Chapter VIII: Special Cases: Relationship of Stupor to Other Reactions

We have described typical cases of benign stupor and isolated certain interrelated symptoms which, when they dominate the clinical picture, we believe establish the diagnosis of stupor, regardless of the severity of the reaction. These symptoms are apathy, inactivity, a thinking disorder and, quite as important as these, an absorbing interest in death. It is typical that the patient contemplates his dissolution with indifference or, at most, with mild or sporadic anxiety. There seems little reason to doubt that when these four symptoms occur alone, we are justified in making a diagnosis of stupor. The next problem is to consider the meaning and classification of cases where these symptoms occur in conjunction with others. This naturally introduces the subject of relationship of stupor to other manic-depressive reactions.

It is probably best to begin with presentation of three such cases.

CASE 16.--_Anna L._ Age: 24. Admitted to the Psychiatric
Institute August 21, 1916.

_F. H._ Maternal grandmother temporarily insane during
illegitimate pregnancy, thereafter a little odd. Mother
high strung and emotional. Father high strung, impulsive
and irritable.

_P. H._ As a child she was quick tempered, quite a spitfire
and given to tantrums. At the age of 14 she became a
vaudeville actress in Cleveland, which was the home of her
childhood. When 17 she married a Jew, although she was
herself a Catholic. Her husband noted that she was fretful,
sensitive, resentful and quick tempered, although apt to
recover quickly from her rages. Previously healthy,
neurotic symptoms began with marriage, taking the form of
stomach trouble and a tendency to fatigue. Shortly after
marriage an abortion was induced. After being married for
two years she had a quarrel and separated from her husband.
They were reconciled later, but in the meantime she had
been having relations with another man. When 20 an
abdominal operation was performed in the hope of relieving
her gastric symptoms, but no improvement occurred. The
patient after recovery stated that she continued to be
nervous, shaky and dizzy, at times trembling when going to
bed at night. Two years later, however, she took up
Christian Science and showed objectively some improvement
in her health, although according to her later accounts she
continued to feel somewhat nervous and fatigable. Her
husband stated that at this time she also began to ponder
much about such questions as the difference between life
and death, what “matter” was, and also studied “grammar”
and “etiquette.” According to the patient some five or six
months before admission she began to have peculiar
sensations following intercourse--a feeling of bulging in
the arms, legs and back of the neck. One evening after an
automobile ride there were peculiar sensations on her right
side like “electricity” or as if she were inhaling an
anesthetic. She gasped and thought she was dying. Two
months before her admission she went with her husband and
his family to a summer resort where she felt increasingly
what had always been a trouble to her, namely, the nagging
of this family.

Just before her breakdown, because she went daily to the
Christian Science rooms in order to avoid the family, they
suspected her of immorality and accused her of going to
meet other men. Even her husband began to question her
motive. Retrospectively the patient herself said that she
now felt she was losing her mind and did not wish to talk
to any one. At the time she told her husband that she felt
confused and as if she were guilty of something and being
condemned. Repeatedly she said she knew she was going to
get the family into a lot of trouble. Once she spoke of
suicide, and for a while felt as if she were dying. Finally
she became excited and shouted so much that she was taken
to the _Observation Pavilion_, where she was described as
being restless and noisy, thinking that she was to be
burned up and that she had been in a fire and was afraid to
go back.

_On admission_ she looked weary and seemed drowsy.
Questions had to be repeated impressively before replies
could be obtained, when she would rouse herself out of this
drowsy state. She seemed placid and apathetic. She said
that nothing was the matter, but soon admitted that she had
not been well, first saying that her trouble was physical
and then agreeing that it had been mental. When asked
whether she was happy or sad, she said “happy,” but gave
objectively no evidence of elation. Her orientation was
defective. She spoke of being in New York and on
Blackwell’s Island, but could not describe what sort of
place she was in, saying merely that it was “a good place,”
or “a nice country place,” again “a good city.” Once when
immediately after her name L. had been spoken and she was
asked what the place was, she said “The L.” She knew that
she had arrived in the hospital that day but said that she
had come from Cleveland, and to further questions, that she
had come by train, but she could not tell how she reached
the Island. She claimed not to know what the month was and
guessed that the season was either spring or autumn
(August). She gave the year as 1917, called the doctor “a
mentalist,” and the stenographer “a tapper,” or “a mental
tapper.” She twice said she was single. When asked directly
who took care of her, said “Mr. Marconi,” who she claimed
at another time had brought her to the hospital. To the
question, who is he? she replied, “Wireless,” and could not
be made to explain further. That night she urinated in her
bed, and later lay quite limp, again held her legs very
tense.

For five days she remained lying quietly in bed for the
most part, although once she called out “Come in, I am
here,” “Jimmie, Jimmie” (husband’s name). Several times she
threw her bed clothes off. Otherwise she made no attempt to
speak and took insufficient food unless spoon-fed. At one
examination she looked up rather dreamily but did not
answer. When shaken she breathed more quickly and seemed
about to cry but made no effort to speak. When left to
herself she closed her eyes and did not stir when told she
could go back to the ward. She was then lifted out of her
chair and took a step or two and stopped. Such urging had
to be repeated, as she would continue to remain standing,
looking about dreamily, although finally when taken hold of
she whimpered. When she got to the dining-table she put her
hand in the soup and then looked at it. So far there is
nothing in this case atypical of what we would call a
partial stupor. The cardinal symptoms of apathy,
inactivity, with a thinking disorder, are all present and
dominate the clinical picture. There is, further, the
history of a delusion of death during the onset of the
psychosis. Had her condition remained like this, there
would be no difficulty in classifying the case, but other
symptoms appeared.

