But when examined quiet, even smiles at a joke. When questioned, denies feeling either worried or depressed. She said she wanted to go home. She gave poor attention to the questions. Later she threw a wet sheet over a patient and laughed (this is rare). Later she slapped another patient. Again she began to talk about wishing to go to the grave. Calls Dr. M. "Uncle John."
December 30: Talks either about wanting to die, or wanting to go to Heaven, or wanting to go to Ireland, all this as usual in an affectless way. Calls Dr. M. "Uncle John." Keeps shouting "Take me to Ireland."
January 9, 1914: Often quiet in bed, again goes to door, talks about wanting to go "to Heaven" or "to Ireland." On the whole, says little.
It seems, then, that the transition was not abrupt, that many traits of the first period remained, but that she was on the whole much quieter, with the exception of some spells when she insisted on going out or killing herself. At such times she showed an affectless, impulsive excitement. Whether there was an element of perplexity then is not clear from the notes. The topics of which she spoke also changed. The idea of wealth was rarely expressed, also the idea of marriage was much in the background, but prominent ideas were those of death, Heaven, killing herself, going to Ireland—all of which she produced in an affectless way. It should be added that she persistently wet and soiled during this, as well as in the first period.
3. Then followed three months of greater inactivity. She lay in bed gazing, moving very little, not even when her meals were brought. She answered but little and consistently wet and soiled. This state lasted from about the middle of February until the beginning of April.
4. From this stuporous state she emerged during the next four weeks, the awakening being associated with persistent efforts to arouse her. She then was, for six or seven weeks, nearly normal, so far as her mood went, but had a tendency to cling to some of her ideas and was overtalkative. Her memory for the earlier phases of the psychosis was good, as she recalled not only many external events but most of her false ideas. She said, however, that her mind had been a blank for the third stage and she remembered nothing of it. At the end of this time she cleared up entirely and was discharged as "recovered." She continued well for some months, during which she was occasionally examined.
This case gives an excellent example of the relationship of stupor to other manic-depressive reactions. She begins with an absorbed state, showing elements of perplexity and mania. With this there are expansive ideas but, also, statements about losing everything and being in prison, which suggest abandonment of life. Next, with increasing apathy, she begins to speak of death and soon makes impulsive suicidal attempts. Evidently her mind was becoming more and more focused on death and with this there was an appropriate emotional change. She was either apathetic or the affect exhibited itself in pure impulsiveness. Then comes the stupor, when all ideas disappear and mentation is reduced or absent. When the stupor lifts, the original ideas appear not only in memory but occasion a wavering insight. It is appropriate that she recalled all of her psychosis fairly well with the exception of the pure stupor, which she remembered only as a time when her mind was a blank.
Footnotes:
[7] Hoch, August, and Kirby, George H.: "A Clinical Study of Psychoses Characterized by Distressed Perplexity." Archives of Neurology and Psychiatry, April, 1919, Vol. I, pp. 415-458.
[8] Hoch, August: "A Study of the Benign Psychoses." Johns Hopkins Hospital Bulletin, May, 1915, XXVI, 165.