In Mary C. (See Chapter II, Case 7) we have, unfortunately, not a direct observation, but we have, at any rate, a description from the Observation Pavilion which seems so plain that we should be justified in using it here. The condition we refer to is described as a dazed uneasiness, with ideas of being shut up in a ship, of the ship being closed up so that no one could get out, of the boat having gone down, of the people turning up. We should add here that the condition was not followed by a typical stupor. Essentially it was a retardation, in which only on one occasion was a definite akinesis observed. During this phase she soiled her bed. Perhaps the persistent complaint of inability to take in the environment belonged also more to the retardation of stupor than to that of depression. We have again, therefore, in this initial phase, a similar situation, namely, ideas belonging essentially to the rebirth motif, formulated as of a threatening character if not as actually dangerous.
We can say, therefore, that what characterizes these three cases, and brings them together, is the fact that all three had ideas belonging to the rebirth motif, but formulated as dangerous situations. Associated with this there was not a typical anxiety with the relative freedom of activity belonging to this state, but an anxiety or distress or uneasiness with traits of stupor reaction, namely, slow movements, lack of contact with the environment, and a dazed facial expression. It would seem that these facts could scarcely be accidental but that they must have a deeper significance. As a discussion of this belongs, however, more into the psychological part of this study, we shall defer it for the present, and be satisfied with pointing out here the clinical facts of observation.
In brief, then, our findings as to the ideational content of the benign stupor are as follows: From the utterances during the incubation period of the psychosis, from the ideas expressed in interruptions of the deep stupor, as well as from the memories of recovered patients, we find an extraordinary paucity and uniformity of autistic thoughts. They are concerned with death, often as a plain delusion of being no longer alive, or with the closely related fancy of rebirth. The rule is a setting of apathy for these ideas, but when they are formulated so as to connect them with the real life and problems of the patient, or when rebirth is represented as a dangerous situation, some affect, usually one of distress, may appear.
[6] Kirby, loc. cit., pointed out that stupor showed resemblance to feigned death in animals, that the reaction suggested a shrinking from life and that ideas of death were common.
[A] We may mention that since this study was made we risked a prediction of stupor, which events justified, in the case of a patient who showed expectation of death without affect. Such opportunities are rare, however, since we usually do not see these cases till the stupor symptoms are manifest. It would be unsafe to dogmatize on the basis of such meager material.
The most constant and significant symptom in the stupor reaction is the change in affect. This extends from mere quietness in the mildest phases of the disease through the stage of indifference where apathy replaces the normal reactions of the personality, to the final condition of complete inactivity in the vegetative stupor where all mental life seems to have ceased. It seems as though there were, as a pathognomonic sign of the morbid process, a lack of energy and loss of the normal élan vital.
We may say, in fact, that the establishment of a specific type of emotional change is justification for classifying all milder stupor reactions with the deep stupors. In other words, our reason for the enlargement of the stupor group to include all apathetic reactions (except those of dementia præcox) is the belief that this dulling of the emotional response is as specific a type of emotional change as is anxiety, depression or elation. Perhaps it would be more accurate to say that this clinical group is founded on the symptom complex which is built around apathy. There is never any resemblance between apathy and the mood of elation or anxiety. A discrimination from depression is the only differentiation worth discussion.
The first point that should be made is that there is a difference between marked depression and the mood of stupor. In the former we get a retardation with a feeling of blocking, rather than of an absence of energy. The expression of the patient is one of dejection, not of vacancy, which bespeaks a mood of sadness, even when the patient is so retarded as to be mute and therefore incapable of describing his emotions. Running through all the stages of stupor, however, there is an emptiness, an indifference that is in striking contrast to the positive pain that is felt or expressed by the depressed patient. It may be objected, of course, that this apathy really represents the final stage in the emotional blocking of the depressed individual, but the development of stupor and recovery from it shows an entirely different type of process. A deep depression recovers by changing the point of view from a feeling of unworthiness and self-blame to one of normality. The stuporous case, on the other hand, evidences merely less and less indifference, and more and more interest in his environment and in himself as he gets well.
