathy, resemblance to absorption, 202
anxiety, 122, 123, 126, 137, 153, 162, 166, 198, 226
apoplexy, 224
arteriosclerotic dementia, 80
attention, 195
atypical features, explanation of, 200
autoerotism, 199
automatism, 268
Baillarger, 252
behavior, 195
“Benommenheit,” 67, 273, 274
bewilderment, 79, 112, 120, 126
Bleuler, 67, 273
blocking, 163
blood-pressure, 181
blushing, 9
Bonhoeffer, 277
boredom, 247
bowels, interest in, 217
brain tumor, 5
breath, holding, 62
Brierre de Boismont, 252
burial, 111, 192
Calculation, 23, 24
Calvary, 111
Cannon, 180
Cases
Adele M. (Case 24), 220
Alice R., 135, 140, _192_
Anna G. (Case 1), _6_, 47, 48, 68, 74, 77, 109, 127, 136, 140, 145,
147, 183
Anna L. (Case 16), 135, _149_, 158
Anna M., 135
Annie K. (Case 5), _24_, 69, 72, 105, 110, 111, 136, 139, 141
Bridget B., 135
Caroline de S. (Case 2), _11_, 68, 109, 141, 178, 193
Catherine H. (Case 23), _216_
Catherine M. (Case 18), _158_
Catherine W. (Case 25), _221_
Celia C. (Case 17), _155_
Celia H. (Case 19), _167_
Charles O., 143, 144, 178
Charlotte W. (Case 12), _83_, 106, 112, 113, 116, 127, 136, 141, 144,
166, 201
Emma K., 71, 140
Harriett C., 138
Helen M., 130
Henrietta B., 138, 140
Henrietta H. (Case 8), _42_, 74, 77, 105, 106, 110, 111, 115, 136
Isabella M., 136, 144, 147
Johanna B., 135, 138
Johanna S. (Case 13), _91_, 120, 127, 136
Josephine G., 138
Laura A., 71, 77, 135, 138, 140, 142, 193
Maggie H. (Case 14), 71, 96, 109, 140, 194
Margaret C. (Case 10), _55_, 75, 78
Mary C. (Case 7), _39_, 42, 71, 74, 77, 121, 136, 138, 178, 194
Mary D. (Case 4), _20_, 47, 69, 70, 71, 74, 76, 109, 136, 145
Mary F. (Case 3), _14_, 68, 105, 110, 111, 115, 140, 142, 164, 183
Mary G., 140, 141
Meta S. (Case 15), _99_, 109, 127, 135
Nellie H. (Case 22), _214_
Pearl F. (Case 9), _51_, 75, 142
Rose S. (Case 21), _210_
Rose Sch. (Case 6), _35_, 74, 75, 145
Rosie K. (Case 11), _62_, 75, 105, 112, 178
Winifred O’M. (Case 20), _207_
catalepsy, 13, 21, 31, 32, 36, 86, 94, 95, 102, 115, 128, _143_, 144,
145, 147, 209, 211, 235, 239
catatonia, 4, 5, 50, 128, 205, 236, 261
catheterization, 85, 86, 102
cemetery, 105, 112
childbirth, 159
childhood, 188, 195
Chotzen, 262
Christ, 86, 115
Christian Science, 150
circular psychosis, 5, 126
circulation, 180
Clark, 184
clouding, 67
Clouston, 258
cocoon, 109
coffin, 88, 106, 114
coma, 176, 223
concussion, aerial, 224
confusion, 163
constipation, 92
convent, 117
convulsive attacks, 15
crime, 248
crucifix, 88
crucifixion, 86, 106, 114, 161
crustaceans, 148
cut-up idea, 94
cyanosis, 32, 63, 180
Dagonet, 3, 249, 250, 253, 254, 258
death, feigned, 5, 83, 137, 196, 246
death, mutual, 192
death, projected, 198
death, relation with affect, 110
death ideas, 3, 46, 47, 50, 52, 58, 65, 83, 97, _104_, 107, 109, 110,
111, 114, 115, 119, 122, 136, 137, 138, 152, 153, 156, 159, 163, 166,
187, 190, 191, 192, 199, 212, 225, 235, 240
death of others, 192
deep stupor, _1_, 6, 41, 199
deep stupor, explanation of, 197
Delasiauve, 253
delirium, 176
delusional stupor, 255, 256
delusions, 165
délire mélancholique, 252