Five days after admission she was restless, somewhat
distressed, and announced that she wanted to talk to the
physician. When examined, the distress, with some
whimpering, continued. She asked the doctor not to be harsh
to her, frequently said there was something wrong and began
to cry. A normal interest appeared only once, when she
spontaneously said she wanted to see her relatives. A most
interesting feature, however, was a certain perplexity that
now appeared. She spoke of this directly: “I do not know
what it is all about. I know you are a doctor, that is all.
I don’t know whether I passed out and came back again or
what--I don’t know what to make of it.” She also felt
confused about her marriage--“There is where all the mixup
is. I was married when I was 16.” She was reminded that she
had said she was single, and replied “I am single.” Then
where is your husband? she was asked. “He must be dead.”
She recalled the examination on admission and remembered
some of the questions that she was asked then, also knew
that she had been at the Observation Pavilion and that she
had reached this hospital by boat. On the other hand she
still claimed that the year was 1917, and in connection
with the delusion of having died was quite unclear as to
the time. She said that it seemed as if she had died many
years ago and that she had come to the hospital years ago.
She also spoke of having died at a summer resort the year
before. When asked for her age, she said that she must be
very old, but on the other hand claimed that she was
supposed to die and to come to the hospital when she was 26
(two years more than her actual age).

Her psychosis continued from then on for about ten weeks.
She soon began to feed herself, but otherwise for most of
this period remained quietly in bed, looking about a good
deal, although showing no particular mood reaction until
questioned, when she was apt to make repeated statements
about her perplexity--that she did not know what it was all
about, every one had mixed her up, everything was so
strange, “my head is mixed up, I am trying to straighten
things up.” She frequently when interviewed became
lachrymose and often with her subjective confusion there
was considerable anxiety. Another unusual phenomenon for a
stupor patient was that she was frightened at a thunder
storm. On the whole, however, her apathy and indifference
were quite marked. For instance, during the latest phase of
her psychosis, when the nurses would sometimes make her
dance with them, she did so but without showing any
interest and not until immediately before her recovery did
she begin to speak spontaneously to any extent whatever. A
marked difference from the ordinary stupor was that this
apathy was invariably broken into when she was questioned
and ideas came to her mind, the nature of which seemed to
be essentially connected with her perplexity.

Not only did ideas appear more frequently than one meets
them in stupor cases, but they were present in greater
variety. The dominant stupor death idea was, it is true,
almost constantly present, but it did not come to the
direct and unequivocal expression which we are accustomed
to see in typical stupor. She did not say “I am dead,” or
“I was dead,” but it was always “It seems as if I were
dead,” or “I think I must have died,” or some such dubious
statement. Other ideas were that her mother was dead and
had been put into a box. She frequently gave her maiden
name and said that she lived in Cleveland with her mother
and that this was Cleveland. At times she thought she was
engaged and was going to be married to her husband shortly.
Again there were notions that her husband had married
somebody else or that some harm was going to come to him.
Sometimes she thought that her mother’s name was her own,
that is, Mrs. L. The hospital once seemed like a convent to
her.

Her subjective and objective confusion seemed quite
definitely to be connected with the insecurity and
changeability of these ideas. It appeared as if insight and
delusion were struggling for mastery in her mind, so that
reality and fancy were alternately, even simultaneously,
possessing her, and that this gave her the feeling of
perplexity from which she suffered. Once when she remarked
“It seems as if I had been dead all the time,” she was
questioned more about this and replied, “Well, sometimes I
thought I was dead, at other times it seemed as if I
wasn’t.” In answer to a direct question about her feeling
of confusion she said “I don’t know. I know I have lots of
good friends, they all want to help me and it seems as if
everything got mixed up between the L.’s (her married name)
and the G.’s (her maiden name).” This was apparently an
elaboration of the wavering ideas she had about her
singleness or her married state. Once after referring to
her husband as her sweetheart whom she was to marry, and
immediately thinking that perhaps he had married somebody
else, she added, with a sigh, “The more this goes on, the
more mixup.” In short, any question, even on some
apparently neutral topic, seemed to start up conflicting
ideas in her mind, the inconsistency of which she
recognized without being able to control their appearance.
Hence, whenever she was spoken to, she became perplexed and
distressed.

Her orientation gradually improved so that, although it
remained vague, it was no longer glaringly inaccurate. Then
quite suddenly she one day came to a nurse and asked how
long she had been in the hospital. When told, she remarked
that it seemed as if she had spent the whole winter there.
She was examined at once and found to be quite clear and at
first in good control of her faculties. She remembered a
good many of her ideas, in fact was able to elaborate a
little from memory on what had already been reported from
her utterances during the psychosis. The recovery was not
immediately complete, however, for at this examination,
when told that she had constantly given her maiden name,
she became distressed and said the physician was trying to
mix her up and was reluctant for this reason to discuss her
ideas. This soon passed, however, and within a few days
she was quite normal and had remained so for some months
after her discharge from the hospital, when last seen. In
fact, according to the husband, she was in better mental
and physical health following the psychosis than she had
been for years.