The associated symptoms are no less dissimilar. The difficulty in thinking which troubles the depressed patient is slight in proportion to his emotional gloom, and he feels himself to be much more incompetent intellectually than examination proves him to be. On the other hand, in the stupor reaction we find that the thinking disorder runs hand in hand with the apathy and that the intellectual capacity of the patient is really markedly interfered with, as can be shown by more or less objective tests. A mere slowing of thought processes accompanied by subjective feeling of effort is the limit reached in true depression, while it is merely the beginning of the intellectual disorder in stupor, for one meets with retardation symptoms only in the partial stupors. The slowing in these cases seems to represent an early stage of the intellectual disturbance which reaches its acme in the mental vacuity and complete incompetence of the deep stupor, just as slow movements in the partial stupors seem to represent a diluted inactivity reaction. This actual thinking disorder is not present in those forms of manic-depressive insanity which are characterized by elation, anxiety or depression but is seen only in stupors, occasionally in absorbed manic states (manic stupor) and sometimes in perplexity states. The psychological mechanisms of this last group are probably analogous to those of stupor, but this is not the place for a discussion of this topic.
Another associated symptom whose manifestations differ in depression and stupor is that of unreality. In the former there is frequently a feeling of unreality that is purely subjective, whereas the stupor case does not usually complain of this but does exhibit a difficulty in grasping the nature of his environment, which the typical depressive case never has.
The occurrence of other mood reactions than apathy in the same patient is also characteristic. Manic states (usually hypomanic) frequently occur during the phase of recovery from the stupor. This is an unusual, although not unknown, phenomenon in recovery from severe retarded depressions. The circular cases who swing from depression to elation usually show the milder types of depressive reaction which would never be confused with stupor. On the other hand, deep stupors very frequently are terminated by manic reactions, and if not by such means, recovery seems to occur merely in virtue of a gradual attenuation of the stupor symptoms. Rarely do we see a change to depression or anxiety heralding improvement. This tendency of the stupor reaction to remain pure or change to hypomania is a peculiarity which seems to put stupor in a class by itself among the manic-depressive reactions, as all the other mood reactions frequently change from one to the other.
Although apathy is the central pathognomonic symptom of stupor conditions, there are other mood anomalies to be noted. One of these is the tendency for inconsistency in, as well as reduction of, the expression of emotion. For instance, in the states where one would expect anxiety during the onset of stupor or in its interruptions, manifestation of this anxiety is often reduced to an expression of dazed bewilderment. In the anxiety states associated with stupor one does not meet with the restlessness and expressions of fear which would be expected. Quite similarly, when a manic tendency is present, it occurs either in little bursts of isolated symptoms of elation (such as smiling or episodic pranks), or some of the evidences of elation which we would expect are missing. For instance, Johanna S. (Case 13) terminated her stupor with a hypomanic state which was natural except for her always wearing an expressionless face. Sometimes laughter occurs alone and gives the impression of a shallow affect, raising a suspicion of dementia præcox. In fact, such evidences of affect as do appear in the course of the stupor are apt to be isolated, queer and "dissociated." It does not seem as if the whole personality reacted in the emotion as it does in the other forms of manic-depressive insanity. For example, we may think of the resistiveness which is so frequently present when the patient seems in other respects to be psychically dead. One may recall the case of Meta S. (Case 15), who, otherwise inert, was occasionally seen with tears or smiles. Anna G. (Case 1), too, was often seen smiling or weeping. It was noted once of Charlotte W. (Case 12) that she ceased answering questions and remained immobile with fixed gaze, but when some mention was made of her going home she flushed and tears ran down her cheeks, although no change in the fixedness of her attitude or facial expression was seen. When Johanna S. was visited by her daughter and was lying motionless in bed, she slowly extended her hands, apparently tried to speak, and then her eyes filled with tears. Two days later, at the end of an interview when she had made a few replies, she settled down into her usual inactivity and, when further urged to answer, her eyes filled with tears. Similarly, too, in fairly deep stupor pin pricking may result in flushing, in tears or an increased pulse rate without the patient giving any other evidence of the stimulus being felt. These examples seem to show a larval effort at normal human response which, failing of complete expression, appeared as single isolated features of emotion suggesting true dissociation. We should also in this connection bear in mind the impulsive suicidal acts which occur either as unexpectedly as the impulsiveness in a true dementia præcox patient, or in a setting of coarse animal-like excitement that seems quite unrelated to the personality. One is reminded of the patient who made suicidal attempts during the period when she shouted like a huckster, giving no evidence whatever by her expression or the tone of her voice of feeling anxiety, sorrow or any other normal emotion.
