On the day after this letter she was distinctly freer, talked a little to the nurse and then improved rapidly. A week after this, January 16, she is described as quite free in her talk and activity, but when asked about the psychosis she merely shrugged her shoulders. However, mere extensive retrospective accounts were taken later.
The retrospective accounts were obtained on January 24 and March 13. As these two accounts do not seem to be fundamentally different for the period of the psychosis, they may here for the sake of brevity be combined.
She remembered clearly going to the Observation Pavilion, and feeling frightened, as she did not know where she was going and what they were going to do with her. She knew when she was in the Observation Pavilion and had a good recollection of the place, also of the transfer to the hospital, the ward she came to, who spoke to her, etc. She did not know what the place was until the doctor told her a day or two after admission. Unfor
tunately definite incidents were inquired into only for the first part (July). But she remembered those clearly. She also claimed to remember all visits which were made to her by her friends, but it was not specifically determined whether there was a period of less clear recollection or not. However, she remembered the tube-feeding, which occurred only during the more marked stupor. Her desire to be killed, to have her head cut off, she recalled but claimed not to know why she wanted to be killed. However, she remembered worrying about being bad, about the fact that she could not "pay for the beds," etc.
Her mutism and refusal of food she was unable to account for. She could not talk, her "tongue would not move." As regards ideas during the more stuporous period, she claimed that (when quite inactive) she heard voices but did not recall what they said. But she remembered having dreams at that time "of fire," "of her dead father and of home."
In a survey of thirty-six consecutive cases of definite stupor, literal death ideas were found in all but one case. They seem to be commonest during the period immediately preceding the stupor, as all but five of these cases spoke of death while the psychosis was incubating. From this we may deduce that the stupor reaction is consequent on ideas of death, or, to put it more guardedly, that death ideas and stupor are consecutive phenomena in the same fundamental process. Two-thirds of these patients interrupted the stupor symptoms to speak of death or attempt suicide, which would lead us to suppose that this intimate relationship still continued. One-quarter gave a retrospective account of delusions of being dead, being in Heaven, and so on. From this we may suspect that in many cases there may be a thought content, although the patient's mind may
seem to be a complete blank. It is important to note that when a retrospective account is gained, the delusions are practically always of death or something akin to it, such as being in prison, feeling paralyzed, stiff, and so on.
In the one case of the thirty-six who presented no literal death ideas, the psychosis was characterized essentially by apathy and mild confusion, a larval stupor reaction. It began with a fear of fire, smelling smoke and a conviction that her house would burn down. It is surely not straining interpretation to suggest that this phobia was analogous to a death fear. When one considers the incompleteness of anamneses not taken ad hoc (for these are largely old cases) and that the rule in stupor is silence, the consistence with which this content appears is striking.
To exemplify the form in which these delusional thoughts occur we may cite the following: Henrietta H. (Case 8) said, retrospectively, that she thought she was dead, that she saw shadows of dead friends laid out for burial, that she saw scenes from Heaven and earth. Annie K. (Case 5) claimed to have had the belief that she was going to die, and to have had visions of her dead father and dead aunt, who were calling her. She also thought that all the family were dead and that she was in a cemetery. Rosie K. (Case 11) said she had the idea that she wanted to die and that she refused food for that purpose, and during the stupor she sometimes held her breath until she was cyanotic. Mary F. (Case
3), before her stupor became profound, spoke of the hereafter, of being in Calvary and in Heaven. In this case, as well as in the above-mentioned Henrietta H., we find, therefore, associated with "death" the closely related idea of Heaven. Whether Calvary merely referred to the cemetery (Mt. Calvary Cemetery) or leads over to the motif of crucifixion, cannot be decided. It is, however, clear that this latter motif may be associated with that of death, as is shown in Charlotte W. (Case 12), who, during intervals when the inactivity lifted, spoke of having been dead, of spirits having told her that she must die, of having gone to Heaven, of God having told her that she must die on the cross like Christ. But this patient also showed in a second subperiod of her stupor another content. She said: "It was like water. I was going down." Or again, she spoke of having gone "under the ground"; "I went down, down in a coffin." She spoke of having gone down "into a dark hole," "down, down, up, up"; again, of having been "on a ship." We shall see in the further course of our study that this type of content occurs not at all infrequently.