Читать книгу Benign Stupors: A Study of a New Manic-Depressive Reaction Type - August Hoch - Страница 4

Case 4.—Mary D. Age: 20. Admitted to the Psychiatric Institute September 17, 1907.

F. H. The grandfather and the father of the patient were alcoholics. The father died three years before the patient's admission; he was killed in an accident. The mother stated that she herself was nervous, but she made a normal impression.

P. H. The patient was described as bright at school and efficient in her work as a dressmaker, but she was rather quiet, inclined to stay at home and had not much inclination to consort with the other sex. She was rather proud. As an example of this is stated the fact that she was always somewhat sensitive, because the family lived in the basement of the house in which her mother was janitress. She did not menstruate until 16. It was about this time that her father was killed in an accident. She was considerably upset by this, talked a good deal about the way he was killed, but did not break down. The patient on recovery stated that it worried her because the father died without having any chance to get a priest.

Six weeks before admission the patient was given a vacation, as there was not work enough in the shop, but she worked at home.

Two or three weeks before admission her appetite failed somewhat, and ten days before admission, without any appreciable cause, she began to sleep badly, seemed somewhat nervous, became a little "fidgety" and said she worried because her mother had to work so hard. Later she began to speak about people saying that the ambulance would come for her and she heard voices saying "You will be dead." It is not known in what emotional setting these remarks were made. Her mother took her to a dispensary. On the way she asked the mother where she was going and said "I can't tell the number and I don't know where I am going. I think I am losing my mind." She also said she could not understand any more what she read. She was put to bed. She then talked less, appeared stupid, and was inclined to refuse food.

Four days before admission she claimed that she could see her dead father beckoning to her, again she said a certain young man was God. She was sent to the Observation Pavilion. On the day she went there she was reported to have shown a slight jaundice.

The patient, after her recovery, added to the above account of the mother, that about two weeks before admission, for no reason which she could state, she began to feel quiet, and that after that her father's death began to prey on her mind, and that later she had a vision of her father. She claimed that in this period she had no fear but that her head felt dizzy and her vision seemed dim.

At the Observation Pavilion the patient was described as constrained, refusing food, mute, resistive of attention, sometimes muttering to herself and having the appearance of uneasiness.

Under Observation: 1. On admission the patient had a slight jaundice, which disappeared in a few days, and the bile test in the urine was negative on admission. She was rather thin, but otherwise in good physical condition. Her temperature was 99.2°.

For three months the patient was very inactive, moving very little. She had to be dressed and undressed, when taken out of bed. She often was markedly constrained, either lying with her head raised from the pillow, or for long periods of time holding her arms or hands in rather constrained positions on her body. But there was at no time any catalepsy when tested by moving her arms. In the beginning, however, before she lay so persistently with her head raised, she was found holding it up from the pillow after her hair had been fixed. Again, she did not correct other, rather uncomfortable, positions in which she had been left. There was also at times a slight or occasionally a somewhat more marked resistance in her arms and neck, but this never amounted to a pronounced resistance. She sometimes did not react to pin pricks, sometimes flinched a little, never warded off the pin, indeed she would put out her tongue repeatedly when asked to do so in order to have a pin stuck into it. She very often wet and soiled, once even immediately after she had been taken to the closet, on which occasion she did not urinate. Her face was usually dull, vacant and immobile, but sometimes, when questioned or when something obtrusive happened, a little puzzled. Occasionally she looked slowly about or followed people with her eyes. There was no evidence of any affect as a rule, but not infrequently she smiled, even quite freely at times, when the physician came to her or on other appropriate occasions. For example, once when a nurse came into the ward whom she had known outside she flushed and smiled a little. Once when the mother came to see her a few tears appeared, the only time this occurred.

Although for the most part immobile, when she did move, she was distinctly slow. When asked to do certain things, she usually did not comply, but now and then, after urging, would show her tongue after delay, or merely open her mouth; or she would bring the hand forward slowly when the physician offered his hand in greeting. Once she fumbled with her braids slowly. When out of bed, she stood about aimlessly or sometimes walked somewhat slowly.