All these queer and larval affective reactions remind one strongly of dementia præcox. The resemblance of the benign stupor to certain dementia præcox types is not merely a matter of identity with catatonic features (catalepsy, negativism). In these anomalous mood reactions it seems as if there were a definite dissociation of affect, and so there is. How then can we differentiate these emotional symptoms from the "dissociation of affect" which is regarded as a cardinal symptom of dementia præcox? The answer is that this term is used too loosely as applied to the latter psychosis. It is a particular type of dissociation which is significant of the schizophrenic reaction, for in it there is an acceptance of what should be painful ideas evidenced either by incomplete manifestations of anxiety or depression or actually by smiling. We never see in dementia præcox the reverse—a painful interpretation of what would normally be pleasant. It is the pleasurable interpretation of what is really unpleasant that gives the impression of queerness in the mood of these deteriorating or chronic cases. In stupor, on the other hand, although this dissociation takes place, the mood is never inappropriate, merely incomplete in that all the components or the full expression of the normal reaction are not seen.
Our description of the mood reactions in stupor would be incomplete if we omitted to mention the occasional appearance of an emotional attitude not unlike that seen in many cases of involution melancholia, which reminds one in turn of the reactions of a spoiled child. The commonest of these manifestations is resistiveness that may occur when an examination is attempted, feeding is suggested, or a sanitary routine insisted upon. One also meets with resentfulness. One patient, who frequently showed this reaction, explained it retrospectively by saying that she wanted to be left alone. Quite analogous to this is sulkiness that occasionally appears. Then we have, particularly as recovery begins, other childish tricks, such as flippancy in answering questions or the playing of pranks. Such tendencies naturally lead over to frank hypomanic behavior.
Finally, a peculiar characteristic of the stupor apathy must be mentioned. This is its tendency to interruptions, when the patient may return to life, as it were, for a few moments and then relapse. Such episodes occur mainly in milder cases or towards the end of long, deep stupors. It is interesting that the occasion for such reappearance of affect is frequently obvious. We usually observe them in response to some special stimulus, particularly something that seems to revive a normal interest. Visits of relatives are particularly common as such stimuli, in fact recovery can often be traced to the appearance of a husband, mother or daughter. It is also important to recognize that with this revived interest, other clinical changes may be manifest, that the thinking disorder may, for instance, be temporarily lifted. Helen M., for example, when visited by her mother was so far awakened as to take note of her environment, and remembered these visits after recovery like oases in the blank emptiness of her stupor. She further remembered that definite ideas were at such a time in her mind that ordinarily was vacant. She then had delusions of being electrocuted.
In summary, then, we may say that the sine qua non of the stupor reaction is apathy in all gradations, and that this apathy is as distinct a mood change as is elation, sorrow or anxiety. Incidental to this loss of affect there is a dissociation of emotional response whereby isolated expressions of mood appear without the harmonious coöperation of the whole personality which seems to be dead. Thirdly, there tends to be associated with the stupor reaction a tendency to childish behavior. Finally, the apathy and accompanying stupor symptoms may be suddenly and momentarily interrupted. An explanation of these apparently anomalous phenomena will be attempted in the chapter on Psychology of the Stupor Reaction.