Essentially, then, this case shows what was at first a typical partial stupor, but soon became complicated by a tendency for questioning to provoke rather a free flow of ideas and a distressed perplexity. This symptom of perplexity soon grew to dominate the clinical picture, so that the psychosis was really a perplexity ushered in by a brief stupor reaction with a background of stupor symptoms running through it. The second case shows similar tendencies but different from the one whose history has just been cited in that the perplexity was never complained of by the patient herself and that her emotional reactions were more marked and varied.

CASE 17.--_Celia C._ Age: 18. Admitted to the Psychiatric
Institute May 2, 1914.

_F. H._ Four years after this attack her mother was a
patient in the hospital with an atypical manic-depressive
psychosis from which she apparently recovered.

_P. H._ The patient herself was described by superficial
observers as being bright, sociable, well-informed and very
ambitious.

When 18 years of age she was working very hard preparing
for some examinations, and worried lest she should fail in
them. Some years later the patient accounted for her
psychosis by saying she had a quarrel with her sister,
immediately after which she began to feel depressed. The
anamnesis states that she was slow, complained of not being
able to think and feeling as if she had no brain. She was
sent to a general hospital, where she was apprehensive,
wanted her mother to stay with her and one night called out
“Mother.”

The case being recognized after a few days as a psychosis,
she was sent to the _Observation Pavilion_, where she was
described as jumping about in bed in a jerky, purposeless
manner, resistive when anything was done for her, and mute.
Her sister reported that when she visited her the patient
said “Go away, I am dead.”

_On admission_ she looked dazed, stared vacantly and had a
tendency to draw the sheet over her. When put on her feet
she let herself fall limply. At times she became agitated,
sobbed and cried loudly, especially when attempts were made
to examine her physically, or, when she was asked
questions, she scarcely spoke.

Her psychosis lasted but a little more than three months
under observation and was characterized by the following
symptoms: She was usually in bed, staring blankly or
appearing otherwise quite indifferent and apathetic, but
not infrequently, especially during the first few weeks,
she was quite restless, resistive, whined and suddenly
appeared startled or distressed with no occasion for this
reaction in the environment. Rarely she was suddenly
assaultive. When attempts were made to examine her, she was
frequently mute or would repeat the question with a rising
inflection, not getting anywhere, or would say, “What shall
I say,” or “I, I----” never finishing her sentence. After
orientation questions she might say “This is--this is--this
is----” all this, together with a rather perplexed
appearance, gave the impression of considerable
bewilderment, but at no time did she complain of
autopsychic perplexity. It was difficult to judge of her
orientation on account of her failure to answer questions,
but it soon appeared that she knew the names of the nurses,
for she sometimes called them spontaneously by name. She
always ate reluctantly.

During these examinations, however, other symptoms often
appeared. When she was talked to, she was apt to indulge in
depressive statements and show considerable distress. Such
remarks were: “I must confess my guilt,” “I am a bad girl
and I have to face my guilt,” or “I have sinned,” or,
standing up with a dramatic air, “I must stand up and tell
the truth.” Once she said, “It is too late to live now.”
She spoke of having lied and usually would not say what
about, but once on questioning replied “I said I would not
tell what happened here.” She was asked, What do you mean?
and answered “I took my oath not to tell anything.” Pressed
further she said that the nurses poisoned her. Another time
she said she was in prison. To her aunt who visited her she
said, “I am a prostitute,” and once she remarked to the
doctor, “I have killed my honor,” and on another occasion
in the middle of the night she called out, “Chinatown
Charlie, come here.” She thought the doctor was her
brother.

Most of these statements were associated with painful
emotion, but there were a few occasions when an element of
elation cropped out. Thus on one occasion she laughed,
another time gripped the doctor’s pad and tried to read it.
When the nurse laughed, she made a funny grimace at her and
said “Why do you laugh?” Again she once sang two songs, but
after the first verse got stuck and kept repeating one
word.

At the end of three months she improved rather rapidly and
was in a condition for discharge as “recovered” a month
later. Retrospectively she said that she recalled feeling
guilty, thinking that her mother was dead, having been
killed by the patient as a result of worrying over the
latter’s failure in her examinations and refusal to eat.
She remembered, too, that at times she thought the building
was burning. Some things like “Chinatown Charlie” she
denied remembering, although she had a good recollection
for the external facts throughout the psychosis. Her
insight was superficially good, but she was reluctant to
discuss her psychosis, in fact claimed that she had been
made more of a lunatic by coming to the hospital than she
was on admission.

Some five years later she had another somewhat similar
attack, again following a quarrel, this time with a fellow
employee. In this second psychosis, however, manic elements
were much more prominent.

Here again, then, we have the symptoms of apparent apathy, inactivity, and similar ideas of death, but the thinking disorder was possibly not very profound, inasmuch as she had a good memory for external events. Her ideas, too, are much more florid than those which we customarily meet with in stupor cases, but the most marked peculiarity was that this “stupor” was liable to constant interruption, either spontaneously or as a result of questioning, which always produced a mood reaction. She was apathetic only so long as she was left alone. In other words, whenever an effort was made to test what seemed to be apathy, the evidences of it disappeared.