She was almost entirely mute, but a few times she returned a greeting quite promptly, or on another occasion (September 23) she said quite promptly, when asked how she felt, "I feel better. I took off my clothes" (correct—she had been up and put to bed again). Again she sometimes answered simple questions by "yes" or "no," though sometimes in a contradictory and rather aimless manner, but promptly enough. Once she said to her mother, "I can't, I have to remain here." There were some other replies which we shall presently take up. Several times it was possible to make her write. On these occasions she wrote her name promptly, or might write only after much delay or stopping in the middle of a word.

This leads us to her capacity to think, the defect of which was perhaps most clear in her writing. Thus, though having been told to write her name, and having written it quickly enough, when, immediately after it, she was asked to write her address or the name of the hospital, she had to be urged much, and then wrote each time merely a repetition of her name, this time much more slowly. On October 13, when she was asked to write her name, she wrote it correctly; then for the address she wrote the house number correctly, but for 90th street she wrote "90theath"; and, urged again for the address, she added "Dr. Wyeth." Again when asked to write the word "watch" she was slow, and finally put down "10." When on October 23 she was asked to write "Manhattan State Hospital," she wrote "Manhatt Hhospshosh," and for "Ward's Island" (which she was told), "Ww Iland." Then she was asked to write "I wish to go home." She wrote "I wish to go home, go West." Here again the first part was written promptly.

We now can add some of the other replies which she gave. Once she was asked "Do you know where you are?" She promptly said, "Yes." (Where?) No reply. On another occasion, at the initial examination, she said she was home or "in papa's house." Once when asked "Do you know me?" she said "Yes." (What is my name?) "Miss D." (her name). On the occasion on which she had stated that she had taken off her clothes, she was asked "Where have you taken off your clothes?" She made the irrelevant reply, "That was the girl the one I had."

2. Then she improved somewhat. On January 5 she walked about a little more, though slowly, and still looked slightly puzzled when questioned. She spoke more readily, counted promptly though once stopped in the middle of the exercise. In calculation she multiplied correctly 3 × 7, but for 4 × 9 repeated the 21, and when given 9 × 9 she did not answer. A few days later, though she lay again motionless with her head raised as before, and, as she had sometimes done, smiled brightly when accosted, she gave few replies, but when asked to write down the month she slowly wrote "December." Asked to write it the second time, she did it promptly. She also replied promptly by saying "Yes" when asked whether Christmas, and again whether New Year's, had passed, but did not reply to the questions how long ago Christmas, or how long ago New Year's, had occurred. On January 23 she was decidedly more free and prompt in her replies, yet she still wet and soiled (in fact this did not cease until the end of the month, when great improvement occurred). At this time she gave quite a number of calculations promptly, about an equal number wrongly. She knew where she was, knew the names of a number of people about her, but thought she had been here about two weeks (four months), and gave the year and the date, the latter as the 28th of January. When then told that it was Thursday, January 23, and that she must remember it, and asked five minutes later what she had been told, she again said "January 28" and left out Thursday. To some questions to which she did not know the answers, since she had an amnesia for the time of their occurrence (the incidents of coming here), she simply remained silent. Even on February 7, when she was much freer, helped the nurses, and said herself she was "smarter," she had difficulty in thinking, said she was 17 (21), gave the date of her birth correctly, but the current year as 1909 (1908) and still insisted she was 17. She then did the calculations on paper, and with considerable difficulty got correctly "22." But she could not straighten out the discrepancy. At that time, also, she still wrote "Hospitital," calculated even simple multiplications with some mistakes, could not get the point of a story, and to retention tests gave poor results. Indeed, even seven days later, when she wrote a very rational letter and appeared quite natural, she made some omissions in her writing, and a few mistakes in spelling.

However, she now improved rapidly, and by March 31 she made a very natural impression, was frank, free, had good insight, calculated well, etc., understood a story, retention was good.

She then gave the retrospective account embodied in the history, and in addition told that she had no recollection of going to the Observation Pavilion, the coming here, or the first part of her stay, including presentation of the case at a staff meeting, a physical examination and a blood examination, and she claimed for a long time not to know where she was, "I was in a kind of dazed condition." She also said she could not understand the questions which were asked her. This probably refers, however, to the second part, i.e., the partial stupor lasting for two months. She did not "feel like talking," the limbs "felt stiff-like."

Case 5.—Annie K. Age: 22. Admitted to the Psychiatric Institute January 7, 1907.

