Stupa

“ In one case we found a marked cyanosis in the extremities. Case 2 showed marked loss of hair. Gain in weight is never observed and marked emaciation is the rule. This we may attribute to the refusal of food.
[33] A perusal of these cases, then, shows that the dominant (and well-nigh exclusive) symptoms of the stupor are inactivity, apathy, negativism and disturbance of the intellectual functions. Benign stupor can be defined as a recoverable psychosis characterized by these four symptoms. The meaning of such vague physical manifestations as the low fever is not clear. ”

“ These formulations of the death idea may occur as tentative solutions of the patient's problems leading to temporary manic episodes while the psychosis is incubating. It seems that stupor as such appears only when death and nullity are accepted.
The above are more or less a priori reasons for regarding the stupor as a regressive reaction. We must now consider the clinical evidence to support this view. In the first place, we always find that stupor occurs in an individual who is unhappy and [192] who has found no other solution than regression for the predicament in which he is. ”

“ We can scarcely account for such phenomena in any other way than by assuming that certain influences may temporarily lift the patient out of the deepest stupor. In spite of the fact that stupors often last for one or two years almost without change, a fact which would argue that the stupor reaction is a remarkably set, stable state, [73] we see in sudden episodes of elation that this is not the case, and other experiences point in the same direction. ”

“ The condition which we call stupor occurs in the course of many different types of mental disease. It is true that it is frequent in catatonia but is not exclusively there. Mongols have black hair and straight hair, but one cannot therefore say that any black and straight haired man is a Mongol. Fortunately Kahlbaum prevented serious error by leaving the prognosis of his catatonia open. When Kraepelin included it in his large group of Dementia præcox, however, it implied that stupor could not be an acute, recoverable condition. ”

“ Tsuda was a genuine man of the world, in his own odd way. Very up-to-date, very devious, subtly sophisticated—a very waggish person, too; though he could upset it all in a minute with revelations of a most utter and child-like simplicity. As for the curious “gn” which now and then punctuated his talk, that mystified rather, till one came to detect about it the humble earmarks of asthma.
“Look here, Mr. Priest,” said King, who had raised his binoculars again, “there’s a queer something or other going on—come here and look through the glasses. ”

“ Then, too, when his ideas are discovered, it is found that they are not exclusively occupied with the topic of death.
[229]
CHAPTER XIII
TREATMENT OF STUPOR
In dealing with cases of benign stupor the first duty of physician and nurse is naturally the physical hygiene of the patient. More is needed to be done in the bodily care of these persons than for most of the inmates of our hospitals for the insane. It is perhaps no exaggeration to claim that a deeply stuporous patient needs as much attention as a suckling babe. In the first place, the patient must be fed. ”

“ His view is that pains tend to preserve the mutism and amnesia, so that there are "inhibitory processes" causing the stupor, which prevent the patient from further suffering. He does [271] not find either in theory or experience reason to believe that these conditions are the result of either suggestion or "fixed ideas." He thinks it natural that the last symptom of the stupor to disappear should be mutism, as speech and vision are the prime factors in communicating with environment. [As has been noted frequently in this book, mutism is a common residual symptom of the benign stupor.] ”

“ Closely related to the apathy, and probably merely an expression of it, is the inactivity which is both muscular and mental. It exists in all gradations from that of flaccidity of voluntary muscles, with relaxation of the sphincters, and from states where there is complete absence of any evidence of mentation to conditions of mere physical and psychic slowness. After recovery the stupor patient frequently speaks of having felt dead, paralyzed or drugged. ”

“ The most constant and significant symptom in the stupor reaction is the change in affect. This extends from mere quietness in the mildest phases of the disease through the stage of indifference where apathy replaces the normal reactions of the personality, to the final condition of complete inactivity in the vegetative stupor where all mental life seems to have ceased. ”