dementia præcox, 4, 5, 62, 123, 127, 128, 205, 225
depression, 5, 117, 123, 137, 156, 236, 253
depression, differentiation of, 48, 124, 226
dermatographia, 102, 180
deterioration, 210
diabetes, 224
diarrhea, 45, 64, 178
dissociation, 225
distress, 119, 122, 154, 156, 162
dreams, 161, 190
drooling, 132, 181
drowning, 87, 192
Earth, 107, 111, 190
echolalia, 275
echopraxia, 275
ecstasy, 91, 162, 191
_élan vital_, 123
elation, 44, 91, 123, 127, 151, 157
electric chair, 85, 110, 119
electricity, 150
emaciation, 8, 32, 58
emotion, 62
emotion, inconsistency of, 126
emotions and contact with reality, 164
energy, 187, 194
epilepsy, 5, 183, 199, 224, 242, 254
epileptic aura, 184
epileptic confusion, 80
epileptic deterioration, 80
erotic, 161
erotic ideas, 90
Esquirol, 251
Etoc-Demazy, 251
Euripides, 2
excretion, habits of, 230
extroversion, 195
family visits, 232
father, 104, 109, 110
fear, 111
fever, 8, 13, 26, 32, 38, 40, 45, 64, 102, 160, _176_, 235, 241
filthiness, 210
fire, 151, 157
flippancy, 129
flushing, 27, 127, 128, 180
food, refusal of, 99, 104
Forel, 182
Froederström, 265
Gadelius, 267, 268
Ganser reaction, 263
Georget, 251
German psychiatry, 259
Gnauck, 277
giggling, 206
God, 115, 160, 162
Golden Age, 187
Gregor, 265
Gucci, 271
guilt, 157
hair, loss of, 32, 58, 180
heat production and loss, 179, 181, 242
Heaven, 87, 88, 104, 106, 108, 109, 111, 114, 115, 117, 118, 160, 162,
166, 171, 191, 240
Hell, 240
Hoch, 164
hyperæmia, 8
hyperesthesia, 268
hypochondria, 225, 253
hypomania, 243
hypnotism (see mesmerism), 145, 213
hysteria, 3, 135, 184, 225, 264, 267, 269
ideational content, 82, 235
immobility, 85, 94, 196
immorality, 150
impulsiveness, 50, 113, 128, 172
impurities in stupor reaction, 66
inaccessibility, 141
inactivity, 17, 30, 40, 48, 56, 62, 88, 97, 102, 123, _132_, 152, 163,
194, 225, 234, 238
inactivity, patients’ explanation of, 134
incest ideas, 209
inconsistency of reaction, 134, 214, 215, 245
incontinence (see _wetting_ and _soiling_), 52, 57
indifference, 123, 124, 142
infantile reactions, 196
infections, 5, _178_, 241
insight, 157
insomnia, 39
instinct of self-preservation, 188, 191, 198
interest, 99, 195
internal secretions, 178
internal thoughts, 163
interruptions of stupor, 130, 197, 238, 244
introversion, 164, 227
involuntary nervous system, 178, 180
involution melancholia, 129, 195, 225, 226
jaundice, 21
Jung, 107
Kahlbaum, 4, 260
Kirby, 4, 6, 164, 234
Knauer, 175, 278
Kraepelin, 4, 260, 269, 271, 272, 273
Kutner, 262
laughter, 56, 141
Leroy, 269
leucocytosis, 8, 13, 40, 64, 178
levels, principle of, 198, 244
Löwenstein, 264
MacCurdy, 2, 184
make-up, mental, 5
malignant stupors, _205_
mania (or manic), 5, 126, 137
mania, absorbed, 125, 226, 245
manic content, 166
manic-depressive insanity, 149, 167
manic-depressive insanity, mixed conditions in, 202
manic-depressive insanity, pathology of, 174
manic episodes, 191
manic stupor, 125, 245, 253
marriage, 160, 169
masturbation, 196, 209, 219
melancholic or conscious stupor, 258
memory (see thinking disorder), 40, 67, 168, 195
