Benign Stupors, by August Hoch, M.D

A word should be said as to the origin and history of this book. When the late Dr. Hoch became Director of the Psychiatric Institute of the New York State Hospitals in 1910, he found there an interest in just the kind of psychiatric research which it was his ambition to further. His predecessor, Adolf Meyer, had developed the conception that the psychoses should be looked on as psychobiological reactions rather than rigid nosological entities and had inculcated the habit of scrupulously thorough examination and record of what the patient said and did. Meyer had broken away from the sterile habit of making diagnoses in accordance with the set terms used to label symptoms; and his work and that of his assistants thus led to a collection of valuable material which could serve as a useful starting point for the keen clinical investigation of Hoch. Specifically, attention had already been fixed on the study of the so-called functional psychoses, comprising what are generally termed Dementia Præcox and Manic-Depressive Insanity. An urgent problem in this field was to separate different reaction types in order to discover which were recoverable and which chronic or progressive. In order to understand psychological reactions, interrelation rather than mere coincidence of symptoms must be studied and, to aid in this, free use was made of the fundamental principles of unconscious mentation as exposed in the theories of Freud and his followers.

Almost at the outset it had been discovered that many patients presented clinical pictures that would not fit into existing diagnostic pigeon holes. Dr. George H. Kirby, whose skill and industry had made the most valuable contributions to the archives of the Institute, published in 1913 a brief paper in which he pointed out, not only that many cases with "catatonic" symptoms recovered, but also that clinically the behavior of stupor showed it to be related to manic-depressive insanity as well as dementia præcox. Dr. Hoch took up the problem at this point. Using Dr. Kirby's material and adding to it his earlier observations as well as current cases, he endeavored to work out the essentials of the stupor reaction. It was his ambition to describe stupor not only in its psychiatric bearing but also as a life reaction.

The significance of this task is to be realized only when one considers the general import of the functional psychoses. They are, biologically, failures of adaptation. The chronic and deteriorating cases give up the struggle permanently, while the temporary insanities lay bare the soul of man as he catches a glimpse of unreality but turns back to face the world as it is. When one realizes that emotional disturbances are characteristic of the benign psychoses, it is easy to imagine how much such studies may ultimately illuminate the problems of normal life.

The technical value of this work to psychiatry is more immediate. Kraepelin laid the foundations for systematic classification with his dementia præcox and manic-depressive groups. But the rigidity of the latter, allegedly descriptive, term has confused the problem of classifying many benign psychoses. It was Hoch's ambition to prove that, although elation and depression were the commonest mood anomalies in this group, they had no more theoretic importance than anxiety, distressed perplexity or apathy. These other moods, although less frequent, are just as characteristic of the psychoses in this group. In other words, the name "Anxiety-Apathy Insanity" would be as appropriate, theoretically, as Kraepelin's term. In 1919 Hoch and Kirby published a report on the perplexity cases. This present book was designed to show that the symptom complex centering around apathy is as distinct as that which is recognized by all psychiatrists as mania with its predominant characteristic of elation.

In 1917 ill health forced Dr. Hoch to resign from his official duties. He retired to California with the purpose of adding to psychiatric literature the fruits of his long experience and unrivaled judgment. His first task was this book. In the midst of this work came a sudden collapse. As I had been in close touch with his researches, coöperating in psychological speculations, and was free to devote some time to it, he asked shortly before his death that I complete the book. This obligation is incommensurate with the debt I owe for years of inspiration, tuition and criticism.

The task has been mainly literary. I found the first five chapters practically completed, while it has not been difficult, as a rule, to discover from his copious notes what his intentions were as to the details of the following chapters. I have been greatly aided by the assistance of Dr. Adolf Meyer and of Dr. Kirby. The latter has been good enough to read the entire manuscript, making invaluable suggestions and criticisms.

John T. MacCurdy.

New York.

CHAPTER		PAGE
	Editor's Preface	vii
I.	Introduction and Typical Cases of Deep Stupor	1
II.	The Partial Stupor Reactions	34
III.	Suicidal Cases	50
IV.	The Interferences with the Intellectual Processes	67
V.	The Ideational Content of the Stupor	82
VI.	Affect	123
VII.	Inactivity, Negativism and Catalepsy	132
VIII.	Special Cases: Relationship of Stupor to Other Reactions	149
IX.	The Physical Manifestations of Stupor	174
X.	Psychological Explanation of the Stupor Reaction	186
XI.	Malignant Stupors	205
XII.	Diagnosis of Stupor	223
XIII.	Treatment of Stupor	229
XIV.	Summary of the Stupor Reaction	234
XV.	The Literature of Stupor	249
	Index	279

The fact that psychiatry lags in development and recognition behind other branches of medicine is due in part to the crudity of its clinical methods. The evolution of interest in science is from simple, obvious and tangible problems to more intricate and impalpable researches. Refined laboratory work has been done in psychiatric clinics, particularly along histopathological lines, but clinical studies follow antiquated methods. The internist does not say, "The patient has sugar in his urine, therefore he has diabetes and therefore he will die." He finds a glycosuria and looks for its cause. If this symptom is found to be related to others in such a way as to justify the diagnosis of diabetes, a therapeutic problem arises, that of adjusting the chemistry of the body. The prognosis depends not on the disease but the interreaction of the organism and the morbid process. Both in diagnosis and treatment an individual factor, the patient's metabolism, is of prime importance. Now in psychiatry, although the personality is diseased, this personal factor has been almost entirely neglected. Text-books furnish us with composite pictures which are called diseases, not with descriptions of reactions brought about by the interplay of personal and environmental factors. Educated people are not satisfied with novels that fail to depict real characters. Clinical psychiatry, however, has been content with the dime-novel type of character delineation. This is all the more disappointing, inasmuch as the study of insanity should contribute largely to our knowledge of everyday life. This defect can only be remedied by looking on every case as a problem in which the origin of each symptom is to be studied and its relation traced to all other symptoms and to the personality as a whole. This is an ambitious task and we do not pretend to any great achievement, merely to a beginning.

No better psychoses could be chosen for a preliminary effort than benign stupors. Every psychiatrist has seen them, although they are wrongly diagnosed as a rule, and they play no small rôle in the world's history. Euripides represents Orestes as having a stupor which is pictured as accurately as any modern psychiatrist could describe an actual case.[1] St. Paul is chronicled as falling to the ground, being thereafter blind and going without food or drink for three days. While apparently unconscious he had a religious vision. St. Catherine of Siena had several unquestionable stupors, which are fairly well described. In fact the mystics in general seem to have had communion with God and the saints most often when they seemed unconscious to bystanders.[2] The obsession with death, which seems so intimate a part of the stupor reaction, is a fundamental theme in poetry, religion and philosophy. The psychology of this interest is, speaking broadly, the psychology of stupor. So, from a general standpoint, our problem is related to the study of one of the most potent ideas which move the soul of man.

Psychiatrically, stupors have long remained an unsolved riddle. In the century prior to 1872 (See the digest of Dagonet's publication in Chapter XV) French psychiatrists wrote some good descriptions of stupor and offered brilliant, though sketchy generalizations about the condition. Two years later an English psychiatrist (Newington, See Chapter XV) improved on the French work. Little light has been thrown on the subject since then. The researches of the later French School showed that stupor often occurs in the course of major hysteria, but this left many of these episodes obviously not hysterical. When serious attempts were made at classification, this ubiquitous symptom complex was hard to handle. Wernicke wisely refrained from attempting more than a loose descriptive grouping. He called all conditions with marked inactivity and apathy "akinetic psychoses" and said that some recovered, some did not. Taxonomic zeal began to blind vision when Kahlbaum formulated his "Catatonia" and included stupor in the symptom complex. 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.[3] He unquestionably advanced psychiatry greatly but his scheme was too ambitious to be accurate. Many observers saw patients, classified as dements according to Kraepelin's formulæ, return, apparently normal, to normal life. Finally Kirby[4] published a series of cases which showed decisively that this classification was too rigid.

Since his paper is the foundation for this present study, it should be reviewed carefully. He first points out that Kraepelin's "Dementia præcox" includes much more than it should with its inevitably bad prognosis. He shows how others have found patients with catatonic symptom complexes proceed to recovery and speaks of these symptoms occurring in epilepsy and even in frankly organic conditions, such as brain tumor, general paralysis, trauma and infections. Kirby's first claim is that there are probably fundamentally different catatonic processes, deteriorating and non-deteriorating. Lack of knowledge has prevented us from understanding the meaning of the symptoms and hence making the discrimination. He points out that stupor seems to represent an attitude of defense, similar to feigned death in animals, and that in a number of his cases it was clear that the stupor symbolized the death of the patient. Apparent negativism, he found to be often a consciously assumed attitude of aversion towards an unpleasant emotional situation. In cases where there had been no prodromal symptoms pointing definitely to dementia præcox the outcome was almost always good. To discriminate the cases with good outlook from those with bad, he discerned no difference in the stupors themselves, but observed that the mental make-up and initial symptoms differed sufficiently for diagnosis to be made. His most important point is, perhaps, that these benign stupors showed a definite relationship to manic-depressive insanity in that some patients passed directly from stupor to typical manic excitement, while in others a "catatonic" attack replaced a depression in a circular psychosis.

Kirby introduces, then, the idea of stupor being a type of reaction which can occur either in dementia præcox or in manic-depressive insanity. The matter cannot be left there, in fact it raises new problems: what constitutes the reaction? how are the various symptoms interrelated? are they different in deteriorating and acute cases? what is the teleological significance of the reaction? if it be an integral part of the manic-depressive group, how does it affect our conceptions of what manic-depressive insanity is? 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.

These five cases will have to suffice for the present. They were given in full in spite of the fact that we shall leave out of our present considerations the history of the cases and certain of the stages, and confine ourselves to that stage of each case which is best qualified to give us a good general survey of the essential features of the stupor reaction.

These phases are: stage 1 of Case 1, lasting five months; stage 3 of Case 2, lasting one year; stage 2 of Case 3, lasting two years; stage 1 of Case 4, lasting three months; stage 1 of Case 5, lasting four months.

We gather from these descriptions that the essentials of the stupor reaction are (1) more or less marked interference with activity, often to the point of complete cessation of spontaneous and reactive motions and speech; (2) interference with the intellectual processes; (3) affectlessness; (4) negativism.

Inactivity: There is a complete cessation or more or less marked diminution of all spontaneous or reactive movements. This includes such voluntary muscle reflexes as contain a psychic component. For instance, there is, often, an interference with swallowing (letting saliva collect and drooling), winking, and even with the inhibitory processes used in holding urine and feces (soiling and wetting). Often there is no reaction to pin pricks or feinting motions. The inactivity also often interferes with the taking of food so that spoon-feeding or tube-feeding has to be resorted to. The patient may keep his eyes covered or stare vacantly, the face often presenting a remarkably immobile wooden, or stolid, expression. Complete mutism is the rule. When activity is not totally interfered with, those movements which are present may be slow. The patient may have to be pushed around and be able to take a few steps, but soon relapses. More often they are of normal rapidity. Speech then may also be slow and low, but usually shows no change except for the fact that it is diminished in amount. Sometimes awkward positions are assumed and retained, and there may be catalepsy.

Negativism: A common symptom is perverse resistiveness. It may consist in a marked stiffening of the body which is assumed spontaneously or appears only when attempts at interference are made, or there may be a more active turning away or even a direct warding off, sometimes with scowling or anger or even swearing and striking. Retention of urine, which is seen at times, should, perhaps, be mentioned here. Now and then we find that a patient is put on the toilet and cannot be induced to urinate or defecate, while soiling and wetting occur at once on returning to bed.

The intellectual processes: Little is known about the intellectual processes from direct observation in these more pronounced cases, except for the fact that in Case 5 questions or obtrusive occurrences sometimes produced a somewhat puzzled facial expression. Moreover, the patient retrospectively stated that she was unable to understand the questions, which points to marked difficulty in apprehension. We also find that occasionally there is evidence of an interference with the intellectual processes which showed itself in what may be called "paragraphic" writing when the patient could be induced to write. Above all, we see that retrospectively very little is remembered of what took place during the stupor, even of such obtrusive events as the moving from one ward to another, tube-feeding, physical examination, the presentation at a staff meeting, and the like.

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.

Physical Condition: Not infrequently we find in the beginning or in the course of the stupor an elevation of temperature to 101°, 102° or even 103°. 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.

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.

The cases thus far considered, namely, those of marked stupor, are fairly well known and have been studied by others. Less well known and formulated, but even more important from a practical as well as from a theoretical point of view, are what may be called partial stupors.

The reader has noted that the states of deep stupor described in the last chapter, did not end abruptly with a sudden return to health or a sudden change to another type of psychosis. They all gradually passed away, not by the disappearance of one symptom after another, but by the attenuation of all. Sometimes a more or less stable condition persisted for months, in which there was no stupor in a literal, clinical sense but when apathy, inactivity, interference with the intellectual functions and negativism all existed. Had these been the only states observed in these patients, there might have been some ground for doubt as to the diagnosis. As it was, it was clear that we were dealing with mild stages of stupor. When a psychiatrist meets with an undeveloped manic state, he calls it a hypomania and does not hesitate to make this diagnosis in the absence of complete development into a florid excitement. This procedure is not questioned, because the manic reaction as distinguished from a mania is well recognized. 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:

With the exception of negativism, which appears only in the anamnesis, all the cardinal stupor symptoms are found in this history. Particularly noteworthy is her intellectual deficiency which seemed to be made up of a real incapacity plus a remarkable disinclination for any mental effort whatever. It is important to note that her attitude towards this disability was usually one of indifference and that, in general, there was no show of affect whatever. Freedom of speech was the last thing for her to regain.