1. Inactivity. We must now turn our attention to the other cardinal symptoms of the stupor reaction, and quite the most important one of these is the inactivity. It is convenient to include under this heading both the reduction of bodily movement and the diminution or absence of speech. This inactivity is, of course, related to the apathy which we have just been discussing, in fact it is one of the evidences of the loss of emotion. We presume that a patient is apathetic when there is no expression in the face and when he does not respond to external stimuli, whether these be physical or verbal, by movement or by word.
Bodily inactivity is present in all degrees, and in some forty consecutive cases was recognizable in every one. In its most extreme form there is complete flaccidity of all the voluntary muscles, and relaxation of some sphincters. As a result of the latter we see wetting, soiling and drooling. Even those reflexes which are only partially under voluntary control, like those of blinking and swallowing, may be in abeyance; for instance, saliva may collect in the mouth because it is not swallowed, and tube-feeding is frequently necessary on account of the failure of the patient to swallow anything that is put into his mouth. The eyes may remain open for such long periods of time that the conjunctiva and sclera may become quite dry and ulcerate. In these extreme cases there is, of course, no response to verbal commands. What is more striking, no reaction appears to pin pricks, so that it seems as if consciousness of pain were lost.
This deep torpor does not usually persist indefinitely. The commonest evidence of some form of consciousness persisting is probably to be seen in blinking when the eye is threatened or the sclera or cornea actually touched. A very large number of patients, when otherwise quite inactive, showed considerable response in their muscular resistiveness, the phenomena of which will be discussed shortly. The relaxation of the sphincters is apt to persist even after control of the rest of the body is exercised to the point of permitting the patient to stand or walk about.
The first phase of obvious conscious control is seen in those patients who will retain a sitting posture in bed or in a chair. The next stage is reached where the stuporous case can be stood upon his feet but cannot be induced to walk. The next degree is that of walking only when pushed or commanded. Finally spontaneous movement is observed in which the inactivity is evidenced merely by a great slowness.
No correlation can be established between restrictions of speech and motion other than that present in the extremes. With complete inactivity there is almost always consistent mutism, and perfect freedom of speech does not, as a rule, appear until the movements are free. In between these extremes all variations are possible, even the deepest stupors are occasionally interrupted by one or two words; for instance, a patient may remain comatose, as it were, and absolutely mute for six months, then to every one's surprise say one or two words and relapse into a year of silence. Again one sees cases where movements have become fairly free and yet the patient says nothing. This is another example of that inconsistency in reaction which we have already noted in connection with the mood or affect.
In so far as inactivity is merely an expression of apathy, its causation will be considered in connection with the psychology of the stupor reaction as a whole. In so far as there may be specific factors, however, it may be of interest to consider what information the patients themselves give us from time to time as to what determined their inactivity. It is really surprising how frequently something can be gained either from careful notes taken during the stupor or from the retrospective accounts of the psychotic experiences. Of course when one considers the degree of amnesia which is usually present and the extent of the intellectual defect in general, it becomes obvious that one cannot think of getting anything like a complete explanation of the behavior of any given case. Nevertheless this material is quite suggestive in the mass; it gives one some idea of the mental state as a whole.
Among 40 cases, 27 offered some explanation either during or following the psychosis. Of these, 20 spoke of feeling dead, numb or drugged, or feeling as if paralyzed or having lockjaw. This group, just half of all the cases, apparently ascribed their disability to something which seemed physical. One might call them somatopsychic cases. The other 7 gave more allopsychic explanations: 3 attributed their inactivity to outside influence; 3 more said they were afraid (one of these because she imagined herself to be in prison), which is analogous to the outside influence; the 7th case thought she would injure people if she moved.