menstruation, 8, 56, 61, 100, 168, _182_, 236, 242
mesmerism, 86, 114, 117, 141, 144
Meyer, Adolf, 260
Meyer, E., 261
midday nap, 247
mixed conditions, 202, 273
Moeli, 264
Moses, 108
mother’s body, 108
movement, spontaneous, 133
muscular resistiveness, 224
mutism, 10, 22, 31, 57, 62, 88, 104, 124, 134, 209, 271
mutual death, 165, 192, 196, 248
Myers, 270, 271
mystics, 3
mythology, 107, 108, 190, 240
negativism, 5, 31, 52, 56, 65, 128, _138_, 139, 199, 209, 225, 235, 238,
243, 276
negativism, explanation of, 196
nephritis, 224
neuropsychic defect, 174
neurotic, 150
nervous, 159
Newington, 3, 254, 255, 257
Nirvana, 166, 188, 200, 248
nourishment, 229, 242
Œdipus, 165
œstrous cycle, 182
onset, 96
onset, depressive, 99
ophthalmic disease, 230
Orestes, 2
organic delirium, 175
organic dementia, 67
organic stupor, 223
orientation (see thinking disorder), 9, 53, 154, 156, 159, 170, 245
Osiris, 108
pain, 133
Papanicolaou, 182
paragraphia, 80
paralysis, feeling of, 105
paralysis, general, 5, 254
partial stupor, _34_, 206
perplexity, 125, 152, 153, 154, 155, 156, 160, 162, 164, 165, 169, 172,
208, 226, 245
perplexity, differentiation of, 227
perseveration, 145, 148, 276
personality, 1
perversity, 138
physical disease, 175
physical symptoms, _174_, 176
Pinel, 249, 251
poison, 97, 172
primitive ideas, 108
prison, 105, 169
prognosis, 4, 5, _206_
prostitution, 157, 161
psychoanalysis, 161
psychobiological reaction, 246
psychogalvanic reflex, 276
psychological explanation, 186
psychological factors, 175
pulse, 63, 92, 128, 180
Rank, 107
reality, 107, 187
recuperation, 189
rebirth, _107_, 110, 114, 115, 119, 120, 121, 122, 187, 189, 190, 191,
240
regression, 187, 188, 191, 192, 194, 198, 199, 243
religious visions or ideas, 2, 162
resentment, 98
resistiveness, 54, 97, 102, 112, 127, 129, 133, 141, 147, 156, 211, 225
respiration, 180
resurrection, 159
restlessness, 53, 120, 169
retention of urine, 224, 230
rheumatism, 175
rigidity, muscular, 142, 179
Romberg sign, 262
rousing, 176
sadness, 111, 113, 121, 122, 124
St. Catherine of Siena, 2
St. Paul, 2
saliva, 30, 63, 181
scattered speech, 207, 208
schizophrenia, 67, 214
seclusiveness, 207
secondary stupor, 259
Seelig, 263
self-injury, _50_, 57
sexual excess, 251, 253, 258
sexual ideas, 209, 219
sexual sensations, 209
ship, 87, 106, 118
sick, 136
skin, dry, 180
skin, greasy, 43, 180
sleep, 188, 189, 247
slowing of thought, 125
slowness, 85, 119, 160
smearing of feces, 142
smiling, 127
social status, 236
soiling, 30, 132, 172, 196, 225, 230, 235
somatopsychic, 135
sphincters, control of, 133
spirits, 89
spoiled child reaction, 129, 139
starvation, 182
stereotypy, 276
Stern, 261
stimulation, mental, 231, 246
Stockard, 179, 182
stubbornness, 142
stupidity, 93
stupor, diagnosis of, _223_
hysterical, 225
malignant, _205_, 206
organic, 223
reaction, _35_, 236
relation to manic-depressive insanity, 173
sudden mental loss, 71
suggestibility, 145, 198, 276
suicidal impulses, _50_, 84, 104, 116, 118, 128, 172, 230, 235, 240
suicide, 188
sulkiness, 129
sullenness, 142
suprarenals, 242
swallowing, 133
