Benign Stupors: A Study of a New Manic-Depressive Reaction Type. August Hoch
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