Читать книгу Benign Stupors: A Study of a New Manic-Depressive Reaction Type - August Hoch - Страница 6

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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.