The third case to be considered is somewhat like that of the first, Anna L. (Case 16), in that with the inactivity and apathy there was a coincident subjective perplexity. The apathy, however, was less marked than in the case of Annie L.

CASE 18.--_Catherine M._ Age: 24. Admitted to the
Psychiatric Institute November 10, 1913.

_F. H._ Information as to the family is confined to the two
parents. The mother, who was frequently seen, seemed to be
a natural, sensible woman. The father, on the other hand,
had been alcoholic all his life, had had two convulsions
while drinking, and had little respect from any member of
the family, including the patient.

_P. H._ The patient was said always to have been healthy,
from a physical standpoint, although never robust. She got
on well at school, and then worked first as a stock girl
and later as clerk in a department store, where her work
was efficient and she advanced steadily. As a child she
played freely with other girls but little with boys. As she
grew older she moved about socially a little more, made the
acquaintance of men as well as of girls, but never cared
much for the former and had no love affairs until she met
her husband. She was never demonstrative but always rather
quiet and modest. Occasionally she spoke of thinking that
people talked about her, but the informant doubted if she
brooded over this, because she was not of a worrying
disposition. Considering the ideas which appeared in her
psychosis, it is striking that in her normal life she was
rather antagonistic towards her father on account of his
alcoholism and the crudity of his speech and manners.

When she met her husband she liked him from the first,
although she at no time became really demonstrative. They
were engaged for a year, during which time she agreed to a
postponement of three months for the marriage, which was
suggested by her mother. For some time before this event
she was working harder than usual and seemed a bit worn
out. She ceased working a month before marriage and
improved physically, although she became rather nervous,
that is, she was more easily startled, an accentuation of
what had been a characteristic for some years. Her husband
stated that at this time she became fearful of the
approaching marriage relations and asked him to be kind to
her in this respect. She was married a year before
admission. For two and a half months she refused
intercourse and visited her mother’s home a great deal. She
finally submitted. She was quite frigid but became pregnant
at once. Her abnormality then became apparent. She kept the
fact of her pregnancy to herself for several months and
then when she told her mother wanted to have an abortion
performed. Neurotic symptoms appeared. She became sensitive
with her husband, correcting his grammar, and cried easily.
She also began to be anxious about the approaching
childbirth, and with this became more religious.

For the first few days after the delivery, she was fussy
with the nurse so that two in succession had to be
discharged. On the fifth day she woke up and seeing a nurse
lying on the couch beside her bed thought the latter was
colored. On the seventh day she had a dream in which she
thought she “nearly died in childbirth.” Then she began to
talk of dying for her baby or of having two babies, of
dying herself and rising again after Easter Sunday. She
became antagonistic to her husband and with this excited
and confused so that she was taken to the Observation
Pavilion.

On _admission_ she looked pale and exhausted, had a slight
temporary fever and a coated tongue. Her orientation was
usually vague but sometimes she gave fair answers. Her
verbal productions were rather fragmentary and with the
exception of some repetitions there did not seem to be any
special topics which dominated her train of thought.

For some days the great weakness and the slight fever
continued, and then, as it gradually cleared up, there came
a change in her mental condition that settled into the
state which characterized the rest of her psychosis. She
talked less and was often quite inactive, frequently lying
with her eyes closed for long periods, or sat or stood
about. Such movements as she made were slow and languid.
Her expression was either blank, absorbed, or gave the
appearance of peculiar appealing perplexity. This last was
not infrequently associated with a rather sheepish smile.
She was never resistive and always ate and slept well. With
the exception of a few times she did not soil herself. The
most interesting feature of her mood reaction was that in a
general setting of a slight perplexity there appeared at
times and evidently associated with definite ideas, changes
in her emotional state. Sometimes this was a matter of
distress or of mild ecstasy, sometimes she became markedly
blocked. There was at no time any frank elation, but often
an appropriate smile, that is, appropriate to the situation
and to the thought to which she was giving expression at
the time. Then, rarely, there were sudden bursts of
peculiar conduct, such as throwing herself on the floor or
running down the hall. When questioned as to her motive for
these acts, she would flush, look perplexed and apparently
be unable to explain them.

Her verbal productions dealt with a rather limited range of
topics which can be briefly summarized. As in the other
cases, the reader will notice that the bulk of these ideas
are of a kind not usually prominent in the typical stupor
cases. Many of her thoughts seemed centered around her
husband. She always knew him when he visited her, but in
her thoughts there was a constant change as to his
personality. She persistently confused him with the
physicians, with her father, and with God, and one remark
is typical, “I thought he was God, priest, doctor,
lawyer--well, I wanted to go to Heaven; I thought he would
still be my husband; I always hoped that I would be home in
Heaven.” Not unnaturally with this confusion there were
doubts about her marriage. People said her marriage was
wrong and her husband bad. Frequently she thought he was
dead, or voices informed her that she was not married to
him, or that he was the devil in Hell. In this connection
she also said that people called her a whore, or it seemed
as if she were accused of not being married.