“ Dressing of the Stump.—From its peculiar shape and position, the escape of any blood into the stump is much{80} to be deprecated, for as it cannot easily get out, on the one hand it gives pain, and may cause sloughing from its pressure, and on the other it is sure eventually to cause suppuration, and delay union. To avoid such results care must be taken to secure every vessel that can be seen; if there is any general oozing it is best merely to pass the sutures through the edges of the flaps, but not bring them together, thus leaving the stump open for some hours ”

“ Scuta, broad, feebly tinted with pink; exterior surface rough, with sharp hood-formed projections, arranged in straight lines radiating from the apex; an inflected portion of the valve along the tergal margin is not roughened. Internally (Pl. 3, fig. 1 d) , the articular ridge is broad and reflexed. An adductor ridge can hardly be said to exist, but a slight prominence borders the gentle hollow in which the lateral depressor muscle is attached. The basal margin, on its inner face, is slightly toothed. ”

“ In the first place one naturally considers the differentiation from conditions of organic stupor or coma. Since psychotic stupors never develop without some signs of mental abnormality, the history is usually a sufficient basis for final judgment. [224] In case no anamnesis is obtainable the functional nature of the trouble may be recognized by the absence of those physical signs which characterize the organic stupors. One sees no violent changes in respiration, pulse or blood-pressure, such as are present in the intoxication comas of diabetes or nephritis. ”

“ The three made their way to the lads’ quarters. Stubbs sat down on the edge of Hal’s bunk and produced a pipe.
“Learned to smoke yet?” he asked of the boys.
“Not yet, Stubbs,” said Hal, “and I guess we never will.”
“Take my advice and learn,” said Stubbs. “It’s a great comfort to a man sometimes.”
“Perhaps,” said Chester. “But it’s a habit too easily cultivated and too hard to stop. I’m satisfied without tobacco.”
“Every man to his taste, as Captain O’Neil says,” commented Stubbs with a laugh. ”

“ So often a stupor begins with the same indefinite kind of upset as does another psychosis that the development may furnish no clew. Any condition where there is inactivity, scanty verbal productivity and poor intellectual performance resembles stupor. This triad of symptoms occurs in retarded depressions, in absorbed manic states and in perplexities. Negativism and catalepsy are never well developed except in stupor. So if these symptoms be present the diagnosis is simplified. But they are often absent from a typical stupor. ”

“ Affect: Complete affectlessness is an integral part of the stupor reaction. Modification of the statement will later be mentioned. The patient is indifferent so far as his basic condition is concerned, and it is only by certain stimuli that at times emotional reactions can be elicitated, some tears at a visit of a relative, an appropriate smile at a joke or a comical situation when the stupor is not too deep or an angry reaction called forth by interference.
Catalepsy: Waxy flexibility or merely a tendency to maintain artificial positions is a frequent but not an essential symptom. ”

“ The next morning she went to the Indrasan Rájá and said, "Who have you married? You have married a Rakshas. Just see. She has been eating cows, and sheep, and chickens. Just come and see." The Rájá went, and when he saw the blood on his wife's mouth he was frightened, and he thought she was really a Rakshas. The shoemaker's wife said to him, "If you do not cut this woman in pieces, some harm will happen to you." So the Rájá took a knife and cut his beautiful wife into pieces. He then went away very sorrowful. The Phúlmattí Rání's arms and legs grew into four houses; her chest became a tank ”

“ More than five years have been spent in endeavors to answer these questions and the results of the study are now presented.
Naturally the first point to be settled is: what constitutes the stupor reaction itself. We can say at the outset that it is seen in the purest form in benign cases, hence they make up the material of this book. To discover the symptoms of the disorder one cannot do better than to study them in their most glaring form in deep stupors, where consistently recurring phenomena may be assumed to be essential to the reaction. ”