This case, although very like the last, differs from it in two particulars. For one day her symptoms were sufficiently marked to suggest a deep stupor. Secondly, her intellectual incapacity was not so marked (always approximately oriented for time) and with this there was some subjective appreciation of her defect. Apparently, however, this insight did not cause her any worry. The affectlessness was equally prominent in both of the foregoing cases, the fact that Mary C. (Case 7) once admitted feeling downhearted in response to leading questions, having little significance in the face of her expression, actions and usual denial of worry. It is interesting to note that, during the bulk of her psychosis, her only complaints were of mental hebetude and dizziness. Possibly the latter was merely an expression of her subjective confusion.

In this case, then, we find that the two months of stupor were ushered in by a brief state in which, in addition to the usual inactivity, there was a certain bewilderment, increased by questions, while the orientation which in the preceding manic state had been good became seriously interfered with. The psychosis bordered on deep stupor for brief periods when the inactivity seemed to be complete or she lay in bed with her head raised from the pillow. On the other hand, there were occasional sudden spells of free activity even with a certain elation. She could often be persuaded to answer questions or to write, the slowness of this spoken or written speech varying considerably. Her replies revealed the fact that she was essentially affectless and that her intellectual processes were interfered with, even to the extent of paragraphic writing. We have, therefore, here again features similar to those of the preceding cases. In addition we must add as important that this patient said retrospectively that she thought she was dead, that she saw "shadows from Heaven and Earth," "shadows of dead friends laid out for burial," all this without any fear. We shall see later that this is a typical stupor content.

We will here include state 3 of Anna G. (See Chapter I, Case 1) who after the pronounced stupor was for two months merely dull, somewhat slowed and markedly apathetic. Although her orientation was not seriously affected, there was considerable interference with her intellectual processes, as shown in her wrong answers or her lack of answers when more difficult questions were asked.

A similar picture was presented in state 2 of Mary D. (See Chapter I, Case 4.) Here, to be sure, there were more marked stupor features in that the patient wet and soiled, in addition to occasional spells when she lay with her head raised. But she spoke and acted fairly freely (even while soiling). By her replies she showed a considerable intellectual inefficiency, although, like Anna G., her orientation was not seriously disturbed. Here again there was complete affectlessness.

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.

A natural criticism is that these cases merely had retarded depressions. Although this topic will be discussed fully in a later chapter, two differential characteristics should be mentioned now. First, depression is a highly emotional state in which the sadness of the patient is as evident from his facial and vocal expression as from what he says, while these stupor reactions are by observation and confession states of indifference. Secondly, there is no such disturbance of the intellectual processes in depression as is here chronicled. Let the retardation once be overcome so that the will is exercised and no real defect is demonstrable. In our experience the cases of apparent depression with intellectual incapacity are found on closer study to be really stupors as other symptoms show.

An important "catatonic" symptom is a tendency to sudden, impulsive, unexplainable acts. Such actions occur occasionally in benign stupors and, since we attempt an understanding of the reaction as a whole, an effort should be made to study these phenomena as well. The cases chosen showed persistent, quite affectless, yet very impulsive attempts at self-injury. They characterized the first of the three cases throughout, were present in one stage (the second) of the second patient, while in the last for one day there was behavior which can be similarly interpreted.

Mention has been made of the prominence, approaching universality, of the death idea in stupor. This is a subject to be discussed in length presently, but for the present we may say that there may be a delusion of death with dramatization of that state or a mere abandonment of the mental activities of life. It is but a step from corpse-like behavior to suicidal attempts, psychologically speaking, yet this transition necessarily modifies the clinical picture, since one necessitates inactivity and the other activity. Secondarily, other atypical clinical features appear, as will be seen.

In addition to the activity incidental to her attempts at self-injury, this patient showed an unusual degree of resistiveness and with this some affect, for she appeared to be irritated and at times moaned. Still more unusual were the appearances of delusions not associated with death but with a vivid form of life, namely, a love affair. Occasionally she spoke of her imaginary lover "Harry." Another atypical feature was a fair memory for the period when she was in stupor. She claimed to remember much of her movements and this claim was substantiated by her answers to questions after recovery.

Considering only the second phase of the psychosis, this deep stupor showed many interruptions, due not merely to her suicidal efforts but also to her resistiveness. The condition, too, was not so completely affectless as one expects a deep stupor to be. In the first stage there was much sudden laughter, reminding one of dementia præcox (except for its never being shallow or silly) and this persisted into the first part of the second phase. The actual attempts at self-injury brought out emotion, for with them she scowled and frowned as well as showing considerable energy.

To these may be added the following case. It is not unlike the ordinary stupor in the fact that there was intense inactivity and mutism with great tenseness. The remarkable trait was, however, that for a whole day she forcibly held her breath until she got blue in the face. The case in detail is as follows:

If this forced holding of the breath had been the only anomaly, one would, perhaps, not be justified in drawing any conclusions as to its significance. But the deep stupor was interrupted again for a day by grunting and screaming of "murder." This is certainly indicative of a compulsive death idea and retrospectively she spoke of having refused food in order to die. The latter seems to indicate some connection between her negativism and death. Consequently, even if we regard the breath holding as resistiveness, it would still be related to her idea of dissolution. Her negativism went beyond ordinary limits in that it affected the expression of the face.

When we consider these three cases together, we see that what would otherwise have been deep stupors with profound inactivity, were modified by activity in two directions: suicidal and resistive. Presuming that the symptoms of stupor are all interrelated, we can see a reason why the affect should also have been altered. When one is modified, this should influence the other. When the activity is increased, the emotional concomitants of impulsive acts tend to break through as well. Hence the changes observed in these cases in facial expression and tone of voice. It is noteworthy, too, that all three showed a tendency for laughter to appear, as if, the emotions once stirred, it was possible for them to be exhibited in other than unpleasant forms. So, too, it was possible for ideas unrelated to the stupor picture, such as those of lovers, to occur sporadically. Finally, since activity must imply some contact with environment, the first of these cases at least showed less interference with the intelligence than is usual. In general, one may conclude that any aberration from the pure type of stupor tends to allow other impurities to appear.

This is one of the most interesting and important of the stupor symptoms. We are accustomed to think of the functional psychoses having symptoms to do with emotions and ideas in the main, and, conversely, that disorientation, etc., observed in such cases is merely the result of distraction, poor attention or coöperation. But in stupor the deficit in understanding, incapacity to solve simple problems and failure of memory seem deep-rooted and fundamental symptoms. So far is this true that Bleuler[5] looks on "schizophrenic" cases with this symptom of "Benommenheit" as organic in etiology. It may be said at the outset that we do not share this view for many reasons. One at least may now be stated as it seems to be final. In benign stupor purely mental stimuli may change the whole clinical picture abruptly and with this produce a change in the intellectual functioning such as we never see in organic dementias or clouded states. We find it more satisfactory to attempt a correlation of this with the other symptoms on a purely functional basis, as will be explained later.

For the study of the interferences with the intellectual processes during stupor reaction, we have two sources of information: The first is derived from the account which the patient is able to give in regard to what he remembers as having taken place around him or in his mind during the stupor period; the second is the direct observation of partial stupor reactions.

We will start with the cases of marked stupor mentioned in Chapter I. Anna G.'s (Case 1) psychosis commenced at home, and under observation lasted with great intensity for five months. She remembered only vaguely the carriage going to the Observation Pavilion, had no recollection of the latter, nor of her transfer to the Manhattan State Hospital and of most of the stay at the Institute ward, including the tube- or spoon-feeding which had to be carried on for four months. She also claimed that she did not know where she was until four or five months after admission. She was amnesic for her delusions and hallucinations. Of Caroline DeS. (Case 2) we have no information. Of Mary F. (Case 3), whose stupor began at home and under observation lasted two years, we find that she had no recollection of coming to the hospital, what ward she came to, who the doctor and nurses were (with whom she became acquainted later), in fact she claimed that for about a year she did not know where she was. But she remembered having been tube-fed (this took place over a long period). Mary D.'s (Case 4) stupor also commenced at home, and under observation lasted for three months. She had no recollection of going to the Observation Pavilion, of the transfer to Manhattan State Hospital, and of a considerable part of her stay here, including such obtrusive facts as a presentation before a staff meeting, an extensive physical and a blood examination, and she claimed not to have known for a long time where she was. Annie K.'s (Case 5) stupor commenced at home. Although she recalled the last days there and some ideas and events at the Observation Pavilion, the memory of the journey to Ward's Island was vague, as was that of entrance to the ward, and she claimed not to have known where she was for quite a while. Specific occurrences, such as the taking of her picture (with open eyes two months after admission), an examination in a special room, her own mixed-up writing (end of second week) were not remembered. But it is quite interesting that an angry outburst of another patient within this same period, which was evidently not recorded, is clearly remembered.

We shall later show that when the patient comes out of a stupor the condition may be such that, for a time at least, retrospective accounts are difficult to obtain. It must also be remembered that not infrequently the more marked stupors may be followed by milder states, and it is important, if we wish to determine how much is remembered, not to confuse the two states or not to let the patient confuse them. For example, Mary D. (Case 4), who showed two separate phases, while she claimed not to know of many external facts, also added that she could not understand the questions which were asked. From observation in other cases it seems that in marked stupor any such recollection about the patient's own mental processes would be quite inconsistent. We have to assume, therefore, that this remark referred in reality to the second milder phase, for which, as we shall see, it is indeed quite characteristic. It is not necessary to burden the reader with other cases, all of which consistently gave such accounts.

We see, then, that in the marked stupor the intellectual processes are regularly interfered with, as evidenced by almost complete amnesia for external events and internal thoughts. In other words, this would indicate that the minds of these patients were blank. Inasmuch as direct observation during the stupor adduces little proof of mentation, we may assume that such mental processes as may exist in deepest stupor are of a primitive, larval order.

Before we examine more carefully the milder grades of stupor, it will be necessary to say a few words about the retrospective account which the patient gives of intellectual difficulties during the incubation period of the psychosis. As a matter of fact, we find that these accounts are remarkably uniform. While some patients, to be sure, speak of a more or less sudden lack of interest or ambition which came over them, others of them speak plainly of a sudden mental loss. Mary. C. (Case 7) claimed she suddenly got mixed up and lost her memory. Laura A. spoke at any rate of suddenly having felt dazed and stunned. Mary D. (Case 4) said she felt she was losing her mind and that she could not understand what she was reading. Maggie H. (Case 14) began to say that her head was getting queer. We see from this that the interferences with the intellectual processes may in the beginning be quite sudden.

In some instances a more detailed retrospective account was taken, which may throw some light upon the interferences with the intellectual processes with which we are now concerned. Emma K., whose case need not be taken up in detail, had a typical marked stupor which lasted for nine months, preceded by a bewildered, restless, resistive state for five days. She was in the Institute ward for the first four months, including the five days above mentioned; later in another ward. When asked what was the first ward which she remembered, she mentioned the one after the Institute ward, and when asked who the first physician was, she mentioned the one in charge of the second ward. However, when taken to the Institute ward, she said it looked familiar, and was able to point to the bed in which she lay, though somewhat tentatively. The same rousing of memory occurred when the first physician, who saw her daily, was pointed out to her. She remembered having seen him, and then even recalled the fact that he had thrown a light into her eyes, but remembered nothing else. This observation would seem to show that with some often repeated or very marked mental stimuli (throwing electric light into her eyes) a vague impression may be left, so that it may at least be possible to bring about a recollection with assistance, whereas spontaneous memory is impossible. In another instance, the patient was confronted with a physician who had seen a good deal of her. She said that he looked familiar to her, but she was unable to say where she had seen him. Here then again evidence that a certain vague impression was made by a repeated stimulus.

Another feature should here be mentioned, namely, that isolated facts may be remembered when the rest is blank. We have seen above that Annie K. (Case 5), while very vague about most occurrences, recalled a sudden angry outburst in detail. Another patient, though the period of the stupor was a blank, recalled some visits of her mother. At these times, as she claimed, she thought she was to be electrocuted and told her mother so, "Then it would drop out of my mind again." These facts are very interesting. 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, we see in sudden episodes of elation that this is not the case, and other experiences point in the same direction. A similar observation was made on a case of typical stupor with marked reduction of activity and dullness. A rather cumbersome electrical apparatus (for the purpose of getting a good light for pupil examination) was brought to her bedside. Whereas before, she had been totally unresponsive, she suddenly wakened up, asked whether "those things" would blow up the place, and whether she was to be electrocuted. During this anxious state she responded promptly to commands, but after a short time relapsed into her totally inactive condition. We have, of course, similar experiences when we try to get stuporous patients to eat, who, after much coaxing may, for a short time, be made to feed themselves, only to relapse into the state of inactivity.

