In studying the ideas which we obtained from the patients by retrospective account after the psychosis or from a retrospective account during freer intervals, it is, of course, difficult, especially in the former case, to say whether they have persisted for any length of time. Probably in most instances this was not the case, and we must remember in this connection that in a considerable number of cases the patients recalled no ideas whatever.
Of the five cases which we may consider as types, Henrietta H. (Case 8) and Mary F. (Case 3) formulated their ideas simply as accepted facts during the stupor. The former thought she was dead, saw dead friends laid out for burial, and scenes from Heaven and earth. The latter spoke, during the stupor, of being in "Calvary," "the hereafter," or "Heaven." We have seen that these stupors were essentially affectless reactions and we can therefore say that, so far as these two cases are concerned, the ideas thus formulated were not associated with any affect.
Annie K. (Case 5) was a little different. During the stupor she made a few utterances about priests and "all being dead," and retrospectively she said that she had thought she was in the cemetery, was going to die, that she had repeated visions of her dead father and once of a dead aunt calling her; that she had thought her family were dead, again that the baby (who was born just before the psychosis) was dead. The formulation is therefore less one of fact than of something prospective, something which is coming—the going to die. Correlated, perhaps, with this anticipation were slight modifications of the usual apathy. The patient often had an expression of bewilderment. She was also more in contact with her environment than many stuporous patients are, for, not infrequently, she would look at what was going on about her. Her apathy was also broken into in a marked degree by her active resistiveness, which was sometimes accompanied by plain anger. It seems that a prospect of death may occur in other instances in a totally affectless state. We have recently seen it in a partial stupor during which the patient spoke and had this persistent idea in a setting of complete apathy. We see here also, as in one of the former cases, the idea of other members of the family being dead.
More difficult and deserving more discussion are the two remaining cases, Rosie K. (Case 11) and Charlotte W. (Case 12). Rosie K. showed a peculiar condition. She said, retrospectively, that during the stupor she had the desire to die and that for this
purpose she refused food. Moreover, she was repeatedly seen to hold her breath with great insistence, though without affect. This is worth noting. We are in the habit in psychiatry to say in a case like this that "there is no affect," and yet there is evidently a considerable "push" behind the action. We shall later have to mention in detail a patient whom we regard as belonging in the group of stupor reactions, and who for a time made insistent, impulsive and most determined suicidal attempts, yet with a peculiar blank affectless facial expression and with shouting which was more like that of a huckster than one in despair. Here also, then, there was a great deal of "push," yet not associated with that which we call in psychiatry an affect. In both instances we see acts which we are in the habit of calling for this very reason "impulsive." Evidently this is an important psychological problem which leads directly into the psychology of affects and deserves further study. For the present it is enough to say that with a different formulation—that of wishing to die—there is here not, as in other psychoses, a definite affect, such as sadness or despair, but no affect, though there may be a good deal of "push" or impulsiveness.
The case of Charlotte W. (Case 12) is a complicated one, for she had short stupor periods with inactivity, catalepsy, resistiveness, etc., which were interrupted with freer spells. A careful analysis of her history has been instructive and justifies a detailed and lengthy discussion. For the purpose in
hand it is necessary to separate the ideas which she expressed only in the freer periods (during which some affect was at times seen) into those which referred retrospectively to the stupor phase and those which referred to the freer periods themselves.
We find that the time during which more marked stupor symptoms appeared may be divided into two subperiods. This is not possible in regard to the manifestations belonging to the general reaction, which seem to have undergone no decided change, but only in regard to the form of the delusions. In this we find there was a first phase in which ideas of death and Heaven (and crucifixion) occurred, and a second phase in which ideas were present which belonged essentially to the motif of rebirth but which were also associated with ideas of Heaven.
About the first subperiod she said: "I was mesmerized," or "I thought I was dead," or "God told me I must die on the cross as He did," or "I went to Heaven in spirit." About the second subperiod she said retrospectively: "We were on a ship and we were 'most drowned." "It was like water, I was going down, down." She said she saw the people of the hospital and "it was all full of water"; or again, "I went under the ground and it was full of water and every one got drowned and a sharp thing struck me"; or "I was out on a ship and I went down in a coffin." She claimed she put up her arms to save the ship. Again she spoke of having gone into a dark hole. She also said: "One day I was in a coffin—that was the day I went to Heaven."
"They used to be coming up and down, that was the day I was coming up in a ship or going down." And when shown her picture in a cataleptic attitude, she said: "That must have been when I went to Heaven—everything seemed strange, things seemed to go up and down—I guess that was the day I thought I was on the ship." Finally she also said: "Once I heard beautiful music—I was waiting for the last trumpet—I was afraid to move."