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Benign Stupors - A Study of a New Manic-Depressive Reaction Type
by August Hoch
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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 Praecox 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 praecox. 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 praecox 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, cooperating 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 role 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 praecox, 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 formulae, 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 praecox" 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 praecox 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 praecox 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 conjunctivae 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 deg. or 103 deg. 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 hyperaemia 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 98-1/2 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 deg. 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 deg. 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 deg.

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 x 7, but for 4 x 9 repeated the 21, and when given 9 x 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 deg. 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 deg., 102 deg. or even 103 deg. 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 praecox, 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 deg. and 100 deg.

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 deg., a coated tongue, suffused conjunctivae. 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.

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