Catatonic Variations

Personality

From these and similar utterances of the patients it clearly follows that their thinking, feeling, and acting have lost the unity and especially that permanent inner dependence on the essence of the psychic personality, which provides the healthy human being with the feeling of inner freedom. A patient said:

I can’t get hold of my will

We may assume that this profound change in the psychic life, which indicates a complete destruction of the personality, must in itself influence the attitude towards the outer world in the most decisive way. The most natural protective measure of the weak consists in shutting himself up and hiding. The more or less distinct feeling of inner constraint and powerlessness which accompanies our patients along with childish susceptibility to influence, could therefore on the other hand play an essential part in the development of their obstinate seclusion. If the disorder of volition can influence the conduct of the patients in both directions and if it at the same time makes it more difficult for them to hold fast to a uniform attitude towards their surroundings, we should also have come nearer to the understanding of the frequent oscillations between heightened sensitiveness to influence and stubborn negativism. It is self-evident here that we must not, as has already been pointed out, think of conscious deliberation. Much rather is it the general change of the personality and its behaviour towards the ordinary events of life that come into consideration as it is conditioned by the perception of its own inner want of independence. If one wishes, one may with more right in my judgment regard the feeling of the destruction of the will which may precede the real onset of the disease under certain circumstances certainly by many years, as a “life trauma” which cannot endure any contact and therefore causes the patient to shut himself up rather than the influence of other chance events of life. That disorder would also to a certain extent explain the tendency of many of the patients to spin themselves round with imaginings; he who is not able to control his own will and with it his life, gladly takes refuge in the realm of dreams.

Practical Efficiency

As the mental, so also the practical efficiency of the patients is invariably greatly encroached on by the disorders of volition. They come to a standstill at every difficulty, must always be driven on again, work extremely unequally, do a great deal of their work wrongly, are completely unreliable, spoil material and tools. At the same time, however, a certain technical skill can be preserved. In their handiwork the loss of taste often makes itself felt in their choice of extraordinary combinations of colour and peculiar forms. The accompanying figure gives an example of the singular works of art of the patients; it represents a handkerchief embroidered with thick silk.

Fig. 8. A handkerchief embroidered with silk.

I also reproduce in Fig. 9 a stocking which was knitted by a patient who had had catatonic stupor for years. The measure placed beside it is 20 cm. The patient knitted for a number of days simply a long pipe, and then when she was told brought the stocking at last to an end. She next added the two remarkable loops and further the point. At the same time the work was without fault in detail. Many patients produce very queer handiwork, a glove made of human hair, linen coverings for horses’ hoofs, dolls made of cotton wool. The musical performances of the patients also show distinctly the decline of fine artistic feeling as they play sometimes without expression, sometimes in an arbitrarily incorrect way. After the more stormy manifestations have run their course, it is often possible to educate the patients again to simple work which they then accomplish without circumspection or self-reliance, and often with all sorts of caprices, but still with the regularity of a machine. A few patients continue work without showing any sign of fatigue or annoyance till they are told to stop.

Self-expression

The general disorders of volition often take many peculiar forms in the movements of expression of the patients. The cessation of the need to express oneself corresponds to the disappearance of volitional activity. The patients become monosyllabic, sparing of their words, speak hesitatingly, suddenly become mute, never relate anything on their own initiative, let all answers be laboriously pressed out of them. They enter into no relations with other people, never begin a conversation with anyone, ask no questions, make no complaints, give their relatives no news. They write no letters or only those with almost nothing in them, stop after writing a few lines. Their facial expression also is vacant and dull; their gestures are limp, few, and monotonous. On this foundation echolalia easily appears, which makes itself known in the involuntary repetition of questions asked or other things said to them, as well as in the introduction of fragments of speech caught up into their own utterances.

In the states of excitement in place of taciturnity a prodigious flood of talk may appear which does not correspond to a need for expression, but usually unburdens itself without any reference to the surroundings. Often it consists of outbursts of filthy abuse, piercing shrieks or singing; a patient whistled tunes all day on a water-bottle; many patients carry on monologues or answer voices loud out, often cursing and abusing, especially in the night. The following is a record of a fairly lively dialogue of this kind, which a patient carried on with his voices:

What does it matter to me then what you think! That has nothing to do with me, is in the highest degree indifferent to me. — What? I must think that? That I must not at all. I can think what I like, and you think what you like! — That would be still better? No, that would not be better at all! I can certainly do with my head what I will! I must wholly misunderstand you! That is entirely your affair if you share your thoughts with me! It is not I who am ill. — You are the patient! I am a real, sensible person, and the superintendent is carrying on the most infamous game, is carrying on criminal fabrication! — What? Am I to shoot myself? I don’t think so! Shoot yourself if you like! I am not going to do you this pleasure! — What? I am stupid? No you are stupid; I am cleverer than you all! I am too clever for you; that’s why you want to keep me in here — It doesn’t help me at all? We’ll see that, if it doesn’t help! There is still a Bavarian State with guaranteed rights, and you will be put in jail! As far as I’m concerned lick me!