As prominently as appeared the ideas of the invalidity or
impossibility of her marriage, to the same extent did her
father assume an important rôle for her. As a rule he
appeared in religious guise as God, but often he was the
doctor--“I knew my father at home and my father in Heaven;
which God do you mean? did you say God or father?” At times
she spoke of being in Heaven and that God seemed to be God,
doctor or priest. In this connection there were ideas of
being under the power of some one, God, devil or father.

As is usually the case where strong interest is expressed
in the father, ideas of the mother being dead occurred,
although in the frankest form she reported them as dreams;
for instance, one night she woke up screaming, said that
she had dreamed that her mother was dead and her sister
dying. That, in the psychoanalytic sense, this represented
a removal of a rival, making union with her father easy,
appeared in the statement that her father was dead but that
she had dreamed he had come to life again for some one
else. When asked what she meant, the question had to be
repeated several times, then she said “My mother died, my
father and mother had a quarrel.” There is more than a
suggestion here of a difference in the significance of
death, in so far as it concerned the two parents. The
mother dies and remains dead, that is, she is gotten rid
of. The father dies but takes on a spiritual existence and
comes to life again, a frequent method in psychoses for
legitimizing the idea of union with the parent by
elimination of the grossly physical.

There were strikingly few allusions to the plainly sexual.
She spoke of being married to the doctor, and even went so
far as to say that they belonged together in bed. On
another occasion she called him “darling.” Once she
reported that it was said that she was going to have babies
and babies and babies. These references were, however,
quite isolated, so that the erotic formed a very small part
of her productions.

Delusions of death, we have seen, are the most constant
content of true stupors. In this case they were present but
distinctly in the background. She spoke quite frequently of
being in Heaven. She also talked of being crucified. Once
she said “I died but I came back again.” This last
utterance was rather significant in that frankly accepted
ideas of death were unusual; for instance, she would say
sometimes, “I think I am in Heaven, again not. It confuses
me, but I know I am in Heaven.”

In general, then, her ideas were, on the whole, not at all
typical of stupor but much more like those met with in
other manic-depressive conditions. Correlated with this was
an unusual mood picture. Quietness and apparent apathy of
the patient were interrupted by little bursts of emotion,
and throughout the psychosis there was a coloring of
perplexity. Not only was this last objectively noticeable,
but she spoke very frequently of it and always in
connection with the inconsistency of the ideas in her mind
which puzzled her. For instance, in speaking to the doctor
she said “I think of you as Bill (her husband’s name)
sometimes--I get confused thinking of Bill as God, doctor,
lawyer, priest.” Again, referring to her husband, she made
these curious statements: “They seemed to speak of him as
being in the wrong--the right--it seems that the right
devil is the wrong one for me--they say he is not the right
one for me; they say he went wrong from the time we were
married.” Again, she said that she did not know who her
father was, and went on: “It puzzles me, this father
business, I knew my father at home and my father in
Heaven.” Again, “Which God do you mean? Did you say God or
father?” A hint as to how this subjective confusion made
the environment seem uncertain comes from the statement,
“You looked like the devil and yet you were God.”

Distress and anxiety appeared not infrequently and always
appropriately. The distress was usually occasioned by an
idea of injury to others, as when she cried over the
fancied accusation of drowning her husband and mother; or
in connection with accusations of herself, such as when she
reported “They called me a whore.” As has been stated,
there was never any frank elation, but an element of
pleasurable expansive emotion was frequently present in
connection with her religious utterances. This came
particularly when she spoke of union with her father as
God. She seemed to swell with ecstatic emotion. It was
especially well marked once when she threw herself on the
floor and when asked what she was trying to do replied, “I
want to do what God wants me to do, drop dead or anything
at all.” Perhaps the most unusual affective reaction was a
blocking which occurred when certain topics appeared. This
is a phenomenon quite unusual for stupor, where speech
seems to stimulate and arouse the patient as a rule. One
got the impression that ideas tended to come into this
patient’s mind which were painful enough to disturb her
capacity for connected thought. A good example of this
reaction was when she was speaking of her father having
died and coming to life again. On being asked what she
meant, she became quite blocked and the question had to be
repeated several times, when finally the apparently
unrelated statements appeared: “I dreamed my mother
died--they had a quarrel.” Who had a quarrel? she was
asked, and replied “My mother and father.” Apparently her
thinking about her father coming to life for some one not
her mother stimulated deeply unconscious ideas concerning
the separation of her mother and father, and her taking the
mother’s place, and these ideas were sufficiently
revolutionary to upset her capacity of speech for the time
being.

She recovered completely about six and a half months after
her admission.

If we consider together the common features of these three cases, we see that they resemble stupors only in the presence of inactivity and apparent apathy. It is true that death appears in the ideational content but not with that prominence, bordering on exclusiveness, which characterizes such delusions in the true stupors. These three patients give one the impression of being absorbed in thoughts that have many variations. It seems as if they had difficulty in grasping the facts of the environment, while feeling at the same time the vividness of the changing internal thoughts, hence a confusion develops which is either subjective, objective, or both. It is probably the introversion of attention which gives rise to the apparent apathy, because normal emotions emerge as part of our contact with reality around us. This lack of contact with the environment leads also to inactivity. If one’s attention and interest is turned inwards, there can be no evidence of mental energy exhibited until the patient is roused to contact with the people or things about him. It is noteworthy that in these cases emotional expression emerged when the patients were stimulated to some productiveness in speech.