The following are some examples of the statements of the somatopsychic group: Laura A.: "I can't move," and retrospectively, "My arms were stiff." Bridget B. claimed retrospectively that she felt dead or drugged, that her limbs were lifeless, she felt as if she had lockjaw. Johanna B. remembered being pricked with a pin on several occasions but claimed that she did not feel the pain at any time. This suggests a definitely hysterical mechanism. Anna L. (Case 16) said retrospectively that she felt as if she were dead, although walking around, and also that she thought she was a ghost and not supposed to speak. Anna M. said she had tried to speak but everything stuck in her throat. Alice R. said that she had no energy, did not want to talk. Meta S. (Case 15) claimed that while stuporous her tongue would not move. Isabella M. in intervals claimed that during the stuporous periods she felt as if dead and said retrospectively when the whole psychosis was over that it was "an effort to speak." Johanna S. (Case 13), while stuporous when pressed with questions would say: "I can't think," "I don't know," "I am twisted." When food was offered her she protested, "I am dead." Charlotte W. (Case 12), in reviewing her case, said: "I was mesmerized," "I thought I was dead." Anna G. (Case 1), in retrospect said: "I don't think I could speak," again "I made no effort," or "I did not care to speak." Henrietta H. (Case 8) said, "I lost speech." She claimed that she did not move because she was tired and had a numb feeling. Mary C. (Case 7) said that her tongue had been thick and that she felt dull. Rose Sch. (Case 6) said during the psychosis that her head was upside down and retrospectively that she had been mixed up, could not remember well, did not feel like talking. Mary D. (Case 4) said that she had been dazed, that she had not felt like talking, and that her limbs "were stiff like." We should probably also include here as a delusion of death the statement of Annie K. (Case 5) who wanted to die and thought she would do so if she kept still enough.
It is rather striking that among all the forty cases only one spoke of being sick—"I am so sick." Only one evaded questions with "that was my illness." One would expect a priori that these patients would offer some vague explanations or make complaints of weakness. If these stupors were purely physical in origin, one would expect such explanations as weakness or illness to be offered in accounting for the inactivity. That there is a rather definite type of explanation offered is, we think, distinctly suggestive. If one tries to correlate and group the death ideas, one sees that they are all delusions of death or of loss of energy or complaints of hysterical symptoms that look like sham death. If the lack of energy complained of be looked upon as lifelessness, one can conceive of these explanations being variations of one theme, namely, that of death. In the last chapter it has been shown that a delusion of dying, being dead, or having been dead is extremely frequent in the stupor group. It would seem only natural then to regard the inactivity, in so far as it may be specifically determined, as an expression of some such delusion.
Psychiatrists are more or less aware of there being typical ideational contents in the different manic-depressive psychoses. For instance, every one is familiar with ideas of wickedness and inadequacy in depression, ideas of violence in anxiety, or expansive and erotic fancies in manic states. Quite similarly we have seen that death is a dominant topic in a stupor. Now in addition to these typical ideas we often hear expressed what we might term non-specific delusions, ideas that seem to have nothing to do with a peculiar type of reaction which the patient presents. It is therefore not surprising to find that inactivity is not consistently ascribed to death or a related delusion.
For instance, Henrietta B. had much talk of higher powers that were controlling her, also said that it was fear which kept her quiet. Josephine G. said retrospectively that she had thought she would injure people if she moved and that if she opened her eyes she would murder the people around her. Johanna B. was afraid to talk because she fancied she was in prison. Laura A.: During her stupor was more vague, saying, "I can't move, they won't let me be," without betraying any suggestion of whom "they" might be. Finally Mary C. (Case 7) was still more indefinite, ascribing her immobility merely to fear. When one considers, however, that these five were the only ones who gave any atypical explanation of their inactivity among the thirty-seven cases, the preponderance of the death idea becomes striking.