F. H. The father was an alcoholic, who died when patient was a child. A paternal aunt had a nervous breakdown, with recovery. The mother appeared to be normal.

P. H. The mother stated that the patient was a rather delicate child. She attended school irregularly, never felt much interest in it, and was always glad to be at home and help the mother take care of the other children. On the other hand, she is said to have been quite lively, rather a tomboy, with a temper. She left school at 14; learned dressmaking for a year, but did not get along well. Then she took several other positions, which she held for about a year, getting on pretty well.

She married at 20. Her husband never supported her well and often beat her. She had to borrow money to get along and worried much. During pregnancy she seemed to worry more, had crying spells, and often seemed absorbed in thought.

Three weeks before admission she gave birth to a child. The labor was somewhat difficult, but she had no fever. She got up on the tenth day, and then seemed to lose all interest, did not attend to the baby, said she was not strong enough. She sat about, appearing depressed. The mother then took her and the baby to her house. There she sat or walked about, said very little. But she repeatedly came to her mother, said she had something to tell her, or that she had "done something," although she could never be induced to say what. Once she came to her and said, "You are not going to die." She often moaned. Finally, she claimed a neighbor had been saying she was poisoning the baby.

The patient herself gave, after recovery, the onset as follows: When she married she knew her husband was not what he should be, but not that he was so bad as he proved to be. He was a gambler, did not support her, and this caused her much worry. When she became pregnant, eight months after marriage, this increased her worry, and throughout the pregnancy she spoke much to a neighbor about her worries, and said she did not know how she could manage, pay the doctor, and the like, but she did not say much about it to her mother (because the latter would have made such a fuss about it, or would have said, "It serves you right"). Then the childbirth came. This further accentuated her worries. She felt her difficult circumstances, wondered how she could get the necessary money, "I lay there worrying." And she claimed she did not sleep at all. About her statement, mentioned by the mother, that she had done something, she said that she thought she had poisoned the child by giving it fennel tea, and that she thought a neighbor who visited her said she had poisoned it. She was then put to bed again, and one night she had a vision of her father. This frightened her. She thought this meant he had come for her and she wanted to die.

At the Observation Pavilion she was dull, staring, resisting attempts at passive motions.

Under Observation: 1. There was nothing noteworthy in her physical condition, except for a rise of temperature to 100° occasionally during the first month of her admission. For the first four months she was often found lying in bed with her head half raised from the pillow, or standing or sitting about in constrained positions, immobile, frequently she let saliva collect in her mouth. She usually wet and sometimes soiled the bed. Sometimes, when sitting in a constrained position, she let herself gradually slide on the floor. She often began to feed herself when urged, but would not finish, and had to be spoon-fed, as a rule. She was never tube-fed. She was often quite stiff and showed marked resistance. This was manifested either when passive motions were tried, at which times she usually resisted passively, i.e., she became more tense; or when there broke through a more active aggression and she would strike. Above all, the opposition showed itself towards the nurses' attention; in this she also showed either a passive, aimless opposition and stiffness, or a more active one; but even in the latter an open show of angry affect, or plain irritation, though present at times, was by no means constant. When it was present, she would strike quite aimfully; once she struck the nurse and said, "You are the cause of it all," and once, when the nurse tried to give her some milk, she said, in an irritated tone, "I wonder people would not let me alone some time." Again, she bit a patient who tried to hold her. On another occasion she quickly jumped up and pulled the hair of a patient who evidently disturbed her by her noisy shouting. As was stated, she usually wet the bed, resisted being taken to the toilet, or when taken there, would not urinate or defecate, but would do so as soon as she was returned to bed; or she urinated while standing. The same perverse opposition was seen when she would refuse a glass of milk, but grab it when it was taken away and then refuse to let go. She often would grasp the bedclothes or other things and hold on aimlessly.

She rarely spoke, answered almost no questions, complied, as a rule, not even with the simplest commands. To pin pricks she did not react except at times by flushing. But she did not stare, rather looked about, and was at times easily attracted by noises or happenings about her, and would then look in that direction not without some interest. Often there was then an expression of bewilderment. Her mood, however, was, as a rule, apathetic, but at times, as stated, she showed some anger. Once she wept, and a few times she smiled or snickered. As a rule, this happened without appreciable cause. But once, when a cheering remark was made, she smiled; or, when her picture was taken (to show the peculiar constrained attitude with the head raised from the pillow), she laughed loudly.