These conditions really constitute a different psychosis in the manic-depressive group, essentially they are perplexity states such as have recently been described by Hoch and Kirby.[7] Not infrequently we see exhibitions of this tendency in what are otherwise typical stupors. For example, Mary F. (Case 3) (the third case to be described in the first chapter), showed for a few days after admission a condition when she was essentially somewhat restless in a deliberate aimless way. At the same time she looked dazed or dreamy. With this restlessness she appeared at times “a little apprehensive.” Although she spoke slowly, with initial difficulty she answered quite a number of questions. Her larval perplexity was evidenced by the doubt expressed in a good many of her utterances, such as, “Have I done something?” “Do people want something?” “I have done damage to the city, didn’t I?” When asked what she had done, she said, “I don’t know.” She asked the physician, “Are you my brother?” and when questioned for her orientation said, “Is not this a hospital?” The atmosphere of perplexity also colored the information which she did recall correctly; for instance, when asked her address, she said, “Didn’t I live at ----?” then giving the address correctly.

As stated in Chapter V dealing with the ideational content of stupor, one has to look on the delusions of patients as symptoms subject to analysis and classification just as truly as the variations in mood or intellectual processes, in fact they should be subject to the same correlation as are the mental anomalies which are usually studied, particularly if we are to understand these psychoses as a whole. Let us, therefore, consider the death ideas in the three cases studied in this chapter. We find that, as in the ordinary stupors, there are delusions of death, also of mutual death (with the father), but there is a tendency to elaboration so that the death is only part of a larger Œdipus drama, the rest of which is usually lacking in stupors. Here it is present. So we have thoughts of the death of the mother or husband, another rival, considerable preoccupation with Heaven, and also erotic fancies.

We find in manic-depressive insanity a tendency for more or less specific ideational contents with different types of the psychoses.[8] For example, there are religious and erotic fancies or ambitious schemes dominating the thoughts of manic patients, fears of aggression and injury met with in anxiety cases, and so on. In stupors, death seems to be a state of non-existence with other meanings lacking or only hinted at occasionally. When it tends to be elaborated, it leads over to formulations suggesting personal attachments and emotional outlet, and then we are apt to find interruptions of the pure stupor picture. For example, Charlotte W. (Case 12), whose case has been described, thought much about being in Heaven and ended with a hypomanic state. Atypical symptoms appear just as constantly in these cases, as do the atypical ideas. In other words, the thought content is definitely correlated with the clinical picture.

As the clinical pictures show the relationship of stupor to other psychoses, so there is also a correlation with varying formulations of the death fancy. We are now in a position to define more narrowly what death means in stupor. It is an accepted fact, a Nirvana state. When death means union with God or appears in other religious guise, manic symptoms tend to develop. When it is unwelcome and appears as “being killed,” we find anxiety symptoms. A patient can conceive of death variously and have various clinical pictures. A knowledge of the metamorphoses of ideas and their relationship to other symptoms enables us to understand such cases, that, without this key, seem confused and lawless jumbles of symptoms. Such theories tend to justify the view of essential unity of the manic-depressive group.

It would be instructive at this point to consider another case which illustrates beautifully how a stupor reaction may crystallize out of other manic-depressive states when attention has become focused on personal death. This patient went through four phases while under observation. First, while showing a perplexed expression but with fair orientation, she gave utterance to erotic and expansive fancies. She was restless, somewhat intractable and gave the impression of brooding over her imaginations rather than luxuriating in them. In other words, her condition seemed to be more that of absorbed than active mania. Second, these same ideas, somewhat reduced, continued in an apathetic state while impulsive symptoms developed: She began to shout like a huckster to be taken to Heaven and made numerous affectless, suicidal attempts. Third, came a true stupor and, fourth, a period of recovery when the stupor symptoms all disappeared but insight into the falsity of her ideas was lacking.

CASE 19.--_Celia H._ Age: 19. Admitted to the Psychiatric
Institute October 22, 1913.

_F. H._ The father was living; he always drank, and
especially in later years contributed little to the support
of the family. The mother was living and said to be
normal, while a brother was coincidentally insane, with a
recoverable psychosis.

_P. H._ The mother stated that the patient was bright at
school, enjoyed company and going out, had a droll wit, was
not at all seclusive, no dreamer, helped to support the
family and was efficient. She was very much attached to her
brother and once said that if anything should ever happen
to him she thought she would die. She also cared much for
her older sister, with whom she worked, and for her mother.

Three months before the patient’s admission her brother
became depressed, mute, seemed worried, cried at times. He
was sent to the country. Two months before admission, when
the mother and the patient went to bring the brother to
town, and while they were at the station, he suddenly tried
to throw himself under a train but was restrained just in
time. The patient appeared intensely frightened, but did
not talk. In fact, she seemed somewhat bewildered and at
once became dull. “Her movement and manner were much as at
present.”

When the patient was able later to give a retrospective
account of the onset, she claimed that for some months
before this incident she saw that her brother was losing
his mind. She worried about this as well as about her work,
and felt worn out. She said that when the brother tried to
throw himself under the train she was terrified and could
not speak or move, and that her mind got upset at once, “I
lost my memory.” The others forgot her and left her alone
on the platform. Strangers put her on another train and she
knew nothing until she arrived at home.