Such variations are paralleled, as we shall later show, by a suddenly pronounced deepening of the thinking disorder. We have already seen that the onset may be quite sudden. All this indicates that, in spite of a certain stability, sudden changes are not uncommon. Finally, we know that, in spite of the fact that stupor is an essentially affectless reaction, certain influences may produce smiles or tears, or, above all, angry outbursts, which again can hardly be interpreted otherwise than by assuming that those influences have temporarily produced a change in the clinical picture, in the sense of lifting the patient out of the depth of the stupor. All these facts suggest that inconsistencies in recollection are correlated with changes in the clinical picture.

As is to be expected, the cases with partial stupors remember much more of what externally and internally happened during their psychoses. Rose Sch. (Case 6), who had a partial stupor during which she answered questions but showed a great difficulty in thinking, said retrospectively that she felt mixed up and could not remember. Although she recalled with details the Observation Pavilion and her transfer, she was not clear about their time relations (how long in the Observation Pavilion, how long in the first ward). Mary C. (Case 7), whose activity was not entirely interfered with and who showed some thinking disorder, said retrospectively that she could not take in things. Henrietta H. (Case 8), who had a partial stupor, claimed to have known all along where she was, but that she felt mixed up, that her thoughts wandered and that she felt confused about people. In the cases where a partial stupor was preceded by a marked one, such as in phase 2 of Anna G. (Case 1) and phase 2 of Mary D. (Case 4), we have no retrospective account regarding the partial stupor, because emphasis in the analysis was naturally laid on the period comprising the most marked disorder. However, we can gather from the few cases at our disposal that the patients retrospectively lay stress chiefly on their inability to understand the situation.

We finally have to consider the group of suicidal cases. We have information only in regard to two cases, namely, Margaret C. (Case 10) and Pearl F. (Case 9). In both of these, we find that a good many things that happened during the period under consideration were remembered, as were also the patients' own actions. In Rosie K. (Case 11) we have at least the evidence that she remembered her own impulses, namely, that she refused food because she wanted to die. In other words, in these partial stupors with impulsive suicidal tendencies the interference with the intellectual processes seems to be moderate, and memory for external events not markedly affected.

The evidence can best be presented by considering the details of some cases.

Rose Sch. (Case 6) was remarkable, in connection with the present problem, in her unusually poor answers. She either merely repeated the questions, or made irrelevant superficial replies, or said she did not know, this even with very simple questions. When better, too, though not quite well, she showed striking discrepancies in time relations and incapacity to correct them. It would seem that in this case there was something more than an acute interference with the intellectual processes, such as we are here discussing. As a matter of fact, we have the statement in the history that the patient herself said she was slow at learning in school and had not much of an education. A congenital intellectual defect and the attitude which it creates may, however, as my experience has repeatedly shown me, very greatly exaggerate an acute thinking disorder. The case, therefore, while it shows us an unquestionably acute interference with the intellectual processes, does not give us useful information about its nature. More information can be gathered from Mary D. (Case 4). Even toward the end of her marked stupor some replies were obtained chiefly by making her write. When asked to write Manhattan State Hospital, she wrote Manhatt Hhospshosh, and for Ward's Island, Ww. Iland. Again, instead of writing 90th Street, she wrote 90theath Street. These are plainly reactions of the path of least resistance or, in these instances, of perseveration. Of the same nature are some of her other replies in writing or speaking. After she had been asked to write her name, she was requested to add her address, or the name of the hospital; she merely repeated the name. Similarly, when asked whether she knew the examiner, she said "Yes," but when urged to give his name, she gave her own. In the partial stupor at a time when she knew where she was, knew the names of some people about her, the year and approximately the date, she made mistakes in calculation and could not get the point of a test story. Moreover, she failed in retention tests without there being any evidence of anything like a marked fundamental retention disorder, such as we find in Korsakoff psychosis. It seems that these results are best termed defects in attention, which chiefly interfere with the apprehension of more difficult tasks. As we shall see later, this seems to be rather characteristic of these cases. Another point which should be mentioned is the fact that her reaction to questions which she was unable to answer (such as matters which referred to her amnesic periods) was peculiar, inasmuch as she did not only not try to think them out, but seemed indifferent to her incapacity, simply leaving the question unanswered. This too, as we shall see later, is characteristic. Laura A., at a time when she could be made to reply, merely repeated the question, again a reaction of least resistance. The same patient sometimes asked, "Where am I?" Mary C. (Case 7) made similar queries. Although she was at times approximately oriented, she would say, "I don't know where I am," or "I can't realize where I am," or more pointedly, "I can't take in my surroundings." She often did not answer and sometimes seemed bewildered by the questions. Henrietta H. (Case 8) again showed some defect of orientation and mistakes in calculation, and above all, marked mistakes in writing (for Manhattan State Hospital—Manhaton Hotspal). A special feature here is that this occurred immediately after she had been quite talkative, but suddenly had relapsed into a dull state. Anna G. (Case 1), during the third phase of her psychosis, showed the following: Although she was approximately oriented and answered promptly simple questions; e.g., about orientation or simple calculation, she, like these other patients, simply remained silent when more difficult intellectual tasks were required of her (more difficult calculations); or when she was asked how long she had been here (which involved data that could not be available to her, owing to her amnesia); or when questions were put to her regarding her feelings or the condition she had passed through. On the other hand, she sometimes gave appropriate replies in the words "yes" or "no," but it was difficult to say whether these answers did not also represent the path of least resistance.

We will finally take up the last phase of Margaret C. (Case 10). Although she was entirely oriented, there was a certain vagueness about her answers which is difficult to formulate. She was telling about the onset of her sickness and said that at that time her mind was taken up with prayers about the salvation of her relatives. She was asked exactly when it was that she thought of this and she answered "Now?" (What period are we talking about?) "The present." (What did I ask you?) "About this period of my sickness." (Which one?) "What sickness?" She said herself at this point, "I am rather stupid." Again when asked how her mind worked, she said, "Pretty quickly sometimes—I don't know." (As good as it used to?) "No, I don't think so." (What is the difference?) "There is no difference." (What did I ask you?) "The difference." (The difference between what?) "You did not say." In this the shallowness of her comprehension and thinking is well shown, and it seems here again perhaps justifiable to formulate the main defect as one of attention, which prevents completion of a complicated process of comprehension. A feature of further interest in this case is that automatic intellectual processes, such as those necessary for the writing of a long poem from memory, were not interfered with.

In the most pronounced stupor we have evidently a more or less complete standstill in thinking processes. Practically no impressions are registered and consequently nothing is remembered except events that occurred in some short periods when some affective stimulus, or a brief burst of elation, lifts the patient temporarily out of the deep stupor. It is impossible to say whether the statement of a complete standstill has to be qualified. In some stupors repeated environmental stimuli sometimes make at least a vague impression, so that while spontaneous recollection is impossible a feeling of familiarity is present when the patient is again confronted with this environment. This might be an exception to the dictum of complete mental vacuity, or it may be that there are somewhat less pronounced stupor reactions. When more is perceived, there is often a retrospective statement of having felt mixed up, being unable to take in things, or, directly under observation, the patient may say, "I cannot realize where I am," "I cannot take in my surroundings." In harmony with this is the fact that questions often produce a certain bewilderment. In quite pronounced states in which some replies can still be obtained, we find that the intellectual processes may be interfered with to the extent of a paragraphia, i.e., a remarkably mixed-up writing in which perseveration (one form of following the path of least resistance) plays a prominent part. This same principle is also seen in such reactions as the repetition of the question or the senseless repetition of a former answer. These phenomena remind us of what we see in epileptic confusions, in epileptic deterioration and in arteriosclerotic dementia.

In milder cases difficulties in orientation may be more or less marked; or there may be incapacity to think out problems, although the orientation is perfect. The more automatic mental processes may run smoothly (memory and calculation may be excellent) and there may yet be a certain shallowness in thinking, a defect of attention (a purely descriptive term) which is most obvious in the patient's inability to grasp clearly the drift of what is going on or the meaning of complicated questions. I am inclined to think that poor results in retention tests are entirely due to this attention disorder, for we have no evidence of any fundamental retention defect such as we find in the totally different organic stupors. From a practical point of view it is important at this place to call attention to the fact that such mild changes are particularly seen in end stages. Even when pronounced negativistic tendencies do not play a prominent rôle, the patient is then apt to be silent chiefly as a result of the residual disorder in the intellectual processes. Still more striking are the conditions which are on a somewhat higher level and in which the shallowness of the responses, due to the residual disorder of attention, together with the last traces of the affectlessness, are apt to create the impression of a dementia. In such cases the opinion is often held that the patient has reached a defect stage from which recovery is impossible, whereas a thorough knowledge of these end stages teaches us that they are not only recoverable but quite typical for the terminal phases of stupor.

Considering these data, especially those gathered in the end stages, it would appear that there is no tendency in this intellectual disorder associated with the stupor reaction for any special side of mental activity to be most prominently affected. It looks rather as if it were a question of a general diminution of the capacity to make a mental effort which in its different intensities accounts for the symptoms.

Brief survey of the ideas associated with stupor: Having thus described the formal manifestations of the various stupor reactions, it will now be interesting to see what ideas seem to be associated with these reactions. It is, of course, impossible to obtain during a considerable part of the stupor any statement of the patients' thoughts. We therefore have to depend on their utterances during periods when the inactivity temporarily ceases, or on the retrospective account which the patient gives after the stupor has completely disappeared; and as we shall see, we also may obtain considerable information by studying the ideas which occur in the period preceding the stupor. These last may be autogenous delusions or thoughts about actual events which precipitated the psychosis.

It is not likely that many observers have a very clear conception about what sort of ideas to expect. We have, as a rule, not been in the habit of paying much attention to the content of delusions, hallucinations, and the like. So far as we could judge, therefore, the ideas expressed might be expected to be fairly multiform, and it was distinctly interesting to us when we found a marked tendency for the trends of ideas to remain within a certain small compass.[6] It was possible, to state this at once, to show that in by far the majority of cases the same set of ideas returned, and that these ideas had among themselves a definite inner relationship, being concerned with thoughts of "death." In isolated instances other ideas were found as well, and they will have to be discussed later. For the present we shall take up more habitual content.

In addition to the eleven cases already described, it may be well to cite four others which present material now of interest to us.

The following typical case of partial stupor is quoted as an example of delusions appearing only during the onset.

The last case is interesting in that a depressive onset to a deep stupor was observed in the Institute. It was characterized by constant repetitions of a request to be killed.

In a survey of thirty-six consecutive cases of definite stupor, literal death ideas were found in all but one case. They seem to be commonest during the period immediately preceding the stupor, as all but five of these cases spoke of death while the psychosis was incubating. From this we may deduce that the stupor reaction is consequent on ideas of death, or, to put it more guardedly, that death ideas and stupor are consecutive phenomena in the same fundamental process. Two-thirds of these patients interrupted the stupor symptoms to speak of death or attempt suicide, which would lead us to suppose that this intimate relationship still continued. One-quarter gave a retrospective account of delusions of being dead, being in Heaven, and so on. From this we may suspect that in many cases there may be a thought content, although the patient's mind may seem to be a complete blank. It is important to note that when a retrospective account is gained, the delusions are practically always of death or something akin to it, such as being in prison, feeling paralyzed, stiff, and so on.

In the one case of the thirty-six who presented no literal death ideas, the psychosis was characterized essentially by apathy and mild confusion, a larval stupor reaction. It began with a fear of fire, smelling smoke and a conviction that her house would burn down. It is surely not straining interpretation to suggest that this phobia was analogous to a death fear. When one considers the incompleteness of anamneses not taken ad hoc (for these are largely old cases) and that the rule in stupor is silence, the consistence with which this content appears is striking.

To exemplify the form in which these delusional thoughts occur we may cite the following: Henrietta H. (Case 8) said, retrospectively, that she thought she was dead, that she saw shadows of dead friends laid out for burial, that she saw scenes from Heaven and earth. Annie K. (Case 5) claimed to have had the belief that she was going to die, and to have had visions of her dead father and dead aunt, who were calling her. She also thought that all the family were dead and that she was in a cemetery. Rosie K. (Case 11) said she had the idea that she wanted to die and that she refused food for that purpose, and during the stupor she sometimes held her breath until she was cyanotic. Mary F. (Case 3), before her stupor became profound, spoke of the hereafter, of being in Calvary and in Heaven. In this case, as well as in the above-mentioned Henrietta H., we find, therefore, associated with "death" the closely related idea of Heaven. Whether Calvary merely referred to the cemetery (Mt. Calvary Cemetery) or leads over to the motif of crucifixion, cannot be decided. It is, however, clear that this latter motif may be associated with that of death, as is shown in Charlotte W. (Case 12), who, during intervals when the inactivity lifted, spoke of having been dead, of spirits having told her that she must die, of having gone to Heaven, of God having told her that she must die on the cross like Christ. But this patient also showed in a second subperiod of her stupor another content. She said: "It was like water. I was going down." Or again, she spoke of having gone "under the ground"; "I went down, down in a coffin." She spoke of having gone down "into a dark hole," "down, down, up, up"; again, of having been "on a ship." We shall see in the further course of our study that this type of content occurs not at all infrequently.