2. Negativism. The next of the cardinal symptoms to be considered is negativism. This term, which is often loosely used, we would define as perversity of behavior which seems to express antagonism to the environment or to the wishes of those about the patient. Naturally it is only in the minor stupors that we see it in well-developed form as active opposition and cantankerousness. For example, Harriett C., who stood about until her feet became edematous, would spit out food when it was placed in her mouth but would eat if she were left alone with the food. Josephine G., in a milder state, would turn her back on people. When more inactive once rolled out of bed and lay on the floor. At this time also she tried to keep people out of her room. Rarely, patients may have angry outbursts, as did Annie K. (Case 5) who would strike at the nurses.
Very often the failure to swallow and anomalous habits of excretion seem to be negativistic in their nature. One thinks at once of the necessity for tube-feeding, which is so common even when patients seem otherwise fairly active. Naturally this form of treatment is necessary only when the patient refuses to swallow. Quite frequently a refusal to urinate is met with so that catheterization is necessary, or a patient may never use the toilet when led to it, but will defecate or urinate so soon as he leaves it. These latter, like some other perversities, suggest reactions of a petulant, spoiled child.
By far the commonest manifestation is muscular resistiveness, often spoken of as "resistiveness." It was present in thirty-two out of thirty-seven of our cases. Usually it takes the form of a contraction of the whole system of voluntary muscles when the patient is touched or the bed approached. Often it appears only when any passive movement of the limb is attempted. All muscles of the limb then stiffen, making the member rigid. Sometimes the negativism is expressed by quite isolated symptoms, such as stiffness in the jaw muscles alone. One patient showed no opposition except by holding her urine for two days. Another kept her eyes constantly directed to the floor. The reaction of another showed no irregularity except for stiffness in the neck and arms and wetting herself once after she had been taken to the toilet. One displayed merely a slight stiffness in her arms. An interesting case was that of Annie G. (Case 1) who kept one leg sticking out of bed. If this were pushed in, she would protrude the other. Mary F. (Case 3) sometimes expressed her antagonism to the environment by slapping other patients. She spoke only twice in a year and a half, and each time it was when interfered with. By far the commonest cause of muscular movement in these inactive cases is resistiveness, and as a rule the inactivity is interrupted only by negativistic symptoms.
If we look for some explanation or correlation of these symptoms, we find that chance references to conduct seem to point in the same direction, namely, to the desire to be left alone. This resentment against interference again reminds us of the reactions of a spoiled child. For instance, Laura A., in manic spells during which she was still constrained and drooled, said, "I don't want to have my face washed." In the intervals she showed an intense muscular resistiveness. Mary G. used to say, "Leave me alone," and covered her head or buried it in the pillows. Maggie H. (Case 14) said in retrospect that she had wanted to be left alone. Similarly Alice R. thought she did not want to talk. Emma K. thought that she was in prison and apparently resented this. Henrietta B. combined in her behavior tendencies both to compliance and opposition. When her arms were raised they retained the new position for a minute. Then she dropped them and said, "Stop mesmerizing me." But then she put them up again of her own accord, and when she had done this presented intense resistiveness to any movement. Later she extended her arms in front of her and said, "I am all right," in a theatrical manner, and then added, "Why don't you go away?"
