A book on "the psychology of manic-depressive insanity" will shortly appear by the editor.
CHAPTER IX
THE PHYSICAL MANIFESTATIONS OF STUPOR
We must now discuss the most difficult of all the aspects of the stupor problem. The subject is so involved and the evidence so inconclusive that observers will probably interpret the phenomena here reported according to their individual preconceptions. What we have to say is therefore published not so much to convince as to stimulate further work. The problem is wider than that of the mere etiology of the stupors we are considering. Their relationship to manic-depressive insanity is so intimate that we must tentatively consider this affectless reaction as belonging to that larger group. A discussion of the basic pathology of manic-depressive insanity is outside the sphere of this book. The author, therefore, thinks it advisable to state somewhat dogmatically his view, as to the etiology of these affective reactions, merely as a starting point for the argument concerning stupors specifically.
It is our view that the manic-depressive psychoses may be, and probably are, determined remotely but fundamentally by an inherent neuropsychic defect, but this physical and constitutional blemish is non-specific. The actual psychosis is determined by
functional, that is, psychological factors. A predisposed individual exposed to a certain psychic stress develops a manic-depressive psychosis. Naturally any physical disease reduces the capacity for normal response to mental difficulties; hence physical illness may facilitate the production of a psychosis. But this intercurrent factor is also non-specific.
Such is our view of the etiology of manic-depressive insanity as a whole. When we approach the study of benign stupors, however, difficult problems appear. As will be discussed in a later chapter on the literature, reactions resembling benign stupors occur as a result of toxins, particularly following acute rheumatism. Recently the medical profession has been called on to treat many cases of encephalitis lethargica where similar symptoms are observed. If the resemblance amounted to identity, we would have to admit that a specific toxin may produce a specific mental reaction which we have concluded on other grounds to be psychogenic. As a matter of fact, in two particulars these reactions show relationship to organic delirium. Knauer reports that in post-rheumatic stupors illusions are frequent—an ice bag thought to be a cannon, or a child, etc.—and there are bizarre misinterpretations of the physical condition, such as lying on glass splinters, animals crawling on the body, and so on. Such illusions are, in our experience, not found in stupor, and, on the other hand, are cardinal symptoms of delirium. Further, Knauer reports that even at the height of post-rheumatic stupor, external stimuli make some
impression, in that a thoughtful facial expression appears. In deep stupors, such as occurred in our series, this response is not seen. The same phenomenon of "rousing," larval in Knauer's cases, is often well marked in encephalitis lethargica and is, of course, a pathognomonic symptom of delirium. We might therefore think that these conditions are mixtures of two organic tendencies, namely, delirium and coma. It is not impossible that resemblances to benign stupor are due to functional elements appearing in the reduced physical state as additions to the organic symptoms. The prominence of pain might be taken as a likely cause for an instinctive reaction of withdrawal, which would account for the emotional palsy of these conditions on psychogenic grounds. [This argument can be better understood when the chapter on Psychological Explanation of Stupor has been read.] We therefore feel justified in holding that the resemblance of the symptoms of certain plainly organic reactions to those of benign stupor do not necessitate a splitting of these stupors from the manic-depressive group.
When we consider certain bodily manifestations of these typical stupors, however, fresh difficulties are encountered. Unlike depressions, elations and anxieties, certain physical symptoms appear with frequency, even regularity. This would seem to indicate the presence of physical disease. Inasmuch as the most constant of them is fever, the natural conclusion would be that we are dealing with an
infection which produces a mental state called stupor. If we were not faced with an obvious relationship to manic-depressive insanity, where such symptoms are usually accidental and intercurrent, we would accept this explanation, but this quandary necessitates further analysis.