The internal relationship among the different ideas associated with stupor: Before we go any further it may be advisable to examine the meaning of such ideas when they arise in other settings than those of the psychoses. If we consider these ideas of death, Heaven, of going under ground, being in water, in a boat, etc., we are impressed with the similarity which they bear to certain mythological motifs. This is, of course, not the place to enter into this topic more than briefly. We are here concerned with a clinical study, and therefore, among other tasks, with the interrelationship of symptoms, but for that purpose it is necessary to point out how these ideas seen in stupor can be shown to have, not only a connection amongst each other, when viewed as deep-seated human strivings, but also are closely related to, or identical with, ideas found in mythology.

To one's conscious mind death may be not only the dreaded enemy who ends life, but also the friend who brings relief from all conflict, strife and effort. Death may, therefore, well express a shrinking from adaptation and reality, and as such may symbolize one of the most deep-seated yearnings of the human soul. But from time immemorial man has associated with this yearning another one, one which, without the adaptation to reality being made, yet includes a certain attempt at objectivation, the desire for rebirth. We need not enter further into possible symbols for death per se, but it is quite necessary to speak briefly of the symbolic forms in which the striving for rebirth has ever found expression. The reader will find a large material collected in various writings on mythology, for the psychological interpretation of which reference may be made to Jung's "Wandlungen und Symbole der Libido" and Rank's "Mythos von der Geburt des Helden." From them it appears how old are the symbols for rebirth, and how they deal chiefly with water and earth, and the idea of being surrounded by and enclosed in a small space. Thus we find a sinking into the water of the sea, enclosure in something which swims on or in the water, such as a casket, or a basket, or a fish, or a boat; again, we find descent into the earth. The striving for rebirth might be assumed to have adopted these expressions or symbols on account of the concrete way in which the human mind knows birth to take place. The tendency for concrete expression of abstract notions causes the desire for another existence to appear, first as a rebirth fantasy and then as a return to the mother's body. One thinks of Job's cry, "Naked came I from my mother's womb and naked shall I return thither," as an example of the literal comparison of death with birth. We need only refer to the myths of Moses and the older one of Osiris, and the many myths of the birth of the hero, to call to the mind of the reader the examples which mythology furnishes. There is probably not one of the ideas expressed by these patients which cannot be duplicated in myths. We have, therefore, a right to speak of these ideas as "primitive," and to see in them, not only deep-seated strivings of the human soul, but to recognize in them an essential inner relationship. It is especially this last fact to which at this point we wish to call attention: that without any obvious connection the fantasies of our forefathers recur in the delusions of our stupor cases. We presume that in each case they represent a fulfillment of a primitive human demand. In one of our cases a vision of Heaven and a conscious longing to be there was followed by a stupor. On recovery the patient compared her condition to that of a butterfly just hatched from a cocoon. No clearer simile of mental rebirth could be given.

Brief survey of the ideas associated with the states preceding the stupor: If we now return to the study of the further occurrence of such ideas in the cases described, we find motifs, similar to those seen in the stupor, in the period which immediately precedes the more definite stupor reaction. Indeed we find the ideas there with greater regularity. In Meta S. (Case 15) the stupor followed upon six days with reduced activity and crying, with self-accusation, but also with entreaties to be allowed to go home and die with her father. At the very onset of her breakdown, the desire for death had also occurred. Anna G. (Case 1) expressed a wish to be with her dead father, and, at the visit of a cousin, she had a vision of the latter's dead mother. A second attack of this same patient began with the idea that the dead father was calling her. Maggie H. (Case 14) saw dead bodies, and during outbursts of greater anxiousness, she thought her husband was going to die. In Caroline De S. (Case 2) the psychosis began with a coarse excitement, with statements about being killed, with entreaties to be shot, with the idea of going to Heaven, again with frequent calling out that she loved her father (who was dead since her ninth year), while immediately before the stupor the condition passed into a muttering state in which she spoke of being killed. Mary D. (Case 4) began by worrying over the father's death (dead four years before), had visions of the latter beckoning, and she heard voices saying, "You will be dead." Mary F. (Case 3) had a vision of "a person in white," and thought she was going to die. In Henrietta H. (Case 8) the stupor was preceded by nine days of elation, with ideas of shooting and of war, but this had commenced with hearing voices of dead friends, and with ideas that somebody wanted to kill her family. In the case of Annie K. (Case 5) we find before the stupor a state of worry, with reduction of activity, and then a vision of the dead father coming for her. In Charlotte W. (Case 12) the stupor was preceded by a state of preoccupation, with distress and entreaties to be saved, partly from being put into a big hole, partly from the electric chair.

We see, therefore, in the introductory phase of the stupor in almost every case ideas of death, and in one case an idea belonging to the rebirth motif, namely, of being put into a dark hole. In well-observed cases apparently we do not find the stupor reaction without either coincident or preceding ideas of death.

Relation of death and rebirth ideas with affect: In order to investigate the relation of these ideas to the affective condition associated with them, it will be necessary to study not only the abstract ideational content but the special formulation in which the content appears. In looking over the enumeration of the ideas given above, it is very clear that these formulations differed considerably from each other. A priori we would say that it is, psychologically, a very different matter whether a person expresses a desire to die, or has the idea that he will die or is dead, or says he will be killed. We associate the first with sadness, the last with fear, while our daily experience does not give us so much information about the delusion of being dead. A vivid expectation of death is usually accompanied by either fear or resignation.

In studying the ideas which we obtained from the patients by retrospective account after the psychosis or from a retrospective account during freer intervals, it is, of course, difficult, especially in the former case, to say whether they have persisted for any length of time. Probably in most instances this was not the case, and we must remember in this connection that in a considerable number of cases the patients recalled no ideas whatever.

Of the five cases which we may consider as types, Henrietta H. (Case 8) and Mary F. (Case 3) formulated their ideas simply as accepted facts during the stupor. The former thought she was dead, saw dead friends laid out for burial, and scenes from Heaven and earth. The latter spoke, during the stupor, of being in "Calvary," "the hereafter," or "Heaven." We have seen that these stupors were essentially affectless reactions and we can therefore say that, so far as these two cases are concerned, the ideas thus formulated were not associated with any affect.

Annie K. (Case 5) was a little different. During the stupor she made a few utterances about priests and "all being dead," and retrospectively she said that she had thought she was in the cemetery, was going to die, that she had repeated visions of her dead father and once of a dead aunt calling her; that she had thought her family were dead, again that the baby (who was born just before the psychosis) was dead. The formulation is therefore less one of fact than of something prospective, something which is coming—the going to die. Correlated, perhaps, with this anticipation were slight modifications of the usual apathy. The patient often had an expression of bewilderment. She was also more in contact with her environment than many stuporous patients are, for, not infrequently, she would look at what was going on about her. Her apathy was also broken into in a marked degree by her active resistiveness, which was sometimes accompanied by plain anger. It seems that a prospect of death may occur in other instances in a totally affectless state. We have recently seen it in a partial stupor during which the patient spoke and had this persistent idea in a setting of complete apathy. We see here also, as in one of the former cases, the idea of other members of the family being dead.

More difficult and deserving more discussion are the two remaining cases, Rosie K. (Case 11) and Charlotte W. (Case 12). Rosie K. showed a peculiar condition. She said, retrospectively, that during the stupor she had the desire to die and that for this purpose she refused food. Moreover, she was repeatedly seen to hold her breath with great insistence, though without affect. This is worth noting. We are in the habit in psychiatry to say in a case like this that "there is no affect," and yet there is evidently a considerable "push" behind the action. We shall later have to mention in detail a patient whom we regard as belonging in the group of stupor reactions, and who for a time made insistent, impulsive and most determined suicidal attempts, yet with a peculiar blank affectless facial expression and with shouting which was more like that of a huckster than one in despair. Here also, then, there was a great deal of "push," yet not associated with that which we call in psychiatry an affect. In both instances we see acts which we are in the habit of calling for this very reason "impulsive." Evidently this is an important psychological problem which leads directly into the psychology of affects and deserves further study. For the present it is enough to say that with a different formulation—that of wishing to die—there is here not, as in other psychoses, a definite affect, such as sadness or despair, but no affect, though there may be a good deal of "push" or impulsiveness.

The case of Charlotte W. (Case 12) is a complicated one, for she had short stupor periods with inactivity, catalepsy, resistiveness, etc., which were interrupted with freer spells. A careful analysis of her history has been instructive and justifies a detailed and lengthy discussion. For the purpose in hand it is necessary to separate the ideas which she expressed only in the freer periods (during which some affect was at times seen) into those which referred retrospectively to the stupor phase and those which referred to the freer periods themselves.

We find that the time during which more marked stupor symptoms appeared may be divided into two subperiods. This is not possible in regard to the manifestations belonging to the general reaction, which seem to have undergone no decided change, but only in regard to the form of the delusions. In this we find there was a first phase in which ideas of death and Heaven (and crucifixion) occurred, and a second phase in which ideas were present which belonged essentially to the motif of rebirth but which were also associated with ideas of Heaven.

About the first subperiod she said: "I was mesmerized," or "I thought I was dead," or "God told me I must die on the cross as He did," or "I went to Heaven in spirit." About the second subperiod she said retrospectively: "We were on a ship and we were 'most drowned." "It was like water, I was going down, down." She said she saw the people of the hospital and "it was all full of water"; or again, "I went under the ground and it was full of water and every one got drowned and a sharp thing struck me"; or "I was out on a ship and I went down in a coffin." She claimed she put up her arms to save the ship. Again she spoke of having gone into a dark hole. She also said: "One day I was in a coffin—that was the day I went to Heaven." "They used to be coming up and down, that was the day I was coming up in a ship or going down." And when shown her picture in a cataleptic attitude, she said: "That must have been when I went to Heaven—everything seemed strange, things seemed to go up and down—I guess that was the day I thought I was on the ship." Finally she also said: "Once I heard beautiful music—I was waiting for the last trumpet—I was afraid to move."

We see, therefore, that most of the ideas which she thus spoke of retrospectively as having been in her mind during this stupor, and which belonged both to the death and the rebirth motifs were formulated as facts (as in the cases of Henrietta H. and Mary F. above mentioned). It was, moreover, a condition which was accepted without protest. Here again an affect was not associated with these ideas, and when the patient was asked whether she had not been frightened, she said herself, "No, I just lay there." The idea that God told her she would have to die on the cross like Christ, is, in the religious form, like the beckoning of the father with Henrietta H. The only exception to the claim that the ideas were formulated as facts and accepted as inevitable seems to be the statement that she held up her arms to save the ship. This would seem to be, in contradistinction to the rest, a formulation as a more dangerous situation. However, this was isolated and we can do no more than to determine main tendencies. We must expect, especially in such variable conditions as we see in this patient, to find occasional inconsistencies.

In summing up we may say, therefore, that so far as the stupor itself is concerned, the ideas are formulated as a rule:—

1. As accepted facts (being dead, being in a ship, etc.).
2. As accepted prospects (going to die).
3. As the wish to die.

In the first two types the ideas are not associated with affect; in the third, though not associated with affect, they are combined with "impulsive" suicidal attempts.

In order not to tear apart the analysis of Charlotte W. (Case 12) too much, we may begin our study of the intervals and the conditions preceding the stupors with the ideas which this patient produced when the stupor lifted somewhat. We shall see that the ideas are closely related to those mentioned above but formulated differently.

It will be remembered that Charlotte W. had freer intervals when she responded and was less constrained generally, and that it was in these that the ideas above mentioned were gathered. Since they were spoken of in the past tense, we regarded them as not belonging to the actual situation but to the more stuporous period. It seems tempting now to see whether the ideas which are expressed in the present tense are different in character, the general aim being to discover whether any tendencies can be found in regard to the types and formulations of delusions associated with different clinical pictures. We see that on November 2 the patient, when speaking much more freely than before, said she had felt that she was mesmerized, was dead, and that she had gone to Heaven, ideas which we have taken up above as belonging to the stupor period. In addition to speaking much more freely in these intervals, she showed at times some affect. Thus to the physician whom she called Christ, she said, with tears, "You came to tell me what was right," or again with tears, "I will have to be crucified," or she spoke in a depressed manner about her children, "I can't see them any more," "I must stay here till I die," and she spoke of having to stay here till she picked her eyes and her brains out; or she claimed her husband or her children had to pick them out. Once she exclaimed crossly and with tears, "You are trying to keep me from Jim" (husband). Another idea was not plainly associated with affect. She said she had come back from Heaven, "The wedding ring kept me on Earth." What strikes one about these formulations is that they are, on the one hand, sometimes associated with an affect, and that, on the other hand, they refer much more to her actual life, her marriage, her husband, her children. At least this seems to be a definite tendency. A similar tendency may be seen later: On November 4, while generally stuporous, this suddenly lifted for a short time, and with feeble voice she uttered some depressive ideas. She said she wanted to go to a convent, that it would be better if she were dead, that she could not do anything right. On November 5 and 6 she said she wanted to go to Jim in Heaven (in contradistinction to the retrospective statements that she had gone to Heaven), and on the 8th, when she had the idea of being in a boat, she said with some anger that she had wanted to get her husband into the boat, but that the doctor kept him out and took his place.