Although she spoke rarely, she made a few utterances in the first few days. Thus she suddenly said: "I want to see Mr. N.—what I said to him was not right," or "Listen! there are the priests calling," or "You are all faking—it is me that done it—they are all dressing up downstairs," or "I told you she was not able to nurse the baby," or "I have nobody, I am lost—I want to know the truth—my mamma," or she called her sister, "They are dead since last night."

Even during the more stuporous state she could, a few times, be made to write a little. Then she either wrote very slowly and not more than a letter, or if she wrote more, it was remarkably mixed up. Thus when asked to write the date, she wrote, "Jane (mother's name) to me to Chrichst," or when asked to write her name: "Annie take you ktusto."

As to her orientation, nothing could be made out as a rule. At first, however, a few weeks after admission, she spoke correctly of the month as January and spoke of the Island. When at that time she was asked if she had a baby, she said, in an annoyed tone, "I don't know."

2. In the beginning of May, i.e., four months after entrance, her condition changed somewhat, and for two months she presented the following state: She stood about, or walked around slowly, usually with her arms folded. She had a tendency to stand near the door. She had to be assisted in dressing, pushed rather than led to her meals, and urged to eat. For the most part, she would not answer questions, but would either smile in a sneering way, or just walk away, or say, "Oh, don't bother me," or "I don't want to talk," and generally her attitude was rather sulky. Nor was this only towards the physicians but towards the husband, sister and child as well. When on May 17 the sister came, she would not speak to her but said "Go away." The baby she simply pushed away sulkily when it was brought to her. To the husband she said on May 31, "Go away, you stink." In the first part of this period, she presented some bursts of elation, on one occasion turned somersaults, indulged in a few pranks with laughter, or once, when a knock at the door was heard, she called out "Holy gee, cheese it, the cop." But these occurred only in the first part of the period. On June 1 she spoke to the nurse, said, "What is the matter with these people, they must be crazy," asked to go home, and was then by the nurse found to be oriented, and to know the names of people around her. But when she was asked about the baby she would not answer, and questioned whether she was not married, she said "I don't know." Yet when the physician desired to talk to her, she was just the same as before and remained so for two more weeks. Another somewhat isolated occurrence was when on June 18 she spoke a little to the physician, but she sat in a constrained position when taken into the office and answered many questions by "I don't know," namely, those regarding her condition and feelings, the questions about orientation, about her mother's address, and her child's age; but when asked how long she had been married she said correctly "Two years."

At the beginning of July she improved quite rapidly, and on July 5 appeared fairly free and gave a fair retrospective account, with some urging, and it was thought that she smiled somewhat too freely. However, on July 27, she seemed perfectly well, had normal insight, and then gave the second retrospective account, which, together with the first, will now be taken up.

Retrospectively: She claimed to remember things at home, and at both interviews said she recalled being taken to the Observation Pavilion. While there she thought she knew where she was, remembered that she did not talk. She had a feeling she was going to die and said "I thought I would die if I kept still." However, the transfer to this hospital was vague in her mind, as was the entrance on the ward, and she claimed not to have known for quite a while where she was. She added that she used to wonder where she was, how she had gotten here, and how she could get out, and thought the questions which were asked were queer. Individual occurrences, too, specifically inquired into were not recollected, such as an examination in a special room. Of the mixed-up writing at the end of the second week, she had no recollection even when it was shown to her. She did not recall having her picture taken (with eyes open) two months after entrance. Yet a sudden angry outburst ten weeks after admission was remembered. She stated that she struck the patient because the latter annoyed her by her shouting. She had a general recollection of being stiff, having her head raised, and of soiling and drooling, but could not account for it. She felt stubborn. She also claimed not to have been hungry and not to have felt pin pricks.

In regard to ideas which she had, she claimed to be afraid at first that she would be cut up. She remembered repeated visions of her father at night, also once of her dead aunt, who said "Come to me." She thought she was in a cemetery, all the family were dead, the baby dead. In the beginning, too, she sometimes heard a priest whom she had known, say "Be good and God will look after you."