There seems to be some correlation between inaccessibility and muscular resistiveness. For example, Charlotte W. (Case 12), whose condition varied a great deal, always lost the resistiveness when she became accessible, during which periods she also showed some facial expression. The resistiveness would invariably return when the inaccessibility reappeared. Caroline DeS. (Case 2) lost her resistiveness as she became more accessible, although the inactivity and apathy persisted. This tendency, which is quite common, suggests that muscular resistiveness represents a lower level of expression of opposition which patients put into words or purposeful actions when there is other evidence of some contact with the environment. Sometimes one observes both general resistiveness and specific acts. For instance, Mary G., who said, "Leave me alone," and covered her head or buried it in the pillows, accompanied her muscular resistiveness with laughter. This shows the affective nature of the apparently purposeless muscular tension. The case of Annie K. (Case 5) is more instructive. In the stage of deeper stupor she had the automatic type of resistiveness but also outbursts of anger, particularly toward the nurses, striking one of them she said, "You are the cause of it all." When food was offered her, she said, "I wonder people would not leave me alone sometimes." Again, when her bed was approached, she would clutch and hold the bed clothes in an apparently aimless way as if the impulse to resist never reached its goal. Retrospectively she could not account for her muscular rigidity on the basis of definite ideas, and could recall only that she felt stubborn. In a later period when more accessible, she felt cross and did not want to be bothered. This emotional attitude was quite conscious with her, whereas the acts and speech of the earlier period, when her stupor was more profound, seemed more automatic and impulsive. In other words, the resistiveness looks like a larval attempt to express an idea which is probably not fully conscious and therefore gives the appearance of being aimless. As another example of this we may cite the case of Pearl F. (Case 9), who said when she recovered, "I was stubborn." In addition to the muscular resistiveness she had shown, she would often bite the bed clothes or scratch herself when she was approached. Mary F. (Case 3), while in a stupor, slapped at nearby patients quite aimlessly. When somewhat better, this conduct appeared in a more conscious form, as sullenness, indifference and smearing of feces (again the behavior of a naughty child). Here one might quote Laura A. once more, whose resistiveness when stuporous was intense but who in her manic spells expressed her negativism in a definite idea, "I don't want my face washed."
To summarize, then, we may say that negativism is apparently the result of a desire to be left alone, and that muscular resistiveness is a larval exhibition of the same tendency. But the appearance of this attitude in such aimless, impulsive acts or habits reminds us strongly of the dissociation of affect, which was commented on in the previous chapter. It would seem to be another example of this rather fundamental tendency of the stupor reaction, not merely to diminish conative reactions in general, but to reduce their appearance to that of isolated, partial and therefore rather meaningless expression.
3. Catalepsy. The last of the cardinal symptoms to be considered is catalepsy. It occurred in thirteen of thirty-seven cases, although it was present only as a tendency in three of these. If we define it as the maintenance of position in which a part of the body is placed regardless of comfort, we can see that sometimes it is difficult to differentiate from the phenomenon of resistiveness with its rigidity. It is most frequently observed in the hands and arms, perhaps because it is, as a rule, most convenient to demonstrate the retention of awkward positions in the upward extremities. But any part or even the whole body may be involved; for example, Charles O. retained standing positions even where balance was difficult. This phenomenon is often accompanied by "waxy flexibility," where the joints move stiffly but retain whatever bend is given them, like a doll with stiff joints.
The significance of catalepsy is best studied by considering its relationship to other symptoms and by noting remarks made by the patients in reference to it. The most important observations which we have made seem to indicate that it never occurs with that degree of deep inactivity which suggests a complete lack of mentation on the part of the patient. One is therefore forced to conclude that back of this phenomenon there must be some purpose, some kind of an ideational content, although this may be of a primitive order. This is demonstrably true in some cases, at least such as that of Isabella M., who left her arm sticking up in the air but took it down to scratch herself and then put it back. Somewhat similarly, Charlotte W. (Case 12), when she was shown during convalescence a photograph of herself in a cataleptic state, said that that was when she was waiting to go to Heaven and was afraid to move. Again she remarked, "I was mesmerized." Josephine G., who showed only a tendency to catalepsy, said that she feared the devil would get control of those about her if she moved. Sometimes there is a development of this symptom from others which seem to be ideational in their origin. For instance, Charles O. began making flail-like movements. These passed over into slow circular motions which finally subsided into the maintenance of fixed position.