Later there were at times ideas expressed which referred to the actual situation or essentially depressive ideas in a depressive setting. Thus on December 3 she appeared sad, retarded, and spoke of not being able to see her children and that she had done wrong in buying carbolic acid (her suicidal attempt). So far as this case is concerned, therefore, we do find a distinct tendency for the ideas which refer to the more stuporous condition to differ from those which refer to the actual situation in the freer intervals, a difference which we may formulate by saying that, though primitive ideas are expressed, the tendency seems to be to connect them more with actual life, or that the primitive character is lost and the ideas take on a more depressive character with a depressive affect. A few words should be added in regard to the peculiar ideas that she or her husband or her child had to pick out her eyes (or her brain). It is probable that this idea belongs to the motif of sacrifice (the Opfer motiv of Jung) into which we need not enter further, except to say that in this instance it was plainly connected, like some of the other ideas just spoken of, with the real situation of her life (husband, children).

It will now be necessary to examine the earlier state of Charlotte W. The condition preceding the stupor set in with pre-occupation, slow talk and slight distress. During the time she asked to be given one more chance, she said to the husband she would not see him again. Then followed a day when she was very slow and with moaning said she was going to be put into a dark hole. Again on the next, when speaking more freely, she begged to be saved from the electric chair, and also said, "Don't kill me, make me true to my husband," etc. [Again the connection with real life!] We see here the idea of death and especially an idea pertaining to the rebirth motif in a setting of distress and slowness, as an introduction to the stupor which had in it both of these motifs. We must leave it undecided whether it is accidental or not that the distress was associated with more slowness (i.e., more marked stupor traits) when she spoke of the dark hole than when she spoke of the electric chair or death. But what interests us is that distress and reduction of activity (not sadness and reduction of activity, which seems as a rule to have a different content) are here associated with ideas seen in stupor but formulated as prospective dangers. We know from experience that we often find associated with the fear of dying considerable freedom of action, and we see at times in involution states conditions with freedom of motion and marked anxiety, whereas the ideas seem to belong to the motif of rebirth; e.g., the fear of being boiled in a tank.[A]

In this connection, however, two other cases should be taken up which show a condition which reminds one somewhat of that we have just discussed, but in which the rebirth motif appeared, not as prospective, but, as in the stupor, as an actual situation. At the same time this situation was not passively accepted but conceived as a dangerous situation. The significant phenomenon in both these conditions was that there was not anxiety with freedom of action but a bewildered uneasiness with marked reduction of activity.

The first case is that of Johanna S., whose history has been given in this chapter. It will be observed that in the fourth period the patient presented two days of typical stupor with the idea that she was dead. We are familiar with this. But this was followed by several days of bewildered uneasiness and slow restlessness, with ideas that she was at the bottom of the deep, dark water and for a time she made attempts at stepping out of the water or swimming motions. All of this was in a general setting of reduction of activity with bewildered uneasiness. In the ideas about being at the bottom of the deep, dark water, we recognize again the rebirth motif, yet the situation is not accepted but attempts are made by the patient to save herself, i.e., the attitude is one in which the situation is taken to be one of danger. It is interesting in this connection that immediately following this state there was one day of ordinary retardation with sadness and ideas of being bad and sick. That is, when the element of anxiety, the uneasiness, disappeared and sadness supervened, the rebirth ideas were no longer present.

In Mary C. (See Chapter II, Case 7) we have, unfortunately, not a direct observation, but we have, at any rate, a description from the Observation Pavilion which seems so plain that we should be justified in using it here. The condition we refer to is described as a dazed uneasiness, with ideas of being shut up in a ship, of the ship being closed up so that no one could get out, of the boat having gone down, of the people turning up. We should add here that the condition was not followed by a typical stupor. Essentially it was a retardation, in which only on one occasion was a definite akinesis observed. During this phase she soiled her bed. Perhaps the persistent complaint of inability to take in the environment belonged also more to the retardation of stupor than to that of depression. We have again, therefore, in this initial phase, a similar situation, namely, ideas belonging essentially to the rebirth motif, formulated as of a threatening character if not as actually dangerous.

We can say, therefore, that what characterizes these three cases, and brings them together, is the fact that all three had ideas belonging to the rebirth motif, but formulated as dangerous situations. Associated with this there was not a typical anxiety with the relative freedom of activity belonging to this state, but an anxiety or distress or uneasiness with traits of stupor reaction, namely, slow movements, lack of contact with the environment, and a dazed facial expression. It would seem that these facts could scarcely be accidental but that they must have a deeper significance. As a discussion of this belongs, however, more into the psychological part of this study, we shall defer it for the present, and be satisfied with pointing out here the clinical facts of observation.

In brief, then, our findings as to the ideational content of the benign stupor are as follows: From the utterances during the incubation period of the psychosis, from the ideas expressed in interruptions of the deep stupor, as well as from the memories of recovered patients, we find an extraordinary paucity and uniformity of autistic thoughts. They are concerned with death, often as a plain delusion of being no longer alive, or with the closely related fancy of rebirth. The rule is a setting of apathy for these ideas, but when they are formulated so as to connect them with the real life and problems of the patient, or when rebirth is represented as a dangerous situation, some affect, usually one of distress, may appear.

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. It seems as though there were, as a pathognomonic sign of the morbid process, a lack of energy and loss of the normal élan vital.

We may say, in fact, that the establishment of a specific type of emotional change is justification for classifying all milder stupor reactions with the deep stupors. In other words, our reason for the enlargement of the stupor group to include all apathetic reactions (except those of dementia præcox) is the belief that this dulling of the emotional response is as specific a type of emotional change as is anxiety, depression or elation. Perhaps it would be more accurate to say that this clinical group is founded on the symptom complex which is built around apathy. There is never any resemblance between apathy and the mood of elation or anxiety. A discrimination from depression is the only differentiation worth discussion.

The first point that should be made is that there is a difference between marked depression and the mood of stupor. In the former we get a retardation with a feeling of blocking, rather than of an absence of energy. The expression of the patient is one of dejection, not of vacancy, which bespeaks a mood of sadness, even when the patient is so retarded as to be mute and therefore incapable of describing his emotions. Running through all the stages of stupor, however, there is an emptiness, an indifference that is in striking contrast to the positive pain that is felt or expressed by the depressed patient. It may be objected, of course, that this apathy really represents the final stage in the emotional blocking of the depressed individual, but the development of stupor and recovery from it shows an entirely different type of process. A deep depression recovers by changing the point of view from a feeling of unworthiness and self-blame to one of normality. The stuporous case, on the other hand, evidences merely less and less indifference, and more and more interest in his environment and in himself as he gets well.

The associated symptoms are no less dissimilar. The difficulty in thinking which troubles the depressed patient is slight in proportion to his emotional gloom, and he feels himself to be much more incompetent intellectually than examination proves him to be. On the other hand, in the stupor reaction we find that the thinking disorder runs hand in hand with the apathy and that the intellectual capacity of the patient is really markedly interfered with, as can be shown by more or less objective tests. A mere slowing of thought processes accompanied by subjective feeling of effort is the limit reached in true depression, while it is merely the beginning of the intellectual disorder in stupor, for one meets with retardation symptoms only in the partial stupors. The slowing in these cases seems to represent an early stage of the intellectual disturbance which reaches its acme in the mental vacuity and complete incompetence of the deep stupor, just as slow movements in the partial stupors seem to represent a diluted inactivity reaction. This actual thinking disorder is not present in those forms of manic-depressive insanity which are characterized by elation, anxiety or depression but is seen only in stupors, occasionally in absorbed manic states (manic stupor) and sometimes in perplexity states. The psychological mechanisms of this last group are probably analogous to those of stupor, but this is not the place for a discussion of this topic.

Another associated symptom whose manifestations differ in depression and stupor is that of unreality. In the former there is frequently a feeling of unreality that is purely subjective, whereas the stupor case does not usually complain of this but does exhibit a difficulty in grasping the nature of his environment, which the typical depressive case never has.

The occurrence of other mood reactions than apathy in the same patient is also characteristic. Manic states (usually hypomanic) frequently occur during the phase of recovery from the stupor. This is an unusual, although not unknown, phenomenon in recovery from severe retarded depressions. The circular cases who swing from depression to elation usually show the milder types of depressive reaction which would never be confused with stupor. On the other hand, deep stupors very frequently are terminated by manic reactions, and if not by such means, recovery seems to occur merely in virtue of a gradual attenuation of the stupor symptoms. Rarely do we see a change to depression or anxiety heralding improvement. This tendency of the stupor reaction to remain pure or change to hypomania is a peculiarity which seems to put stupor in a class by itself among the manic-depressive reactions, as all the other mood reactions frequently change from one to the other.

Although apathy is the central pathognomonic symptom of stupor conditions, there are other mood anomalies to be noted. One of these is the tendency for inconsistency in, as well as reduction of, the expression of emotion. For instance, in the states where one would expect anxiety during the onset of stupor or in its interruptions, manifestation of this anxiety is often reduced to an expression of dazed bewilderment. In the anxiety states associated with stupor one does not meet with the restlessness and expressions of fear which would be expected. Quite similarly, when a manic tendency is present, it occurs either in little bursts of isolated symptoms of elation (such as smiling or episodic pranks), or some of the evidences of elation which we would expect are missing. For instance, Johanna S. (Case 13) terminated her stupor with a hypomanic state which was natural except for her always wearing an expressionless face. Sometimes laughter occurs alone and gives the impression of a shallow affect, raising a suspicion of dementia præcox. In fact, such evidences of affect as do appear in the course of the stupor are apt to be isolated, queer and "dissociated." It does not seem as if the whole personality reacted in the emotion as it does in the other forms of manic-depressive insanity. For example, we may think of the resistiveness which is so frequently present when the patient seems in other respects to be psychically dead. One may recall the case of Meta S. (Case 15), who, otherwise inert, was occasionally seen with tears or smiles. Anna G. (Case 1), too, was often seen smiling or weeping. It was noted once of Charlotte W. (Case 12) that she ceased answering questions and remained immobile with fixed gaze, but when some mention was made of her going home she flushed and tears ran down her cheeks, although no change in the fixedness of her attitude or facial expression was seen. When Johanna S. was visited by her daughter and was lying motionless in bed, she slowly extended her hands, apparently tried to speak, and then her eyes filled with tears. Two days later, at the end of an interview when she had made a few replies, she settled down into her usual inactivity and, when further urged to answer, her eyes filled with tears. Similarly, too, in fairly deep stupor pin pricking may result in flushing, in tears or an increased pulse rate without the patient giving any other evidence of the stimulus being felt. These examples seem to show a larval effort at normal human response which, failing of complete expression, appeared as single isolated features of emotion suggesting true dissociation. We should also in this connection bear in mind the impulsive suicidal acts which occur either as unexpectedly as the impulsiveness in a true dementia præcox patient, or in a setting of coarse animal-like excitement that seems quite unrelated to the personality. One is reminded of the patient who made suicidal attempts during the period when she shouted like a huckster, giving no evidence whatever by her expression or the tone of her voice of feeling anxiety, sorrow or any other normal emotion.

All these queer and larval affective reactions remind one strongly of dementia præcox. The resemblance of the benign stupor to certain dementia præcox types is not merely a matter of identity with catatonic features (catalepsy, negativism). In these anomalous mood reactions it seems as if there were a definite dissociation of affect, and so there is. How then can we differentiate these emotional symptoms from the "dissociation of affect" which is regarded as a cardinal symptom of dementia præcox? The answer is that this term is used too loosely as applied to the latter psychosis. It is a particular type of dissociation which is significant of the schizophrenic reaction, for in it there is an acceptance of what should be painful ideas evidenced either by incomplete manifestations of anxiety or depression or actually by smiling. We never see in dementia præcox the reverse—a painful interpretation of what would normally be pleasant. It is the pleasurable interpretation of what is really unpleasant that gives the impression of queerness in the mood of these deteriorating or chronic cases. In stupor, on the other hand, although this dissociation takes place, the mood is never inappropriate, merely incomplete in that all the components or the full expression of the normal reaction are not seen.

Our description of the mood reactions in stupor would be incomplete if we omitted to mention the occasional appearance of an emotional attitude not unlike that seen in many cases of involution melancholia, which reminds one in turn of the reactions of a spoiled child. The commonest of these manifestations is resistiveness that may occur when an examination is attempted, feeding is suggested, or a sanitary routine insisted upon. One also meets with resentfulness. One patient, who frequently showed this reaction, explained it retrospectively by saying that she wanted to be left alone. Quite analogous to this is sulkiness that occasionally appears. Then we have, particularly as recovery begins, other childish tricks, such as flippancy in answering questions or the playing of pranks. Such tendencies naturally lead over to frank hypomanic behavior.

Finally, a peculiar characteristic of the stupor apathy must be mentioned. This is its tendency to interruptions, when the patient may return to life, as it were, for a few moments and then relapse. Such episodes occur mainly in milder cases or towards the end of long, deep stupors. It is interesting that the occasion for such reappearance of affect is frequently obvious. We usually observe them in response to some special stimulus, particularly something that seems to revive a normal interest. Visits of relatives are particularly common as such stimuli, in fact recovery can often be traced to the appearance of a husband, mother or daughter. It is also important to recognize that with this revived interest, other clinical changes may be manifest, that the thinking disorder may, for instance, be temporarily lifted. Helen M., for example, when visited by her mother was so far awakened as to take note of her environment, and remembered these visits after recovery like oases in the blank emptiness of her stupor. She further remembered that definite ideas were at such a time in her mind that ordinarily was vacant. She then had delusions of being electrocuted.

