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° and 100°.

_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°, a coated tongue, suffused conjunctivæ. 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.

On April 4, at the end of this period, she suddenly
laughed, again ran down the hall, said she had done nothing
to be kept on Ward’s Island. But she quickly lapsed again
into the dull state. Later, on the same day, when the
doctor was near, she said, in a natural tone, “Thank God,
the truth is coming out.” (What do you mean?) “That I have
been trusting in a false name and that Miss S. (the nurse)
should not nurse me.” Then she got suddenly duller,
calculated slowly and with some mistakes, 3×17=41, 4×19=56,
and when asked to write Manhattan State Hospital she wrote
(not very slowly) “Mannahaton Hotspalne.”

4. Next day it was noted that she was more stuporous, and
she remained so for two weeks, now showing a decided
tendency to catalepsy and more resistance than before,
though not marked, except in the jaw. She lay often with
head raised, sometimes with eyes partly open, or staring in
a dull, dreamy way, neither soiling nor drooling, however;
a few times she looked up when spoken to sharply. There was
no spontaneous speech. Usually she did not answer at all,
but a few times a short low response was obtained. Once she
wrote slowly a simple addition, put down on paper. When, on
one occasion, asked how she felt, she, as before, said, “I
feel better.”

5. Then, with the exception of a day at the end of the
month, when the more stuporous state was again in evidence,
she returned to her former condition without catalepsy or
resistiveness and without staring, but essentially with
inactivity or slowness. She now even dressed herself,
answered slowly though not consistently, but she again
denied feeling troubled or sad, “I feel better.”

On July 7 she got brighter but was still rather slow. She
then even began to do some work. She again denied feeling
sad.

In a few weeks, while having a temperature of 102° with
vomiting and diarrhea, she suddenly got freer. She then
said, in answer to questions, that she did not speak
because she was not sure whether it would be right, again
because she seemed to lose her speech. She did not move
because she was tired, had a numb feeling. She said she
had not been sad, “but I had different thoughts,” “saw
shadows on the walls of animals, living people and dead
people.” She was not frightened, “I just looked at them.”
People moved so quickly that she thought everything was
moved by electricity. She thought her head had been all
right.

After a few days she relapsed into a duller state again,
but then got quite free and natural in her behavior. On
August 28 she gave a _retrospective_ account of her
psychosis, a part of which has been embodied in the
history. She had insight in so far as she knew she had been
mentally ill. She claimed to remember the Observation
Pavilion and her coming to the hospital, also the incidents
during the manic state, when she heard cannon and thought a
war was on, and voices she could not recognize nor
understand. Then she became stupid, although neither sad
nor happy.

Then, she claimed, she got stupid, but neither sad nor
happy. She claimed to have known all along where she was,
but felt mixed up at times, her thoughts wandered and she
felt confused about the people. She thought she was in
everybody’s way, thought others wanted to get ahead of her,
did not speak because she did not know if it were right or
wrong, felt she might cause disturbance if she answered.
(It is not clear whether she had complete insight into the
morbid nature of these statements.) She also claimed again
that all along she “saw shadows on the wall,” “scenes from
Heaven and Earth,” “shadows of dead friends laid out for
burial.” She had insight into the hallucinatory nature of
these visions. Sometimes she thought she was dead also. She
claimed that she began to feel better when these shadows
stopped appearing in June (the actual time of her
improvement).

She was discharged recovered a month later, after having
been sent to another ward.

In this case, then, we find that the two months of stupor were ushered in by a brief state in which, in addition to the usual inactivity, there was a certain bewilderment, increased by questions, while the orientation which in the preceding manic state had been good became seriously interfered with. The psychosis bordered on deep stupor for brief periods when the inactivity seemed to be complete or she lay in bed with her head raised from the pillow. On the other hand, there were occasional sudden spells of free activity even with a certain elation. She could often be persuaded to answer questions or to write, the slowness of this spoken or written speech varying considerably. Her replies revealed the fact that she was essentially affectless and that her intellectual processes were interfered with, even to the extent of paragraphic writing. We have, therefore, here again features similar to those of the preceding cases. In addition we must add as important that this patient said retrospectively that she thought she was dead, that she saw “shadows from Heaven and Earth,” “shadows of dead friends laid out for burial,” all this without any fear. We shall see later that this is a typical stupor content.

We will here include state 3 of Anna G. (See Chapter I, Case 1) who after the pronounced stupor was for two months merely dull, somewhat slowed and markedly apathetic. Although her orientation was not seriously affected, there was considerable interference with her intellectual processes, as shown in her wrong answers or her lack of answers when more difficult questions were asked.

A similar picture was presented in state 2 of Mary D. (See Chapter I, Case 4.) Here, to be sure, there were more marked stupor features in that the patient wet and soiled, in addition to occasional spells when she lay with her head raised. But she spoke and acted fairly freely (even while soiling). By her replies she showed a considerable intellectual inefficiency, although, like Anna G., her orientation was not seriously disturbed. Here again there was complete affectlessness.

This gives us, therefore, five states which may be analyzed for the symptoms of partial stupor. The pictures of all five are unusually consistent. There is inactivity, marked but not complete; poverty of affect without perfect apathy; and a marked interference with the intellectual processes. The last can be studied better than in the deep stupors because these partial cases are more or less accessible to examination. There is a tendency for the patient to think much of death either in the onset or during the psychosis. Negativism seems much less prominent than in the deep stupors.

A natural criticism is that these cases merely had retarded depressions. Although this topic will be discussed fully in a later chapter, two differential characteristics should be mentioned now. First, depression is a highly emotional state in which the sadness of the patient is as evident from his facial and vocal expression as from what he says, while these stupor reactions are by observation and confession states of indifference. Secondly, there is no such disturbance of the intellectual processes in depression as is here chronicled. Let the retardation once be overcome so that the will is exercised and no real defect is demonstrable. In our experience the cases of apparent depression with intellectual incapacity are found on closer study to be really stupors as other symptoms show.