References to hypnotism are not infrequent, and in many cases there is evidence of a delusion that the posture is desired by those in charge of the patient. Annie G. (Case 1) said so directly. In retrospect she explained the holding of her arms in the air by saying, "I thought you wanted me to have them up." Henrietta B. at one examination kept her arms raised in the position in which they had been put for a minute and then dropped them, saying, "Stop mesmerizing me." But she then put them up again of her own accord and now presented intense resistance to any motion. Later she extended her arms in front of her and said, "I am all right," in a theatrical manner. Some patients give evidence in other symptoms of larval efforts at coöperation with the actual or supposed wishes of the physician and in such cases it is not impossible that passive movements are interpreted as orders. One must remember in this connection that the more primitive are the mental operations of any individual, the more important do signs, rather than speech, come to be a medium of communication with other people. As an example of this type we might mention Rose Sch. (Case 6), who flinched from pin pricks (showing that she felt them) but made no effort to get away. When somewhat clearer she said that she was "here to be cured." Similarly Mary D. (Case 4), who showed no catalepsy from ordinary tests, kept her head off the pillow for a long time after it was raised to have her hair dressed. She showed such perseveration in many constrained positions. She too flinched from pin pricks but not only made no effort to prevent them but would even stick out her tongue to have a pin stuck in it.
The relationship of catalepsy to resistiveness is interesting but unfortunately complicated and unclear. In only one of our cases was catalepsy definitely present without resistiveness, and in one other a "tendency to catalepsy" was noted without muscular rigidity being observed. In this latter case, when the catalepsy became unquestionable, resistiveness also appeared. It is one thing to note this coexistence and another to explain it adequately. All that we can offer are mere speculations as to the real meaning of the association of these phenomena. It may be that the tension of muscles that occurs when resistiveness is present gives the idea to the patient of holding the position. There would be two possible explanations for this. We might think there is a dissociation of consciousness, like that of hysteria, where the feeling of tenseness in the muscles that comes from the resistance to gravity is not discriminated from the resistance to the movements made by the examiner. On the other hand, there might be a similar dissociation where the perception of contraction in the antagonistic muscles is interpreted as the action of the examiner in placing the limb in a given position. This latter view would seem, on the face of it, ridiculous, inasmuch as its presumes the existence of two directly opposed tendencies, namely, those of opposition to the will of the physician and compliance with it. But ambivalent tendencies are frequently present in psychopathic states, and moreover we find occasionally some evidence in the behavior of the patient to substantiate this view. For example, at one stage of the stupor of Annie G. (Case 1), her arm could be moved without resistance. Then the elbow would catch and at this moment the position would be maintained. Such observation is highly suggestive of the resistance being signal for the catalepsy. In Isabella M. the catalepsy appeared when resistance to passive movements also developed. On the other hand, when the resistance became extreme, the catalepsy was reduced, and vice versa. This makes one think of two tendencies: suggestibility on the one hand, and opposition on the other. We might presume that when both are present and equally strong, stiffness with passive movements results as a kind of compromise, but when there is a greater development of one, the other is inhibited.
Such speculations remind one strongly of the psychology of conversion hysteria and of hypnotism. In some cases of stupor hysterical symptoms are quite definitely present. For instance, Celia G. began her psychosis with hysterical convulsions which would terminate with short periods of stupor. Later the stupor became persistent and during this stage she had catalepsy (and restiveness as well) in her left arm only. On recovery from her stupor she complained of stiffness in her hands, which examination proved to be a purely hysterical difficulty.
This whole subject is without question obscure and many more and very careful observations are needed before really satisfactory explanations can be given for these phenomena. That it is a reaction which is related to the primitiveness of the mental content and the intellectual deficit in stupor would seem to be a reasonable view, inasmuch as quite similar phenomena have been observed in a large number of animals, even among crustaceans. As a result of our own observations the only thing we feel at liberty to state with real confidence is that catalepsy is presumably a phenomenon mental in origin rather than somatic, because it always occurs in conditions which show other evidence of mentation.
Whatever may be the origin of the idea of the posture assumed, there can be little doubt that its indefinite maintenance is a phenomenon of perseveration. The conception of the position being in the patient's mind, it is easier to hold it than elaborate another idea. This, of course, is part of the intellectual disorder in stupor. In fact, it is difficult to imagine any one whose critical faculty was functioning coöperating in a test for catalepsy.
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.