In summary, then, we may say that the sine qua non of the stupor reaction is apathy in all gradations, and that this apathy is as distinct a mood change as is elation, sorrow or anxiety. Incidental to this loss of affect there is a dissociation of emotional response whereby isolated expressions of mood appear without the harmonious coöperation of the whole personality which seems to be dead. Thirdly, there tends to be associated with the stupor reaction a tendency to childish behavior. Finally, the apathy and accompanying stupor symptoms may be suddenly and momentarily interrupted. An explanation of these apparently anomalous phenomena will be attempted in the chapter on Psychology of the Stupor Reaction.

1. Inactivity. We must now turn our attention to the other cardinal symptoms of the stupor reaction, and quite the most important one of these is the inactivity. It is convenient to include under this heading both the reduction of bodily movement and the diminution or absence of speech. This inactivity is, of course, related to the apathy which we have just been discussing, in fact it is one of the evidences of the loss of emotion. We presume that a patient is apathetic when there is no expression in the face and when he does not respond to external stimuli, whether these be physical or verbal, by movement or by word.

Bodily inactivity is present in all degrees, and in some forty consecutive cases was recognizable in every one. In its most extreme form there is complete flaccidity of all the voluntary muscles, and relaxation of some sphincters. As a result of the latter we see wetting, soiling and drooling. Even those reflexes which are only partially under voluntary control, like those of blinking and swallowing, may be in abeyance; for instance, saliva may collect in the mouth because it is not swallowed, and tube-feeding is frequently necessary on account of the failure of the patient to swallow anything that is put into his mouth. The eyes may remain open for such long periods of time that the conjunctiva and sclera may become quite dry and ulcerate. In these extreme cases there is, of course, no response to verbal commands. What is more striking, no reaction appears to pin pricks, so that it seems as if consciousness of pain were lost.

This deep torpor does not usually persist indefinitely. The commonest evidence of some form of consciousness persisting is probably to be seen in blinking when the eye is threatened or the sclera or cornea actually touched. A very large number of patients, when otherwise quite inactive, showed considerable response in their muscular resistiveness, the phenomena of which will be discussed shortly. The relaxation of the sphincters is apt to persist even after control of the rest of the body is exercised to the point of permitting the patient to stand or walk about.

The first phase of obvious conscious control is seen in those patients who will retain a sitting posture in bed or in a chair. The next stage is reached where the stuporous case can be stood upon his feet but cannot be induced to walk. The next degree is that of walking only when pushed or commanded. Finally spontaneous movement is observed in which the inactivity is evidenced merely by a great slowness.

No correlation can be established between restrictions of speech and motion other than that present in the extremes. With complete inactivity there is almost always consistent mutism, and perfect freedom of speech does not, as a rule, appear until the movements are free. In between these extremes all variations are possible, even the deepest stupors are occasionally interrupted by one or two words; for instance, a patient may remain comatose, as it were, and absolutely mute for six months, then to every one's surprise say one or two words and relapse into a year of silence. Again one sees cases where movements have become fairly free and yet the patient says nothing. This is another example of that inconsistency in reaction which we have already noted in connection with the mood or affect.

In so far as inactivity is merely an expression of apathy, its causation will be considered in connection with the psychology of the stupor reaction as a whole. In so far as there may be specific factors, however, it may be of interest to consider what information the patients themselves give us from time to time as to what determined their inactivity. It is really surprising how frequently something can be gained either from careful notes taken during the stupor or from the retrospective accounts of the psychotic experiences. Of course when one considers the degree of amnesia which is usually present and the extent of the intellectual defect in general, it becomes obvious that one cannot think of getting anything like a complete explanation of the behavior of any given case. Nevertheless this material is quite suggestive in the mass; it gives one some idea of the mental state as a whole.

Among 40 cases, 27 offered some explanation either during or following the psychosis. Of these, 20 spoke of feeling dead, numb or drugged, or feeling as if paralyzed or having lockjaw. This group, just half of all the cases, apparently ascribed their disability to something which seemed physical. One might call them somatopsychic cases. The other 7 gave more allopsychic explanations: 3 attributed their inactivity to outside influence; 3 more said they were afraid (one of these because she imagined herself to be in prison), which is analogous to the outside influence; the 7th case thought she would injure people if she moved.

The following are some examples of the statements of the somatopsychic group: Laura A.: "I can't move," and retrospectively, "My arms were stiff." Bridget B. claimed retrospectively that she felt dead or drugged, that her limbs were lifeless, she felt as if she had lockjaw. Johanna B. remembered being pricked with a pin on several occasions but claimed that she did not feel the pain at any time. This suggests a definitely hysterical mechanism. Anna L. (Case 16) said retrospectively that she felt as if she were dead, although walking around, and also that she thought she was a ghost and not supposed to speak. Anna M. said she had tried to speak but everything stuck in her throat. Alice R. said that she had no energy, did not want to talk. Meta S. (Case 15) claimed that while stuporous her tongue would not move. Isabella M. in intervals claimed that during the stuporous periods she felt as if dead and said retrospectively when the whole psychosis was over that it was "an effort to speak." Johanna S. (Case 13), while stuporous when pressed with questions would say: "I can't think," "I don't know," "I am twisted." When food was offered her she protested, "I am dead." Charlotte W. (Case 12), in reviewing her case, said: "I was mesmerized," "I thought I was dead." Anna G. (Case 1), in retrospect said: "I don't think I could speak," again "I made no effort," or "I did not care to speak." Henrietta H. (Case 8) said, "I lost speech." She claimed that she did not move because she was tired and had a numb feeling. Mary C. (Case 7) said that her tongue had been thick and that she felt dull. Rose Sch. (Case 6) said during the psychosis that her head was upside down and retrospectively that she had been mixed up, could not remember well, did not feel like talking. Mary D. (Case 4) said that she had been dazed, that she had not felt like talking, and that her limbs "were stiff like." We should probably also include here as a delusion of death the statement of Annie K. (Case 5) who wanted to die and thought she would do so if she kept still enough.

It is rather striking that among all the forty cases only one spoke of being sick—"I am so sick." Only one evaded questions with "that was my illness." One would expect a priori that these patients would offer some vague explanations or make complaints of weakness. If these stupors were purely physical in origin, one would expect such explanations as weakness or illness to be offered in accounting for the inactivity. That there is a rather definite type of explanation offered is, we think, distinctly suggestive. If one tries to correlate and group the death ideas, one sees that they are all delusions of death or of loss of energy or complaints of hysterical symptoms that look like sham death. If the lack of energy complained of be looked upon as lifelessness, one can conceive of these explanations being variations of one theme, namely, that of death. In the last chapter it has been shown that a delusion of dying, being dead, or having been dead is extremely frequent in the stupor group. It would seem only natural then to regard the inactivity, in so far as it may be specifically determined, as an expression of some such delusion.

Psychiatrists are more or less aware of there being typical ideational contents in the different manic-depressive psychoses. For instance, every one is familiar with ideas of wickedness and inadequacy in depression, ideas of violence in anxiety, or expansive and erotic fancies in manic states. Quite similarly we have seen that death is a dominant topic in a stupor. Now in addition to these typical ideas we often hear expressed what we might term non-specific delusions, ideas that seem to have nothing to do with a peculiar type of reaction which the patient presents. It is therefore not surprising to find that inactivity is not consistently ascribed to death or a related delusion.

For instance, Henrietta B. had much talk of higher powers that were controlling her, also said that it was fear which kept her quiet. Josephine G. said retrospectively that she had thought she would injure people if she moved and that if she opened her eyes she would murder the people around her. Johanna B. was afraid to talk because she fancied she was in prison. Laura A.: During her stupor was more vague, saying, "I can't move, they won't let me be," without betraying any suggestion of whom "they" might be. Finally Mary C. (Case 7) was still more indefinite, ascribing her immobility merely to fear. When one considers, however, that these five were the only ones who gave any atypical explanation of their inactivity among the thirty-seven cases, the preponderance of the death idea becomes striking.

2. Negativism. The next of the cardinal symptoms to be considered is negativism. This term, which is often loosely used, we would define as perversity of behavior which seems to express antagonism to the environment or to the wishes of those about the patient. Naturally it is only in the minor stupors that we see it in well-developed form as active opposition and cantankerousness. For example, Harriett C., who stood about until her feet became edematous, would spit out food when it was placed in her mouth but would eat if she were left alone with the food. Josephine G., in a milder state, would turn her back on people. When more inactive once rolled out of bed and lay on the floor. At this time also she tried to keep people out of her room. Rarely, patients may have angry outbursts, as did Annie K. (Case 5) who would strike at the nurses.

Very often the failure to swallow and anomalous habits of excretion seem to be negativistic in their nature. One thinks at once of the necessity for tube-feeding, which is so common even when patients seem otherwise fairly active. Naturally this form of treatment is necessary only when the patient refuses to swallow. Quite frequently a refusal to urinate is met with so that catheterization is necessary, or a patient may never use the toilet when led to it, but will defecate or urinate so soon as he leaves it. These latter, like some other perversities, suggest reactions of a petulant, spoiled child.

By far the commonest manifestation is muscular resistiveness, often spoken of as "resistiveness." It was present in thirty-two out of thirty-seven of our cases. Usually it takes the form of a contraction of the whole system of voluntary muscles when the patient is touched or the bed approached. Often it appears only when any passive movement of the limb is attempted. All muscles of the limb then stiffen, making the member rigid. Sometimes the negativism is expressed by quite isolated symptoms, such as stiffness in the jaw muscles alone. One patient showed no opposition except by holding her urine for two days. Another kept her eyes constantly directed to the floor. The reaction of another showed no irregularity except for stiffness in the neck and arms and wetting herself once after she had been taken to the toilet. One displayed merely a slight stiffness in her arms. An interesting case was that of Annie G. (Case 1) who kept one leg sticking out of bed. If this were pushed in, she would protrude the other. Mary F. (Case 3) sometimes expressed her antagonism to the environment by slapping other patients. She spoke only twice in a year and a half, and each time it was when interfered with. By far the commonest cause of muscular movement in these inactive cases is resistiveness, and as a rule the inactivity is interrupted only by negativistic symptoms.

If we look for some explanation or correlation of these symptoms, we find that chance references to conduct seem to point in the same direction, namely, to the desire to be left alone. This resentment against interference again reminds us of the reactions of a spoiled child. For instance, Laura A., in manic spells during which she was still constrained and drooled, said, "I don't want to have my face washed." In the intervals she showed an intense muscular resistiveness. Mary G. used to say, "Leave me alone," and covered her head or buried it in the pillows. Maggie H. (Case 14) said in retrospect that she had wanted to be left alone. Similarly Alice R. thought she did not want to talk. Emma K. thought that she was in prison and apparently resented this. Henrietta B. combined in her behavior tendencies both to compliance and opposition. When her arms were raised they retained the new position for a minute. Then she dropped them and said, "Stop mesmerizing me." But then she put them up again of her own accord, and when she had done this presented intense resistiveness to any movement. Later she extended her arms in front of her and said, "I am all right," in a theatrical manner, and then added, "Why don't you go away?"

There seems to be some correlation between inaccessibility and muscular resistiveness. For example, Charlotte W. (Case 12), whose condition varied a great deal, always lost the resistiveness when she became accessible, during which periods she also showed some facial expression. The resistiveness would invariably return when the inaccessibility reappeared. Caroline DeS. (Case 2) lost her resistiveness as she became more accessible, although the inactivity and apathy persisted. This tendency, which is quite common, suggests that muscular resistiveness represents a lower level of expression of opposition which patients put into words or purposeful actions when there is other evidence of some contact with the environment. Sometimes one observes both general resistiveness and specific acts. For instance, Mary G., who said, "Leave me alone," and covered her head or buried it in the pillows, accompanied her muscular resistiveness with laughter. This shows the affective nature of the apparently purposeless muscular tension. The case of Annie K. (Case 5) is more instructive. In the stage of deeper stupor she had the automatic type of resistiveness but also outbursts of anger, particularly toward the nurses, striking one of them she said, "You are the cause of it all." When food was offered her, she said, "I wonder people would not leave me alone sometimes." Again, when her bed was approached, she would clutch and hold the bed clothes in an apparently aimless way as if the impulse to resist never reached its goal. Retrospectively she could not account for her muscular rigidity on the basis of definite ideas, and could recall only that she felt stubborn. In a later period when more accessible, she felt cross and did not want to be bothered. This emotional attitude was quite conscious with her, whereas the acts and speech of the earlier period, when her stupor was more profound, seemed more automatic and impulsive. In other words, the resistiveness looks like a larval attempt to express an idea which is probably not fully conscious and therefore gives the appearance of being aimless. As another example of this we may cite the case of Pearl F. (Case 9), who said when she recovered, "I was stubborn." In addition to the muscular resistiveness she had shown, she would often bite the bed clothes or scratch herself when she was approached. Mary F. (Case 3), while in a stupor, slapped at nearby patients quite aimlessly. When somewhat better, this conduct appeared in a more conscious form, as sullenness, indifference and smearing of feces (again the behavior of a naughty child). Here one might quote Laura A. once more, whose resistiveness when stuporous was intense but who in her manic spells expressed her negativism in a definite idea, "I don't want my face washed."

