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perament, after a protracted or instrumental labor, passes into a condition of violent excitement, which may continue during a few days, and then she may fall into a condition of stupor, which may continue for months.
A young woman, who, perhaps, has never been a dozen miles from her father's house, is induced to emigrate to a foreign land, where she has been told it is easy to secure a living and lay up money. After arriving, she finds herself among strangers and helpless. She is unable to find employment, and, perhaps, even to make her wishes understood. The disappointment is overwhelming; she becomes sad and dejected, and soon falls into a condition of stupor, which remains indefinitely.
In such cases there exists a short intermediate abnormal mental state, and, doubtless, a predisposition; they are not common, and the condition of stupor is more generally associated with one of the stages of melancholia, of which it is the most conspicuous feature for the time being,
It consists in a suspension, more or less complete, of the physical and mental faculties, and is, therefore, a greatly intensified form of the pre-existent apathetic condition which is a feature of melancholia. In some cases there is mental bewilderment combined with exaggerated inhibition; the emotional tone may or may not be of a painful character. The patient is in a condition which may be likened to that of a waking nightmare, in which the apprehension of impending evil may be exceedingly intense, with entire lack of power to make any effort to escape.
It does not usually develop without previous indications. The anxiety becomes less in degree, the hallucinations less vivid, and the false beliefs, which had made so powerful an impression and dominated the course of mental activities and the forebodings, less absorbing. But these changes
are not attended by a return of the mind to channels of healthy activity. The character of the mental concepts does not become normal, only those of an abnormal character become less distinct and fade out ultimately. The mind appears to be void of ideas, or those present are in such a state of confusion and chaos that they are not represented in consciousness with sufficient distinctness to be apprehended or remembered by the ego during any lengthened period. He is indifferent as to his relations to others and to his own personal appearance, so that his apparel is utterly neglected and is only used when it is placed upon him by others.
His sense of shame and delicacy is lost, and the habit of cleanliness, which exercises so strong an influence when in a state of health, is now gone. The presence of danger, even, has little effect upon him, and cases are reported in which patients remain impassive when exposed to death by fire.
This may be the effect of the delusion that they are unable to move, or that they are commanded not to move, and that if they do so they will be subject to punishment or injured by wild beasts. In short, some patients seem to be existing in an inner mental world-absorbed by their imaginations—and utterly unconscious of the world of reality with which they are surrounded, and of their friends who endeavor to minister to their requirements. In some cases the change is so great as to consist in a nearly total suspension of the emotional and intellectual faculties. The will also appears to be in abeyance when the condition of stupor becomes fully pronounced. It is to be understood that there may exist all degrees of this state, from that of merely an apparent indifference, to one so profound as to be mistaken for dementia.
When this condition has become established, it is evident to the most superficial observer that a profound change has come over the state of the individual as evinced in his attitude and physiognomy. While the general lineaments and features of the face remain, yet the ordinary expression which gives more or less character to it, while in the condition of anxiety and depression, is entirely lost. The countenance is almost a blank, while the person remains wherever he is put, standing or sitting, during indefinite periods of time. In reality, movements are apparently attended with much discomfort, and the limbs will remain in most unusual and constrained positions without much nconvenience. The state of stupor, however, does not usually (though it sometimes does) reach that into which the cataleptic passes, and there is absence of all rigidity in the limbs and body.
In other cases there may remain some faint impressions of such delusions and hallucinations as have previously dominated the mind; the patient seeks to hide behind a chair or the sofa or under the bed, where he will remain until forcibly removed. He does not attempt to make his fears known to others except by the peculiar character of his conduct and the expression of his countenance. He will not speak or institute any kind of movement in consequence of anything addressed to him, except physical assistance or force.
Some features of this condition may be illustrated by the case of a young woman who has been under my care. During several months it was impossible to induce her to speak, but she persisted, if left to herself, in remaining seated, or rather crouched, upon the floor, partly secluded in some corner of the hall or in her room, where she would remain for hours, if permitted to do so, in such a position as would be extremely painful to persons in ordinary health. She would not voluntarily take food or drink, and seemed to be frightened when it was offered to her. She was doubtless dominated by some impressions or voices which commanded her not to take food; or possibly by the delusion that the food contained poison; or, again, by a hallucination of sight by which there appeared to her some foreign substance or vermin in the food. She was largely insensible to pain, and on one occasion, when carelessly placed by her attendant too near the radiator, put her hand upon it long enough to inflict a severe burn and subsequent sloughing of the tissues before the act was observed; yet she did not indicate by word or movement any degree of suffering.
This refusal of food is a very common and characteristic symptom while the patient is in the condition of stupor, and in many cases it results from some deeply seated delusion or hallucination of sight or hearing When this is the case, the patient will exhaust every effort in the endeavor to avoid swallowing the food. Other cases may experience no craving for food, or have any sense of hunger, and yet will swallow it without resistance when it is placed in the mouth. Patients have sometimes explained, after passing through the experience of stuporous states of mind and recovering, that they were wholly dominated either by voices of persons or by the distressing delusion that they would experience the infliction of torments of various kinds, such as being roasted alive, or being scalped, or plunged in boiling water, if they should move in certain directions, or otherwise fail to comply with what is demanded of them.
There can be little doubt that this mental lethargy is due to morbid changes which have taken place in the brain. This is evinced by the indications presented. For instance,
Melancholia with Excitement-Mental Pain and Anxiety-Fixed Delusions
Destructiveness—Self-infliction of Injury-Religious Type of Melancholia-Characteristics—Self-accusations-Homicidal Tendencies—Cases without Delusions-Sudden Changes in Mental States-Suicide-May Result from Hallucinations—Necessity of Great Watchfulness in Refer. ence to all Persons Affected with Melancholia - Medico-legal Aspect of Suicide -An Attempt to Commit Suicide not Necessarily a Proof of Insanity-Some Experiences are More Terrible than Loss of Life and Destroy any Desire for It-Prognosis- Patients May Recover after the Disease has Existed for Several Years—Cases—Treatment— Importance of Removing the Exciting Cause—Change of Scene, Physical Conditions—Abundance of Easily Digested Food-Sleep—The Use of Opium—Artificial Feeding by Stomach or Nasal Tubes-Importance of an Early Use of the Tube when Patients Refuse to Eat-Melancholia as a Symptom in Other Forms of Mental Disease.
There are other cases of melancholia, sufficient in number to form a class by themselves-Melancholia with Excitement-which present symptoms quite the opposite of those of stupor. A state of intense restlessness predominates, and patients are unable to remain quiet for a moment. This feature is quite as marked and as characteristic of them as that of stupor or lethargy is of the former class. The mental pain, anxiety, and sadness, united with the dominant influence of deep-seated delusions, seems to impel them to be constantly on the move. The sphere of motor activity is frequently limited, and the patient, if left