for the production of adrenalin. It is therefore inconceivable that the blood could receive its normal supply of adrenalin with an apathy of the degree seen in stupor unless some purely hypothetically substitutive excitant were found.
We may therefore tentatively assume that the fever which marks the onset and frequently the course of these benign stupors is the result of a failure of the heat loss function, this being due to an imbalance in the involuntary nervous system that is occasioned, in turn, by insufficient circulating adrenalin, and the final cause for the poor suprarenal function is to be traced to the most consistent symptom of the stupor, namely, apathy. This hypothesis is welcome, not only because it would account adequately for the fever, but it also tends to accentuate the relationship with other forms of manic-depressive insanity, all of which are marked fundamentally by a pathological emotion. Naturally enough, one turns to the records again to see if the blood-pressure of these patients was low, as would be expected with a poor adrenalin supply. Unfortunately record was made of the blood-pressure in only two cases, in both of which the reading was 110 m.m. Two such isolated observations mean, of course, nothing whatever. It is possible that the drooling which so many stupor cases show is not merely the result of the failure of the swallowing reflex, but represents as well a compensation for anhydrosis by excessive salivary secretion.
Another symptom suggestive of involuntary ner
vous system or endocrine disorder is the highly frequent suppression of the menstrual function. At times this may occur as a sequel to mental shock, as it did in the case of Celia H. (Case 19), who was menstruating when, frightened by the suicidal attempt of her brother, the flow ceased abruptly. That purely psychic factors can produce marked changes in such functions has been demonstrated by Forel and other hypnotists time and again; presumably the effect is produced by way of alteration in the endocrine or involuntary nervous system influence. In such cases, however, we can trace the menstrual suppression directly to an emotional cause. On the other hand, most women in stupor fail to menstruate during the bulk of the psychosis at a time when we believe emotions to be absent or greatly reduced in their intensity. The recent work of Papanicolaou and Stockard[9] offers a simple explanation for this phenomenon. They have shown that in the guinea pig the œstrous cycle can be delayed by starvation, while in weaker animals a period may be suppressed completely. When one considers that even with the greatest care the nutrition of tube-fed patients is bound to be poor, it would be only natural to suppose that this malnutrition would cause such a disturbance in the œstrous cycle and was evidenced objectively by a failure to menstru
ate. Even in patients who are not tube-fed, under-nutrition is to be expected and, as a matter of fact, is usually observed. The work of Pawlow and Cannon has shown how essential psychic stimulus is for gastric digestion. Any condition of apathy would therefore tend to retard digestion and indirectly affect nutrition.
Finally, under the heading of Physical Manifestations of Stupor, we must consider epileptoid attacks, of which there was a history in two of our cases, both of which have already been described in the first chapter of this book. Anna G. (Case 1), in her second attack, was treated at another hospital, and from the account which they sent it appears that the stupor was immediately preceded by a seizure in which the whole body jerked. This is, of course, rather thin evidence of the existence of a definite convulsion, but in the case of Mary F. (Case 3) we have a fuller description. During the two days when the stupor was incubating, she had repeated seizures of the following nature. She sometimes said that prior to the attacks it became dark before her eyes and that her face felt funny or that she had a pain in the stomach which worked toward her right shoulder. The attack would begin when sitting in a chair, with the closing of her eyes, clenching her fists and pounding the side of the chair. She would then get stiff and slide on to the floor, where she would thrash her arms and legs about and move her head to and fro. The warning of the pain working from the stomach to the right shoulder is highly
suggestive of an epileptic aura, although the other symptoms mentioned so far could have been considered hysterical or poorly described epileptic phenomena. The rest of the description indicates an epileptic seizure more strongly. She frothed at the mouth and once wet herself during an attack. They lasted only for a few minutes and she would breathe heavily after them. At the end of one attack she wiped the froth from her mouth with her handkerchief and gave it to her aunt, saying, "Burn that, it is poison." This is perhaps a little less like epilepsy. It is plainly impossible for us to say with any positiveness that either these were or were not genuine convulsions, but it is nevertheless important to record them, because such phenomena are observed fairly frequently in dementia præcox cases but are practically unknown in manic-depressive insanity. This, then, would be another example of the resemblance to dementia præcox in these stupors which are unquestionably benign.[10]
We see, then, in reviewing all the physical manifestations of the benign stupors, that none occurred which cannot be explained as secondary to the mental changes, and therefore, until such time as physical symptoms are reported which cannot be so explained, we see no reason for changing our view that the benign stupor is to be regarded as one of the manic-depressive reactions.
Footnotes:
[9] Papanicolaou, G. N., and Stockard, C. R., "Effect of Under-feeding on Ovulation and the Œstrous Rhythm in Guinea-pigs." Proceedings of the Society of Experimental Biology and Medicine, Vol. XVII, No. 7, Apr. 21, 1920.