To summarize, then, we may say that negativism is apparently the result of a desire to be left alone, and that muscular resistiveness is a larval exhibition of the same tendency. But the appearance of this attitude in such aimless, impulsive acts or habits reminds us strongly of the dissociation of affect, which was commented on in the previous chapter. It would seem to be another example of this rather fundamental tendency of the stupor reaction, not merely to diminish conative reactions in general, but to reduce their appearance to that of isolated, partial and therefore rather meaningless expression.

3. Catalepsy. The last of the cardinal symptoms to be considered is catalepsy. It occurred in thirteen of thirty-seven cases, although it was present only as a tendency in three of these. If we define it as the maintenance of position in which a part of the body is placed regardless of comfort, we can see that sometimes it is difficult to differentiate from the phenomenon of resistiveness with its rigidity. It is most frequently observed in the hands and arms, perhaps because it is, as a rule, most convenient to demonstrate the retention of awkward positions in the upward extremities. But any part or even the whole body may be involved; for example, Charles O. retained standing positions even where balance was difficult. This phenomenon is often accompanied by "waxy flexibility," where the joints move stiffly but retain whatever bend is given them, like a doll with stiff joints.

The significance of catalepsy is best studied by considering its relationship to other symptoms and by noting remarks made by the patients in reference to it. The most important observations which we have made seem to indicate that it never occurs with that degree of deep inactivity which suggests a complete lack of mentation on the part of the patient. One is therefore forced to conclude that back of this phenomenon there must be some purpose, some kind of an ideational content, although this may be of a primitive order. This is demonstrably true in some cases, at least such as that of Isabella M., who left her arm sticking up in the air but took it down to scratch herself and then put it back. Somewhat similarly, Charlotte W. (Case 12), when she was shown during convalescence a photograph of herself in a cataleptic state, said that that was when she was waiting to go to Heaven and was afraid to move. Again she remarked, "I was mesmerized." Josephine G., who showed only a tendency to catalepsy, said that she feared the devil would get control of those about her if she moved. Sometimes there is a development of this symptom from others which seem to be ideational in their origin. For instance, Charles O. began making flail-like movements. These passed over into slow circular motions which finally subsided into the maintenance of fixed position.

References to hypnotism are not infrequent, and in many cases there is evidence of a delusion that the posture is desired by those in charge of the patient. Annie G. (Case 1) said so directly. In retrospect she explained the holding of her arms in the air by saying, "I thought you wanted me to have them up." Henrietta B. at one examination kept her arms raised in the position in which they had been put for a minute and then dropped them, saying, "Stop mesmerizing me." But she then put them up again of her own accord and now presented intense resistance to any motion. Later she extended her arms in front of her and said, "I am all right," in a theatrical manner. Some patients give evidence in other symptoms of larval efforts at coöperation with the actual or supposed wishes of the physician and in such cases it is not impossible that passive movements are interpreted as orders. One must remember in this connection that the more primitive are the mental operations of any individual, the more important do signs, rather than speech, come to be a medium of communication with other people. As an example of this type we might mention Rose Sch. (Case 6), who flinched from pin pricks (showing that she felt them) but made no effort to get away. When somewhat clearer she said that she was "here to be cured." Similarly Mary D. (Case 4), who showed no catalepsy from ordinary tests, kept her head off the pillow for a long time after it was raised to have her hair dressed. She showed such perseveration in many constrained positions. She too flinched from pin pricks but not only made no effort to prevent them but would even stick out her tongue to have a pin stuck in it.

The relationship of catalepsy to resistiveness is interesting but unfortunately complicated and unclear. In only one of our cases was catalepsy definitely present without resistiveness, and in one other a "tendency to catalepsy" was noted without muscular rigidity being observed. In this latter case, when the catalepsy became unquestionable, resistiveness also appeared. It is one thing to note this coexistence and another to explain it adequately. All that we can offer are mere speculations as to the real meaning of the association of these phenomena. It may be that the tension of muscles that occurs when resistiveness is present gives the idea to the patient of holding the position. There would be two possible explanations for this. We might think there is a dissociation of consciousness, like that of hysteria, where the feeling of tenseness in the muscles that comes from the resistance to gravity is not discriminated from the resistance to the movements made by the examiner. On the other hand, there might be a similar dissociation where the perception of contraction in the antagonistic muscles is interpreted as the action of the examiner in placing the limb in a given position. This latter view would seem, on the face of it, ridiculous, inasmuch as its presumes the existence of two directly opposed tendencies, namely, those of opposition to the will of the physician and compliance with it. But ambivalent tendencies are frequently present in psychopathic states, and moreover we find occasionally some evidence in the behavior of the patient to substantiate this view. For example, at one stage of the stupor of Annie G. (Case 1), her arm could be moved without resistance. Then the elbow would catch and at this moment the position would be maintained. Such observation is highly suggestive of the resistance being signal for the catalepsy. In Isabella M. the catalepsy appeared when resistance to passive movements also developed. On the other hand, when the resistance became extreme, the catalepsy was reduced, and vice versa. This makes one think of two tendencies: suggestibility on the one hand, and opposition on the other. We might presume that when both are present and equally strong, stiffness with passive movements results as a kind of compromise, but when there is a greater development of one, the other is inhibited.

Such speculations remind one strongly of the psychology of conversion hysteria and of hypnotism. In some cases of stupor hysterical symptoms are quite definitely present. For instance, Celia G. began her psychosis with hysterical convulsions which would terminate with short periods of stupor. Later the stupor became persistent and during this stage she had catalepsy (and restiveness as well) in her left arm only. On recovery from her stupor she complained of stiffness in her hands, which examination proved to be a purely hysterical difficulty.

This whole subject is without question obscure and many more and very careful observations are needed before really satisfactory explanations can be given for these phenomena. That it is a reaction which is related to the primitiveness of the mental content and the intellectual deficit in stupor would seem to be a reasonable view, inasmuch as quite similar phenomena have been observed in a large number of animals, even among crustaceans. As a result of our own observations the only thing we feel at liberty to state with real confidence is that catalepsy is presumably a phenomenon mental in origin rather than somatic, because it always occurs in conditions which show other evidence of mentation.

Whatever may be the origin of the idea of the posture assumed, there can be little doubt that its indefinite maintenance is a phenomenon of perseveration. The conception of the position being in the patient's mind, it is easier to hold it than elaborate another idea. This, of course, is part of the intellectual disorder in stupor. In fact, it is difficult to imagine any one whose critical faculty was functioning coöperating in a test for catalepsy.

We have described typical cases of benign stupor and isolated certain interrelated symptoms which, when they dominate the clinical picture, we believe establish the diagnosis of stupor, regardless of the severity of the reaction. These symptoms are apathy, inactivity, a thinking disorder and, quite as important as these, an absorbing interest in death. It is typical that the patient contemplates his dissolution with indifference or, at most, with mild or sporadic anxiety. There seems little reason to doubt that when these four symptoms occur alone, we are justified in making a diagnosis of stupor. The next problem is to consider the meaning and classification of cases where these symptoms occur in conjunction with others. This naturally introduces the subject of relationship of stupor to other manic-depressive reactions.

It is probably best to begin with presentation of three such cases.

Essentially, then, this case shows what was at first a typical partial stupor, but soon became complicated by a tendency for questioning to provoke rather a free flow of ideas and a distressed perplexity. This symptom of perplexity soon grew to dominate the clinical picture, so that the psychosis was really a perplexity ushered in by a brief stupor reaction with a background of stupor symptoms running through it. The second case shows similar tendencies but different from the one whose history has just been cited in that the perplexity was never complained of by the patient herself and that her emotional reactions were more marked and varied.

Here again, then, we have the symptoms of apparent apathy, inactivity, and similar ideas of death, but the thinking disorder was possibly not very profound, inasmuch as she had a good memory for external events. Her ideas, too, are much more florid than those which we customarily meet with in stupor cases, but the most marked peculiarity was that this "stupor" was liable to constant interruption, either spontaneously or as a result of questioning, which always produced a mood reaction. She was apathetic only so long as she was left alone. In other words, whenever an effort was made to test what seemed to be apathy, the evidences of it disappeared.

The third case to be considered is somewhat like that of the first, Anna L. (Case 16), in that with the inactivity and apathy there was a coincident subjective perplexity. The apathy, however, was less marked than in the case of Annie L.

If we consider together the common features of these three cases, we see that they resemble stupors only in the presence of inactivity and apparent apathy. It is true that death appears in the ideational content but not with that prominence, bordering on exclusiveness, which characterizes such delusions in the true stupors. These three patients give one the impression of being absorbed in thoughts that have many variations. It seems as if they had difficulty in grasping the facts of the environment, while feeling at the same time the vividness of the changing internal thoughts, hence a confusion develops which is either subjective, objective, or both. It is probably the introversion of attention which gives rise to the apparent apathy, because normal emotions emerge as part of our contact with reality around us. This lack of contact with the environment leads also to inactivity. If one's attention and interest is turned inwards, there can be no evidence of mental energy exhibited until the patient is roused to contact with the people or things about him. It is noteworthy that in these cases emotional expression emerged when the patients were stimulated to some productiveness in speech.

These conditions really constitute a different psychosis in the manic-depressive group, essentially they are perplexity states such as have recently been described by Hoch and Kirby.[7] Not infrequently we see exhibitions of this tendency in what are otherwise typical stupors. For example, Mary F. (Case 3) (the third case to be described in the first chapter), showed for a few days after admission a condition when she was essentially somewhat restless in a deliberate aimless way. At the same time she looked dazed or dreamy. With this restlessness she appeared at times "a little apprehensive." Although she spoke slowly, with initial difficulty she answered quite a number of questions. Her larval perplexity was evidenced by the doubt expressed in a good many of her utterances, such as, "Have I done something?" "Do people want something?" "I have done damage to the city, didn't I?" When asked what she had done, she said, "I don't know." She asked the physician, "Are you my brother?" and when questioned for her orientation said, "Is not this a hospital?" The atmosphere of perplexity also colored the information which she did recall correctly; for instance, when asked her address, she said, "Didn't I live at ——?" then giving the address correctly.

As stated in Chapter V dealing with the ideational content of stupor, one has to look on the delusions of patients as symptoms subject to analysis and classification just as truly as the variations in mood or intellectual processes, in fact they should be subject to the same correlation as are the mental anomalies which are usually studied, particularly if we are to understand these psychoses as a whole. Let us, therefore, consider the death ideas in the three cases studied in this chapter. We find that, as in the ordinary stupors, there are delusions of death, also of mutual death (with the father), but there is a tendency to elaboration so that the death is only part of a larger Œdipus drama, the rest of which is usually lacking in stupors. Here it is present. So we have thoughts of the death of the mother or husband, another rival, considerable preoccupation with Heaven, and also erotic fancies.

We find in manic-depressive insanity a tendency for more or less specific ideational contents with different types of the psychoses.[8] For example, there are religious and erotic fancies or ambitious schemes dominating the thoughts of manic patients, fears of aggression and injury met with in anxiety cases, and so on. In stupors, death seems to be a state of non-existence with other meanings lacking or only hinted at occasionally. When it tends to be elaborated, it leads over to formulations suggesting personal attachments and emotional outlet, and then we are apt to find interruptions of the pure stupor picture. For example, Charlotte W. (Case 12), whose case has been described, thought much about being in Heaven and ended with a hypomanic state. Atypical symptoms appear just as constantly in these cases, as do the atypical ideas. In other words, the thought content is definitely correlated with the clinical picture.

As the clinical pictures show the relationship of stupor to other psychoses, so there is also a correlation with varying formulations of the death fancy. We are now in a position to define more narrowly what death means in stupor. It is an accepted fact, a Nirvana state. When death means union with God or appears in other religious guise, manic symptoms tend to develop. When it is unwelcome and appears as "being killed," we find anxiety symptoms. A patient can conceive of death variously and have various clinical pictures. A knowledge of the metamorphoses of ideas and their relationship to other symptoms enables us to understand such cases, that, without this key, seem confused and lawless jumbles of symptoms. Such theories tend to justify the view of essential unity of the manic-depressive group.

It would be instructive at this point to consider another case which illustrates beautifully how a stupor reaction may crystallize out of other manic-depressive states when attention has become focused on personal death. This patient went through four phases while under observation. First, while showing a perplexed expression but with fair orientation, she gave utterance to erotic and expansive fancies. She was restless, somewhat intractable and gave the impression of brooding over her imaginations rather than luxuriating in them. In other words, her condition seemed to be more that of absorbed than active mania. Second, these same ideas, somewhat reduced, continued in an apathetic state while impulsive symptoms developed: She began to shout like a huckster to be taken to Heaven and made numerous affectless, suicidal attempts. Third, came a true stupor and, fourth, a period of recovery when the stupor symptoms all disappeared but insight into the falsity of her ideas was lacking.

This case gives an excellent example of the relationship of stupor to other manic-depressive reactions. She begins with an absorbed state, showing elements of perplexity and mania. With this there are expansive ideas but, also, statements about losing everything and being in prison, which suggest abandonment of life. Next, with increasing apathy, she begins to speak of death and soon makes impulsive suicidal attempts. Evidently her mind was becoming more and more focused on death and with this there was an appropriate emotional change. She was either apathetic or the affect exhibited itself in pure impulsiveness. Then comes the stupor, when all ideas disappear and mentation is reduced or absent. When the stupor lifts, the original ideas appear not only in memory but occasion a wavering insight. It is appropriate that she recalled all of her psychosis fairly well with the exception of the pure stupor, which she remembered only as a time when her mind was a blank.