“ A vision of a new world is a content occurring not infrequently in manic states, but before the universe can be remolded it must be destroyed. Before the individual can enjoy new life, a new birth, he must die, and stupor often marks this death phase of a dominant rebirth fantasy. In this connection it was not without significance to note that stupors almost universally recover by way of attenuation of the stupor symptoms, or in a hypomanic phase where there seems to be an abnormal supply of energy. Antæus-like, they rise with fresh vigor from the Earth. ”

“ We believe that there is just as distinctive a stupor reaction which may be exhibited either in deep stupors or what we may term partial stupors. Theoretically, complete apathy, inactivity, etc., make up the clinical picture of a deep stupor. When these symptoms appear rather as tendencies than as perfect states, a partial stupor is the product. That partial stupors occur as well-defined psychoses, developing and disappearing without the appearance of deep stupor, we shall attempt to show in the following three typical cases ”

“ To this end we first examined typical cases of deep stupor and found that the clinical picture is made up of the following symptoms: In the foreground stands poverty of affect. The patients are almost unbelievably apathetic, giving no evidence by speech or action of interest in themselves or their environment, unmoved even by painful stimuli. Their faces are wooden masks; their voices as colorless when words are uttered. In some cases sudden mood reactions break through at rare intervals. The second cardinal symptom is inactivity. ”

“ The real problem is to determine the psychiatric group into which the case should be placed. This is a difficult task, for the differential diagnosis rests on the observation and utilization of minute and unobtrusive details. A correct interpretation can be only reached by obtaining a complete history of the onset and observing the behavior and speech of the patient for a long period, usually of weeks, sometimes of months. With these precautionary words in mind, it may be well to summarize briefly the diagnostic problems in connection with benign stupor. ”

“ I found that Stubbs had been fed by the ancient servitor, and set off with him towards Dieppe. Our horses proved themselves but indifferent steeds in respect of endurance, and we were slow upon the road, so that it was already dark when we reached our hostelry. Being wearied with the journey, as well as exceeding vexed in mind, I was in no mood for aught but a good supper and then bed, and I deferred to acquaint Jean Prévost with my barren errand until the morrow. Stubbs gave me a hard look when I bade him good-night, as though he would fain question me on the present posture of the affair ”

“ This gives us, therefore, five states which may be analyzed for the symptoms of partial stupor. The pictures of all five are unusually consistent. There is inactivity, marked but not complete; poverty of affect without perfect apathy; and a marked interference with the intellectual processes. The last can be studied better than in the deep stupors because these partial cases are more or less accessible to examination. There is a tendency for the patient to think much of death either in the onset or during the psychosis. Negativism seems much less prominent than in the deep stupors. ”

“ The radii are pale pink, or nearly white: the opercular valves have either their upper parts, or nearly their whole surface, clouded with pinkish-purple: the epidermis is not persistent: the walls are moderately strong: the largest specimen was one inch, but generally full-grown specimens are about half an inch in basal diameter.
The Scuta have the lines of growth highly prominent. From one to five or six rows (7 b, 7 c) of nearly circular, or transversely oblong, deep pits, extend down the middle of the valve; rarely there is not even one row ”

“ Sutherland. Keepsakes are sometimes dangerous, Tsuda. I must have neglected to warn you.”
Tsuda shivered a little with terror and foreboding. However, Captain Utterbourne made no further comment in this connection.
“I’m going in alone,” the Captain said. “It might excite Mr. King if we all descended upon him together. He might think us some of Tsuda’s ogres—the Ogres of Oyeyama.... Sometimes frenzy carries them very far—h’m? There’s a story told of an opium fiend in Java—or perhaps it was hashish, I don’t remember. ”

“ Even yet her mind had not recovered sufficient elasticity to entirely throw off this soporific load. Stupor still seemed to clog her senses and maintain her in a condition of waking sleep. The scenes of the past night still floated through her brain and mingled with what was actually occurring, as if on common ground of unsubstantiality. The pale, soft crescent of the moon hung phantom-like in her distempered mind, just as it had struck upon her gaze over the Pretorian’s shoulder ”