Finally, a peculiar characteristic of the stupor apathy must be mentioned. This is its tendency to interruptions, when the patient may return to life, as it were, for a few moments and then relapse. Such episodes occur mainly in milder cases or towards the end of long, deep stupors. It is interesting that the occasion for such reappearance of affect is frequently obvious. We usually observe them in response to some special stimulus, particularly something that seems to revive a normal interest. Visits of relatives are particularly common as such stimuli, in fact recovery can often be traced to the appearance of a husband, mother or daughter. It is also important to recognize that with this revived interest, other clinical changes may be manifest, that the thinking disorder may, for instance, be temporarily lifted. Helen M., for example, when visited by her mother was so far awakened as to take note of her environment, and remembered these visits after recovery like oases in the blank emptiness of her stupor. She further remembered that definite ideas were at such a time in her mind that ordinarily was vacant. She then had delusions of being electrocuted.
In summary, then, we may say that the sine qua non of the stupor reaction is apathy in all gradations, and that this apathy is as distinct a mood change as is elation, sorrow or anxiety. Incidental to this loss of affect there is a dissociation of emo
tional response whereby isolated expressions of mood appear without the harmonious coöperation of the whole personality which seems to be dead. Thirdly, there tends to be associated with the stupor reaction a tendency to childish behavior. Finally, the apathy and accompanying stupor symptoms may be suddenly and momentarily interrupted. An explanation of these apparently anomalous phenomena will be attempted in the chapter on Psychology of the Stupor Reaction.
CHAPTER VII
INACTIVITY, NEGATIVISM AND CATALEPSY
1. Inactivity. We must now turn our attention to the other cardinal symptoms of the stupor reaction, and quite the most important one of these is the inactivity. It is convenient to include under this heading both the reduction of bodily movement and the diminution or absence of speech. This inactivity is, of course, related to the apathy which we have just been discussing, in fact it is one of the evidences of the loss of emotion. We presume that a patient is apathetic when there is no expression in the face and when he does not respond to external stimuli, whether these be physical or verbal, by movement or by word.
Bodily inactivity is present in all degrees, and in some forty consecutive cases was recognizable in every one. In its most extreme form there is complete flaccidity of all the voluntary muscles, and relaxation of some sphincters. As a result of the latter we see wetting, soiling and drooling. Even those reflexes which are only partially under voluntary control, like those of blinking and swallowing, may be in abeyance; for instance, saliva may collect in the mouth because it is not swallowed, and
tube-feeding is frequently necessary on account of the failure of the patient to swallow anything that is put into his mouth. The eyes may remain open for such long periods of time that the conjunctiva and sclera may become quite dry and ulcerate. In these extreme cases there is, of course, no response to verbal commands. What is more striking, no reaction appears to pin pricks, so that it seems as if consciousness of pain were lost.
This deep torpor does not usually persist indefinitely. The commonest evidence of some form of consciousness persisting is probably to be seen in blinking when the eye is threatened or the sclera or cornea actually touched. A very large number of patients, when otherwise quite inactive, showed considerable response in their muscular resistiveness, the phenomena of which will be discussed shortly. The relaxation of the sphincters is apt to persist even after control of the rest of the body is exercised to the point of permitting the patient to stand or walk about.
The first phase of obvious conscious control is seen in those patients who will retain a sitting posture in bed or in a chair. The next stage is reached where the stuporous case can be stood upon his feet but cannot be induced to walk. The next degree is that of walking only when pushed or commanded. Finally spontaneous movement is observed in which the inactivity is evidenced merely by a great slowness.