Towards the end of August she had pneumonia, which did not change her condition.
By October she was well, having gradually settled down. She had good insight.
Retrospectively: She laid very little stress on the false report of the father's death. She claimed to remember being at the Observation Pavilion, but to recall very little of the other hospital. Unfortunately an inquiry was not made regarding her memory during the stupor period under observation with the exception of the fact that she said she wanted to die and therefore refused food.
She was seen in March, 1913, appeared perfectly well, and stated she had been well during the entire interval.
If this forced holding of the breath had been the only anomaly, one would, perhaps, not be justified in drawing any conclusions as to its significance. But the deep stupor was interrupted again for a day by grunting and screaming of "murder." This is certainly indicative of a compulsive death idea and retrospectively she spoke of having refused food in order to die. The latter seems to indicate some connection between her negativism and death. Consequently, even if we regard the breath holding as resistiveness, it would still be related to her idea of dissolution. Her negativism went beyond ordinary limits in that it affected the expression of the face.
When we consider these three cases together, we see that what would otherwise have been deep stupors with profound inactivity, were modified by activity in two directions: suicidal and resistive. Presuming that the symptoms of stupor are all interrelated, we can see a reason why the affect should
also have been altered. When one is modified, this should influence the other. When the activity is increased, the emotional concomitants of impulsive acts tend to break through as well. Hence the changes observed in these cases in facial expression and tone of voice. It is noteworthy, too, that all three showed a tendency for laughter to appear, as if, the emotions once stirred, it was possible for them to be exhibited in other than unpleasant forms. So, too, it was possible for ideas unrelated to the stupor picture, such as those of lovers, to occur sporadically. Finally, since activity must imply some contact with environment, the first of these cases at least showed less interference with the intelligence than is usual. In general, one may conclude that any aberration from the pure type of stupor tends to allow other impurities to appear.
CHAPTER IV
THE INTERFERENCES WITH THE INTELLECTUAL PROCESSES
This is one of the most interesting and important of the stupor symptoms. We are accustomed to think of the functional psychoses having symptoms to do with emotions and ideas in the main, and, conversely, that disorientation, etc., observed in such cases is merely the result of distraction, poor attention or coöperation. But in stupor the deficit in understanding, incapacity to solve simple problems and failure of memory seem deep-rooted and fundamental symptoms. So far is this true that Bleuler[5] looks on "schizophrenic" cases with this symptom of "Benommenheit" as organic in etiology. It may be said at the outset that we do not share this view for many reasons. One at least may now be stated as it seems to be final. In benign stupor purely mental stimuli may change the whole clinical picture abruptly and with this produce a change in the intellectual functioning such as we never see in organic dementias or clouded states. We find it more satisfactory to attempt a correlation of this with the other symptoms on a purely functional basis, as will be explained later.