sweating, 63, 102, 179, 180
swimming movements, 94
syncopal attacks, 64
tears, 95, 98, 117, 128, 153
tense of ideas, 116
thinking disorder, 22, 31, 37, 39, 41, 45, 48, 59, _67_, 75, 124, 125,
148, 152, 157, 235, 239, 247
thinking disorder, explanation of, 195
tongue, coated, 13
toxins, 175
trauma, 5, 224
treatment, _229_
ulceration of eyes, 133
unconscious ideas, 163
motives, 186
unconsciousness, physiological, 199, 224, 277
underground, 240
understanding, 67
uneasiness, 93, 94, 95, 121
unfaithfulness, 97
unhappiness, 192
urine, retention of, 31
Villermay, 250
Vogt, 276
vomiting, 45
water, 94, 95, 106, 107, 114, 120
weakness, 137, 160
wealth, 169
wedding ring, 117
weight (see emaciation), 38, 52, 61
Wernicke, 3, 273
wetting, 30, 40, 132, 151, 170, 172, 196, 225, 230, 235
Wetzel, 276
whining, 171, 225
Whitwell, 276
Wilmanns, 261
womb, 108
worry, 110
writing, 27
Ziehen, 276
[Transcriber’s Note:
The following corrections have been made:
p. 1: antequated to antiquated (antiquated methods)
p. 11, 97, 100: period to colon (Under Observation:)
p. 53: extra “when” removed (from “In June, 1914, when she was seen
smiling at times.” to “In June, 1914, she was seen smiling at times.”)
p. 64: period to colon (Physical condition during the stupor:)
p. 84: 24 italicized to match other dates (October 24)
p. 91: missing blank line added between Case 12 and 13
p. 93: aswer to answer (in answer to questions)
p. 145: diaeresis added to coöperation to match other instances
p. 150: fatiguable to fatigable (nervous and fatigable)
p. 153: phenomenom to phenomenon (unusual phenomenon for a stupor
patient)
p. 159: comma added (correcting his grammar, and cried easily.)
p. 161: missing “in” added (appeared in the statement that her father)
p. 171: missing open quote added (she wants to go “to the river,”)
p. 198: funadmental to fundamental (most fundamental symptoms)
p. 211: salivia to saliva (drooling saliva)
p. 220: inaccesibility to inaccessibility (disinterestedness and
inaccessibility)
p. 252: dimunition to diminution (just as well in the diminution)
p. 256: or to of (relaxation of sphincter muscles)
p. 262, Footnote 19: v. to u. (Zeitschr. f. d. ges. Neur. u.
Psychiatrie)
p. 265, Footnote 23: Zeitsch. to Zeitschr. to match other instances
(Zeitschr. f. d. ges. Neur. u. Psychiatrie)
p. 271, Footnote 27: Archivo to Archivio (Archivio italiano per le
malattie nervose)
p. 280, Index: catherization to catheterization
p. 282, Index: ophtalmic to ophthalmic (ophthalmic disease)
Irregularities in capitalization (e.g. Dementia vs. dementia) and
hyphenation (e.g. off-hand vs. offhand) have not been corrected. A
repetitive sentence on p. 46 (Then she became stupid, although neither
sad nor happy. Then, she claimed, she got stupid, but neither sad nor
happy.), and two spaced em-dashes on p. 87 have also been retained.
Minor punctuation errors (e.g. missing period, missing close or open
quote where intended placement is clear) have been corrected without
note. The abbreviations “p.m.”, “e.g.” and “i.e.” have been
standardized, with no space.]