Incoherence of the train of thought, as we have already depicted it, is usually distinctly noticeable in the conversation of the patients. The most different ideas follow one another with most bewildering want of connection, even when the patients are quite quiet. A patient said:

Life is a dessert-spoon

Another:

We are already standing in the spiral under a hammer

A third:

Death will be awakened by the golden dagger

A fourth:

The consecrated discourse cannot be over split in any movement

A patient:

I don’t know what I am to do here, it must be the aim, that means to steal with the gentlemen.

The page, which is reproduced as a specimen of writing No. 1 with notes of a patient, as he used to produce them in large number, gives a good impression of this incoherence. The arrangement of the notes, the handwriting changing in size and form, the irregular grouping, the underlining of different kinds and colours make it appear peculiar and incomprehensible. In detail we have a varied mixture of broken words and fragments of sentences before us, among which there is no connection whatsoever. We only notice the recurrence of single parts (“Bau,” “baum,” “Hauptbau,” “Charakter,” “Wortschatzbuch,” “Wort-stiel-baum,” “Geist-Stoff,” “Haft,” “wahrhaftigste,” “fort”). The affected use of hyphens is further noticeable (“Bau-m,” “Grammatik,” “Orthographie”) and of marks of exclamation (”!!Weide!!,” ”!!Werde:!”), and the writing above the line of the last letters in numerous words, and lastly among the other notes the curiously encouraging remark “(sig-ste-was?),” and “grundfalsch” written with a flourish across it.

Still more incoherent is the above piece of writing (Specimen of writing 2). Here there are certainly still some connected words decipherable (“the day’s no longer far off and the night greets us again,” “salutation and blessing from the apostolic over”), but intermixed there are irregularly strewn incomprehensible aggregations of letters, childish drawings, single signs like letters and numbers, a group of similar strokes, which let the tendency to persistence of the movements of writing appear clearly, as do also the words that return in various forms, “Juden,” “Gus-Gruss-Grund,” “Hohen-Hoch-Hohre.” The extraordinary irregularity of the hand-writing should also be noticed here.

In the drawings of the patients also there invariably appears on the one hand incoherence, on the other hand persistence of impulse to movement.

Fig. 10. Drawings in Dementia Praecox (Metamorphoses).

Fig. 10 reproduces one of the senseless, childish drawings which a patient produced in large numbers daily; there are wonderful combinations of strokes and flourishes with hints of stereotypy. They correspond completely with what Pfersdorff has named metamorphoses; there were endless variations of the same recurring fundamental form.

The second example, Fig. 11, gives the impression at the first glance of a pen and ink drawing. It is composed, however, of senseless combinations of strokes. Besides these there are notes with written verbigeration, enumerations and plays on words (“Irre-Irrengarten - Irrenspaziergange, Irrenreichman” and so on, “Irrenwurz, Eierwurz,” “Abtritt-Pissoir, Latrine-Scheisskerle,” “Lukretia, Metardus, Onophrius, Primus-Benignus”). Such expressions of quite divergent stamp are interpolated in the most elegant and regular handwriting. The third example also (Fig. 12) shows besides the startling senselessness and tastelessness of the design, the monotonous recurrence of the same details, and lastly the incoherent inscriptions in which “Semiramis,” “Jeremias,” “Apollo” are joined with “Ludovicum Napoleon,” “Markus,” “Chamisso” and “Voltaires.”

Similarity in Sound can be recognised here and there as a certain link in the disconnected utterances of the patients. They rhyme, “Ott Gott,” “simbra-umbra”; they play senselessly with words and sounds. A patient spoke of “Khebrecher and Heinbrecher,” another of “verhort und verstort,” a third of “Sauspiel and Schauspiel.” A fourth explained his spitting with “Zurtuss, Einfluss, and Ausfluss”; a fifth said “jetzt mussen Sie mich herunter fragen, damit es wieder heruntergeht.” a sixth, “Ich bin der Besitzer und Ihr seid die Schwitzer”; a seventh wished “Vorrichten statt Nachrichten”; an eighth called himself “Gottes Sohn und Gottes Schwur”; a patient spoke of Albicocca, Kokken, Kokain.