The mother added that at the time when the incident with
the brother happened, the patient was menstruating and that
this ceased at once.

At home she sat about inactive and did not seem even to
worry. Whenever any one asked her about her brother she
replied that he was dead. For two weeks before admission
she said she was rich, that she owned all the property
around. She also said she was married to Mattie S. In this
connection the mother says that a foolish neighborwoman,
the mother of Mattie S., told the patient since her
sickness, by way of encouragement, that she should marry
her son (the man mentioned). Finally, the patient also
expressed the idea that her mother was a stranger, that her
real mother was dead.

At the _Observation Pavilion_ she was described as
wandering about in a perplexed manner, restless, resistive,
answering few questions and in a low tone. She said things
were “changed,” also that she was married to S.

_Under Observation:_ 1. For about ten days the patient’s
condition may be described as follows: The most striking
feature was a certain restlessness with insistence on going
out, with complaints that this and that had been done to
her and with senseless struggling when interfered with. But
all the motions were slow, the whole restlessness aimless
and impulsive. Although the facial expression was somewhat
perplexed, it changed remarkably little, and whenever asked
whether she felt worried or anxious she denied it, and,
indeed, there was only a suggestion of perplexity in her
face.

The ideas which she expressed during this time referred to
a few topics only, namely, marriage, wealth, and State
prison. The remarkable fact was that all the ideas about
marriage and wealth were spoken of, often immediately,
again after some interval, now in the positive and again in
the negative sense. Thus she said she was “Mrs. S.,” again
“You kept me from marrying Mattie S.,” or “I am not
supposed to be here--I am a married person,” but also “You
kept me from getting married.” Or, “Take off that black
dress, I am a bride,” again “You have taken my bridal crown
off my head,” “The steamboats (seen from the window) are
mine--I own the ships, the oceans, the land and
everything,” or again, she said she owned a kingdom, was
Sh.’s wife, a wealthy woman, had millions. Sometimes she
connected the millions with Sh. “Sh. has millions.” On the
other hand, she said: “I owned all this before I came. I
have nothing now,” or “You have taken the regal crown from
me,” “You have made a pauper of me,” “They did it again,
they took my millions away,” or “Let me out, they are
taking my millions.”

Other ideas throughout this period were that this was a
State prison, that “bums” were around. On one occasion she
said “You can’t put down all these things and make me out a
lunatic.” At another time she pulled a patient’s hair and
then said without fun: “I fixed the leading lady of the
dump--she knows a lot, but she does not know enough to
keep her soup cool.” When questioned about this woman (who
at the time while cleaning had moved the furniture), she
said: “I don’t know where I am at.”

The orientation during these days was not markedly
disordered, when one got down to it. Although she spoke of
State prison, it was always found she knew the name and the
location of the hospital, the names of people around her,
even the date approximately, though she was apt to say it
was February 19, 1492, or October 19, 1492, or when the
year was not given as 1492 she said it was “1900 or 1901,
or 1911 or 1912.” Frequently, however, it was hard to hold
her attention.

Finally, it should be mentioned that she very often wet
herself in bed or when standing, even when standing in the
examining room.

2. The period following and lasting for two months may be
given in the form of abstracts of each note.

_November 7:_ Yesterday quiet, though struggling. Says
without change of expression, “I saw four people killed--my
mother, my brother, a priest, and my dear sister--we were
all killed.” Again, “I don’t know where I am,” “I am an
orphan, my people died” (without affect).

_November 20:_ More quiet recently, says little, but tries
to get out when brought to the examining room, but when not
prevented walks slowly about as before, says she wants to
go home. Looks peculiarly blank.

_November 23:_ Has remained quiet, says she is Dr. M.’s
wife. But when told she is not married, she agrees. Her
attitude towards the doctor is not changed, but when the
nurses talk to him, she has tried to prevent it.

_December 6:_ Has remained quietly in bed, gazing about.
Slow in motion. She has spoken of being Dr. M.’s wife,
again President Wilson’s wife, again “Vincent (brother) is
the ruler of the world.”

At interview says little, seems abstracted, answers briefly
in low tone. (Does anything bother you?) “No.” (Are you
natural?) “Yes.” (Who are you?) “C. H.” (correct). (You
said you were the President’s wife?) “No.” (Are you
married?) “No.” (You talked about the kingdom?) “I own the
kingdom” (affectlessly). (Where is Vincent?) “Here.” (Have
you heard him?) “Yes.” (What did he say?) “Nothing.” (Is
he all right?) “Yes.” (Where is your mother?) “Home.” (Why
don’t you go home?) “I can’t.” (Why not?) “I can’t.” (Why
not?) “The family tree is broken, the Cardinal.” (What
about him?) “Nothing.” (Retrospectively she said later she
thought her brother was a cardinal.)

_December 8:_ When her mother visited her she said “It is
about time you come--I thought you were dead.” Has walked
down the hall “looking” for her dead cousin. When asked if
she wanted to see her brother, said, “Ain’t he dead?”

_December 12:_ Cries out in an affectless tone like a
huckster, “Father MacN., take me to Heaven,” repeating this
over and over.