In regard to the later period, she recalled that she got up in May and felt cross. She did not answer because she did not want to be bothered. She pushed the baby away because she did not think it belonged to her, the husband because she did not like him. (She did not think she was not married.) She evidently remembered the visits, thought she knew where she was, knew she stood near the door "because I wanted to go home." Besides the idea that the baby was not hers, she recalled none, and thought she had no hallucinations.

She was discharged perfectly well six months after admission to the hospital. Soon after that, she left the husband, once had him arrested in 1908 and sent to the workhouse. She was again examined in 1913, and was found to be perfectly well, and she stated she had been well since the discharge.

These five cases will have to suffice for the present. They were given in full in spite of the fact that we shall leave out of our present considerations the history of the cases and certain of the stages, and confine ourselves to that stage of each case which is best qualified to give us a good general survey of the essential features of the stupor reaction.

These phases are: stage 1 of Case 1, lasting five months; stage 3 of Case 2, lasting one year; stage 2 of Case 3, lasting two years; stage 1 of Case 4, lasting three months; stage 1 of Case 5, lasting four months.

We gather from these descriptions that the essentials of the stupor reaction are (1) more or less marked interference with activity, often to the point of complete cessation of spontaneous and reactive motions and speech; (2) interference with the intellectual processes; (3) affectlessness; (4) negativism.

Inactivity: There is a complete cessation or more or less marked diminution of all spontaneous or reactive movements. This includes such voluntary muscle reflexes as contain a psychic component. For instance, there is, often, an interference with swallowing (letting saliva collect and drooling), winking, and even with the inhibitory processes used in holding urine and feces (soiling and wetting). Often there is no reaction to pin pricks or feinting motions. The inactivity also often interferes with the taking of food so that spoon-feeding or tube-feeding has to be resorted to. The patient may keep his eyes covered or stare vacantly, the face often presenting a remarkably immobile wooden, or stolid, expression. Complete mutism is the rule. When activity is not totally interfered with, those movements which are present may be slow. The patient may have to be pushed around and be able to take a few steps, but soon relapses. More often they are of normal rapidity. Speech then may also be slow and low, but usually shows no change except for the fact that it is diminished in amount. Sometimes awkward positions are assumed and retained, and there may be catalepsy.

Negativism: A common symptom is perverse resistiveness. It may consist in a marked stiffening of the body which is assumed spontaneously or appears only when attempts at interference are made, or there may be a more active turning away or even a direct warding off, sometimes with scowling or anger or even swearing and striking. Retention of urine, which is seen at times, should, perhaps, be mentioned here. Now and then we find that a patient is put on the toilet and cannot be induced to urinate or defecate, while soiling and wetting occur at once on returning to bed.

The intellectual processes: Little is known about the intellectual processes from direct observation in these more pronounced cases, except for the fact that in Case 5 questions or obtrusive occurrences sometimes produced a somewhat puzzled facial expression. Moreover, the patient retrospectively stated that she was unable to understand the questions, which points to marked difficulty in apprehension. We also find that occasionally there is evidence of an interference with the intellectual processes which showed itself in what may be called "paragraphic" writing when the patient could be induced to write. Above all, we see that retrospectively very little is remembered of what took place during the stupor, even of such obtrusive events as the moving from one ward to another, tube-feeding, physical examination, the presentation at a staff meeting, and the like.

Affect: Complete affectlessness is an integral part of the stupor reaction. Modification of the statement will later be mentioned. The patient is indifferent so far as his basic condition is concerned, and it is only by certain stimuli that at times emotional reactions can be elicitated, some tears at a visit of a relative, an appropriate smile at a joke or a comical situation when the stupor is not too deep or an angry reaction called forth by interference.

Catalepsy: Waxy flexibility or merely a tendency to maintain artificial positions is a frequent but not an essential symptom.

Physical Condition: Not infrequently we find in the beginning or in the course of the stupor an elevation of temperature to 101°, 102° or even 103°. In one case we found a marked cyanosis in the extremities. Case 2 showed marked loss of hair. Gain in weight is never observed and marked emaciation is the rule. This we may attribute to the refusal of food.

A perusal of these cases, then, shows that the dominant (and well-nigh exclusive) symptoms of the stupor are inactivity, apathy, negativism and disturbance of the intellectual functions. Benign stupor can be defined as a recoverable psychosis characterized by these four symptoms. The meaning of such vague physical manifestations as the low fever is not clear.