How the train of thought may be interrupted by meaningless plays on words is shown by the following passage which was written by a young patient who amused himself a great deal with writing:

da droben auf dem Gebirge war einmal ein Jager aufgefunden worden. Auf der Felsenwand in der Nähe der Sennhütte, Senner und Sennerin hat ein eines schönen Tages ein von Felsenwand achasant drihahol di ietal am droben auf der Wand. Vesuv, Vilz, Ventus, Verlend, Vaterland, Wist, Vogel. Veinstningerstadt, Venus, Vondertan Vogt, Vugler, Vangfisch, Vidtrich, Versendung, Viendling, Vach, Vieh, Viehzucht, Versicherung, Velzler, Vanter, Ente, Entrich, Elsass, Erlangen, Eidling, Eidschuir, Eid, Endlang, Esel, Ellenbogen, Eiter, Edling, Entdeckung, Erfindung, Erdboden, Erdenhügel, Erdenwall, Engel. (There follow still forty-seven words beginning with E, partly quite senseless, then thirty-two words with U, thirty-five with K; then comes Die Wacht am Rhein, “Morgenrot,” “Zu Strassburg auf der Schanz,” “Ich hab’ mich ergeben,” “Der gute Kamerad,” lastly 127 words beginning with K, twenty-two with P, two with A, two with B, three with Sp, fifteen with W.)

Besides the purely outward connection of ideas by similarity of sound there appears here clearly the persistence in the direction of the thought which has once come into view [mountain, huntsman, cliff, herdsman, Vesuvius and so on].

Stereotypy is shown in the frequent recurrence of the same turns of expression which occasionally are “done to death.” A patient added on to everything; “We Germans don’t have that,” another always answered, “Certainly, certainly,” a female patient invariably interpolated “bitt schon.” The following passage is another characteristic example:

Ein venerisches Feldherrentalent, ein venerisches Arzttalent; Sie haben über zu sein, wenn ich will. Die Anstalt ist ein venerisches Feldherrentalent; ist sie nicht über, ist sie nicht über; sie ist nicht venerisch, über zu sein; dann bin ich aber der L., wo ich über zu sein bin. Ich bin über zu sein, was ich bin. Jeder Anstreicher ist hier am Geiste zu sprechen. Sie kommen hinausel; das ist ja über Esel, hinausel! Und da ist dieser venerische Maler; so tappig ist er am Geist zu sprechen, 17-18 Jahre alt, über zu sein, was ich bin. Kein vernünftiges Wort ist über zu hören im Geist. Einer muss über werden. Kommt da ein Baron, so ein Baron, der über sein will; der is gar nicht über. Der ist ja gar nicht über zu sein, was ich bin; der B. ist nicht über: der ist eigentlich über was ganz gefährlich über zu sein.

In this senseless rigmarole single words and phrases are always brought forward again, sometimes exactly the same, sometimes with all sorts of changes, specially “über sein,” “venerisch-renerisch,” “Arzttalent-Feldherrntalent,” “was ich bin,” “im Geist-am Geist,” “hinausel.”

If stereotypy is still more strongly pronounced, the morbid symptom of verbigeration is developed, the endless repetition of the same sentences, usually in measured cadence. A female patient repeated the following sentence from seven o’clock to half-past nine:

I beg you to put me in another bed, in the bed where it was got ready yesterday; else I shall not get out of hell any more. Jesus, dear Master mine, let me rely faithfully on thee; lead me in the right path, O do lead me heavenward. You are my mother’s lady’s maid, and my mother is also there.

If the endless repetition seems here to be partially explained by the form of prayer, the following examples of verbigeration from the same patient show distinctly that it is a case of monotonous instinctive flow of speech: “Mutterle, führe mich ums Kirchlein herum bin um uns um zu verfuttern,” “Zar mein Milchen ums Eckbrett in alle Zimmer.” Sometimes verbigeration takes the form of a senseless ringing of the changes on a syllable. A patient connected the following with the word “Bett” which was called out to him:

Bett, Bett, Bett, dett, dett,