_December 15:_ Quiet as a rule, then for a time at the
door, pulling at it and with whining voice but affectlessly
saying “Give me the key--I want to go to the river--you
can’t keep me from Heaven--it is either Heaven or the
river, give me the keys, give me the keys, open the door,”
“The niggers are taking possession.” To the physician to
whom she had claimed to be married, often repeats “You
don’t belong to me, I don’t belong to you.” (What about the
niggers?) “A band of niggers, that is all they are.” (Are
the nurses niggers?) “That is all they are.” Asked about
her people, she says “They are in Heaven.” (Where are you?)
“I am in Heaven” (without change of expression). Again,
when asked where her people are, says “At home.” Then she
went willingly back to bed and was quiet. In the afternoon
she again went to the door and tried to get out. When
questioned, she said “I don’t want to be an animal,”
“Everybody is making an animal of me” (pointing to an
animal picture). Then again, while trying the door, repeats
in the same affectless manner that she wants to go “to the
river,” “to the bottom of the river,” “to Heaven to see my
mother.” This last was said in a whining tone, with some
tears. She kept turning the knob, tried to get the keys,
and struggled impulsively when prevented.

_December 23:_ Though quiet on the whole, when a visitor
came yesterday, she ran after this woman saying “I want my
generations,” and clung to her, and to-day at intervals
keeps talking about wanting to see her generations but is
often quiet. (Retrospectively she said she wanted to see
all her ancestors from the beginning of time.)

_December 27:_ Of late often talks affectlessly about
wanting to die or wanting to go to Heaven, struggling
impulsively to get medicine away from the nurses, asking
for poison, trying to drink her own urine, or even the
fluid in the bed pan after she had been given an enema, all
evidently with suicidal intent.

_December 28:_ Still constant, impulsive and apparently
affectless attempts at suicide, tries to get medicine away
from nurses, to get the fire extinguisher bottles, a bottle
of ink, etc., struggling when prevented.

But when examined quiet, even smiles at a joke. When
questioned, denies feeling either worried or depressed. She
said she wanted to go home. She gave poor attention to the
questions. Later she threw a wet sheet over a patient and
laughed (this is rare). Later she slapped another patient.
Again she began to talk about wishing to go to the grave.
Calls Dr. M. “Uncle John.”

_December 30:_ Talks either about wanting to die, or
wanting to go to Heaven, or wanting to go to Ireland, all
this as usual in an affectless way. Calls Dr. M. “Uncle
John.” Keeps shouting “Take me to Ireland.”

_January 9, 1914:_ Often quiet in bed, again goes to door,
talks about wanting to go “to Heaven” or “to Ireland.” On
the whole, says little.

It seems, then, that the transition was not abrupt, that
many traits of the first period remained, but that she was
on the whole much quieter, with the exception of some
spells when she insisted on going out or killing herself.
At such times she showed an affectless, impulsive
excitement. Whether there was an element of perplexity then
is not clear from the notes. The topics of which she spoke
also changed. The idea of wealth was rarely expressed, also
the idea of marriage was much in the background, but
prominent ideas were those of death, Heaven, killing
herself, going to Ireland--all of which she produced in an
affectless way. It should be added that she persistently
wet and soiled during this, as well as in the first period.

3. Then followed three months of greater inactivity. She
lay in bed gazing, moving very little, not even when her
meals were brought. She answered but little and
consistently wet and soiled. This state lasted from about
the middle of February until the beginning of April.

4. From this stuporous state she emerged during the next
four weeks, the awakening being associated with persistent
efforts to arouse her. She then was, for six or seven
weeks, nearly normal, so far as her mood went, but had a
tendency to cling to some of her ideas and was
overtalkative. Her memory for the earlier phases of the
psychosis was good, as she recalled not only many external
events but most of her false ideas. She said, however, that
her mind had been a blank for the third stage and she
remembered nothing of it. At the end of this time she
cleared up entirely and was discharged as “recovered.” She
continued well for some months, during which she was
occasionally examined.

This case gives an excellent example of the relationship of stupor to other manic-depressive reactions. She begins with an absorbed state, showing elements of perplexity and mania. With this there are expansive ideas but, also, statements about losing everything and being in prison, which suggest abandonment of life. Next, with increasing apathy, she begins to speak of death and soon makes impulsive suicidal attempts. Evidently her mind was becoming more and more focused on death and with this there was an appropriate emotional change. She was either apathetic or the affect exhibited itself in pure impulsiveness. Then comes the stupor, when all ideas disappear and mentation is reduced or absent. When the stupor lifts, the original ideas appear not only in memory but occasion a wavering insight. It is appropriate that she recalled all of her psychosis fairly well with the exception of the pure stupor, which she remembered only as a time when her mind was a blank.

FOOTNOTES:

[7] Hoch, August, and Kirby, George H.: “A Clinical Study of Psychoses Characterized by Distressed Perplexity.” _Archives of Neurology and Psychiatry_, April, 1919, Vol. I, pp. 415-458.

[8] Hoch, August: “A Study of the Benign Psychoses.” _Johns Hopkins Hospital Bulletin_, May, 1915, XXVI, 165.

A book on “the psychology of manic-depressive insanity” will shortly appear by the editor.