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.

Let us first consider the fever. In 35 cases, on whom data of temperature could be found from the records extant, 28 showed fever usually running between 99° and 100°, often up to 101° or slightly over this point. When these cases were analyzed, however, it was found that 27 were typical and 8 atypical, showing pictures resembling those described in the last chapter. Of the latter only one had a rise of temperature, while of the typical group only one was afebrile. Therefore, since out of 27 typical cases 26 had the typical slight fever, we must conclude it to be a highly specific symptom. Of these 28 cases the incidence of the fever was as follows: 8 showed it only on admission; in 7 it was highest on admission but continued at a low rate throughout the rest of the psychosis; in 5 it extended without much variation throughout the psychosis; in 4 it appeared intermittently, while in 2 it was accentuated during periods when the mental symptoms were most pronounced. We see, then, that there is a distinct tendency for the fever to be associated with the onset of the disease.

When we look for other data from which we might discover causes for the fever, we find less than we would like. The records are of observations made, some of them, twenty years ago. Although the mental examinations were careful, the records of the physical symptoms either were not made or were lost in many cases. Consequently our description must be tentative and is published merely to stimulate further research as cases come to the attention of psychiatrists.

One looks, first, for other evidence of infection. Some of the cases were thoroughly examined with modern methods and nothing whatever found. Blood examinations were made in five cases; three of these had rather high temperature with the following blood pictures: Charles O., 103°, leucocytosis of 23,000, with 91.5% polymorphonuclears; Annie G. (Case 1), 103°, leucocytosis of 12,000 to 15,000, and 89% polymorphonuclears; Caroline DeS. (Case 2), 104°, 15,000 leucocytes, no differential made, Widal and diazo reaction negative. These three cases, then, had marked febrile reactions and leucocytosis. It is quite possible that they had infections which were not discovered. Of the other two Rosie K. (Case 11) had a temperature of 100° and 17,500 leucocytes associated with a fetid diarrhea, an unquestioned infection, while Mary C. (Case 7), with a temperature of only 100°, had no rise in number of total white cells but 41% of lymphocytes. This last might be due to an internal secretion or an involuntary nervous system anomaly. The possibility of the three high temperatures with leucocytosis being due to intercurrent infections must be considered. Charles O. had high fever only for ten days during a psychosis of several months. Annie G.'s high fever was of about the same duration. Caroline DeS. had short periods of marked pyrexia in the first and seventh months of her long psychosis. Except for these episodes, these three patients had the typical slight elevation of temperature. Three cases out of thirty-five, in which high fever and leucocytosis appeared episodically, are hardly enough to justify the view that stupors are the result of a specific infection. We must remember, too, that no focal neurological symptoms are ever observed, which makes the possibility of a central nervous system infection highly unlikely.

An alternative view might be that the slight rise of fever is somehow the result of stupor, not the cause of it. The editor consulted Professor Charles R. Stockard, of Cornell Medical College, as to this possibility. The following argument is the result of his suggestions:

What we call a normal temperature is, of course, the result of a balance maintained between heat production and heat loss. Either an increase in the former or a decrease in the latter must produce fever. It is possible that heat production may be increased in many stupors as a result of the muscular rigidity. Some cases showed higher temperature when this was more marked, but this was not sufficiently constant to justify any conclusions being drawn.

Heat loss occurs preponderantly as a result of radiation from the skin and by sweating with consequent evaporation of the secretion. These processes are functions of the skin and surface circulation. Are they disturbed in our stupors? We find considerable evidence that they are. Flushing or dermatographia occurred in six cases, cold or blue extremities in four cases, greasy skin in four, marked sweating in three, the hair fell out in two cases, while the skin was pathologically dry in one case, in fact there were few patients who showed normal skin function. Circulatory anomalies were also observed. The pulse was very rapid in eleven cases, weak or irregular in two, and slow in one case. All these symptoms are expressions of imbalance in the involuntary nervous system, further evidence of which is found in the rapid respiration of six cases and the shallow breathing of one patient. These pulse and respiration findings are the more striking in that individuals in stupor are, by the very nature of their disease, free from emotional excitement.

This imbalance could result from a poverty of circulating adrenalin which is necessary for the activation of the sympathetic nerves. A cause for low suprarenal function is to be found in the apathy of the stupor case. As Cannon and his associates have so conclusively demonstrated, any emotion which was open to investigation resulted in an increase of adrenalin output. As our emotions are constantly operating during the day—and often enough during sleep as well in connection with dreams—we must presume that emotional stimulus is a normal excitant 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 nervous 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 menstruate. 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.

In the previous chapter mention has been made of our view that manic-depressive insanity is a disease fundamentally based on some constitutional defect, presumably physical, but that its symptoms are determined by psychological mechanisms. In accordance with this hypothesis we seek, when studying the different forms of insanity presented in this group, to differentiate between the different types of mental mechanisms observed, and by this analysis to account for the manifestations of the disease on purely psychological lines. If benign stupors belong to this group, then we should be able to find some specific psychology for this type of reaction.

All speech and all conduct, except simple reflex behavior, are presumably determined by ideas. When an individual is not aware of the purpose governing his action, we assume, in psychological study, that an unconscious motive is present, so that in either case the first step in psychological understanding of any normal or abnormal condition is to discover, if possible, what the ideas are that lead to the actions or utterances observed. In the case of stupors the situation is fairly simple, in that the ideational content is extremely limited. As has been seen, it is confined to death and rebirth fancies, other ideas being correlated with secondary symptoms, such as belong to mechanisms of other manic-depressive psychoses. It is not necessary to repeat the catalogue of the typical stupor ideas, as they have been given in an earlier chapter. Our task is now to consider the significance of these death and rebirth delusions and their meaning for the stupor reaction.

Thoughts concerned with future and new activities require energy for their completion in action and are therefore naturally accompanied by a sense of effort which gives pleasure to an active mind. When the sum of energy is reduced, one observes a reverse tendency called "regression." It is easier to go back over the way we know than to go forward, so the weakened individual tends to direct his attention to earlier actions or situations. To meet a new experience one must think logically and keep his attention on things as they are, rather than imagine things as one would like to have them.

Progressive thinking is therefore adaptive, while regressive thinking is fantastic in type, as well as concerned with the past—a past which in fancy takes on the luster of the Golden Age. Sanity and insanity are, roughly speaking, states where progressive or regressive thinking rule. The essence of a functional psychosis is a flight from reality to a retreat of easeful unreality.

Carried to the extreme, regression leads one in type of thinking and in ideas back to childhood and earliest infancy. The final goal is a state of mental vacuity such as probably characterizes the infant at the time of birth and during the first days of extra-uterine life. In this state what interest there is, is directed entirely to the physical comfort of the individual himself, and contact with the environment is so undeveloped that efforts to obtain from it the primitive wants of warmth and nutrition are confined to vague instinctive cries. Evolution to true contact with the world around implies effort, the exercise of self-control, and also self-sacrifice, since the child soon learns that some kind of quid pro quo must be given. Viewed from the adult standpoint, the emptiness of this early mental state must seem like the Nirvana of death. At least death is the only simple term we can use to represent such a complete loss of our habitual mental functions. When life is difficult, we naturally tend to seek death. Were it not for the powerful instinct of self-preservation, suicide would probably be the universal mode of solving our problems. As it is, we reach a compromise, such as that of sleep, in which contact with reality is temporarily abandoned. In so far as sleep is psychologically determined, it is a regressive phenomenon. It is interesting that the most frequent euphemism or metaphor for death is sleep. Sleep is a normal regression. It does not always give the unstable individual sufficient relaxation from the demands of adaptation and so pathological regressions take place, one of which we believe stupor to be. It is important to note that objectively the resemblance between sleep and stupor is striking. So far as mental activity in either state can be discovered by the observer, either the sleeper or the patient in stupor might be dead. Briefly stated, then, our hypothesis of the psychological determination of stupor is that the abnormal individual turns to it as a release from mental anguish, just as the normal human being seeks relief in his bed from physical and mental fatigue. When this desire for refuge takes the shape of a formulated idea, there are delusions of death.

The problem of sleep is, of course, bound up with the physiology of rest, and as recuperation, in a physical sense, necessitates temporary cessation of function, so in the mental sphere we see that relaxation is necessary if our mental operations are to be carried on with continued success. This is probably the teleological meaning of sleep in its psychological aspects, for in it we abandon diurnal adaptive thinking and retire to a world of fancy, very often solving our problems by "sleeping over them." The innate desire for rest and a fresh start is almost as fundamental a human craving as is the tendency to seek release in death. In fact the two are closely associated both in literature and in daily speech, for in many phases we correlate death with new life. If one is to visualize or incorporate the conception of new life in one term, rebirth is the only one which will do it, just as death is the only word which epitomizes the idea of complete cessation of effort. Not unnaturally, therefore, we find in the mythology of our race, in our dreams and in the speech of our insane patients, a frequent correlation of these two ideas, whether it comes in the crude imagery of physical rebirth or projected in fantasies of destruction and rebuilding of the world. Many of our psychotic patients achieve in fancy that for which the Persian poet yearned:

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. They do not pass into depressions or anxieties.

Rebirth fancies unquestionably, then, contain constructive and progressive elements, but, as has been stated above, any thinking which implies a lapse of contact with the environment is, in so far as that lapse is concerned, regressive, and in consequence rebirth fancies, as dramatized by the stupor patients, are regressive, just as are the delusions of death itself.

It is obvious that an acceptance of death implies rather thorough mental disintegration. Before that takes place there may be some mental conflict. The instinct of self-preservation may prevent the individual from welcoming the notion of dissolution, so that this latter idea, though insistent, is not accepted but reacted to with anxiety; hence we often meet with onsets of stupor characterized by emotional distress. It has already been suggested that death may foreshadow another existence. Often in the psychoses we meet with the idea of eternal union in death with some loved one whom the vicissitudes and restrictions of this life prevent from becoming an earthly partner. This fancy is frequently the basis of elation. Similarly, new life in a religious sense as expressed in the delusion of translation to Heaven, is a common occasion for ecstasy. 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 who has found no other solution than regression for the predicament in which he is. There is nothing specific in the cause of this unhappiness. At times the factors producing it are mainly environmental; at others, the problem is essentially of the patient's own making. Of course almost any type of functional psychosis may emerge from such a state of dissatisfaction, but it is important to note that unlike manic states, for instance, stupors invariably develop from a situation of unhappiness. Quite frequently the choice of the stupor regression is determined by some definitely environmental event which suggests death. This often comes as the actual death of the patient's father (in the case of a woman) or employer, events which inflate the already existing, although perhaps unconscious, desire for mutual death. Again, the precipitating factor may be a situation which adds still another problem and makes the burden of adaptation intolerable, forcing on him the desire for death. In these cases the actual psychosis is sometimes ushered in dramatically with a vision of some dead person (often a woman's father) who beckons, or there are dream-like experiences of burial, drowning, and so on.

A few cases taken at random from our material exemplify these features of the unhappiness in which the psychosis appears as a solution with its development of the death fancy.

Alice R., at the age of 25, was much troubled by worrying over her financial difficulties and the shame of an illegitimate child. Retrospectively she stated, "I was so disgusted I went to bed—I just gave up hope." Shortly before admission she said she was lost and damned, and to the nurse in the Observation Pavilion she pleaded, "Don't let me murder myself and the baby."

Caroline DeS. (Case 2) for some time was worried over the engagement of her favorite brother to a Protestant (herself a Catholic) and the threatened change of his religion. At his engagement dinner she had a sudden excitement, crying out, "I hate her—I love you—papa, don't kill me." This excitement lasted for three weeks, during two of which she was observed, when she spoke frequently of being killed and going to Heaven. The conflict was frankly stated in the words, "I love my father but don't want to die." Then for two weeks she had some fever, was tube-fed, muttered about being killed or showed some elation, there being apparently interrupted stuporous, manic and, possibly, anxiety episodes. Finally she settled down to a year of deep stupor.

Laura A. had for three months poor sleep with depression over her failure in study. Another cause for worry was that her father was home and out of work. She reached a point where she did not care what happened but continued working. Ten days before admission she was not feeling well. The next morning she woke up confused and frightened, speedily became dazed, stunned, could not bring anything to her memory. This rather sudden stupor onset was not accompanied by any false ideas, at least none which the family remembered.

Mary C. (Case 7) was an immigrant who felt lonely in the new country. Two weeks before admission her uncle with whom she was living died. She thought she had brought bad luck, complained of weakness and dizziness, then suddenly felt mixed up, her "memory got bad," and she thought she was going to die. Next she was frightened, heard voices, thought there was shooting and a fire. For a short time she was inactive and later began shouting "Fire!" When taken to the Observation Pavilion, she was dazed, uneasy, thought she was on a boat or shut up in a boat which had gone down; all were drowned. Then came a mild stupor.

Maggie H. (Case 14), while pregnant, fancied that her baby would be deformed and that she would die in childbirth. Three weeks before admission this event took place. For five days she worried about not having enough milk, about her husband losing his job (he did lose it) and thought her head was getting queer. On the fifth day she cried, said she was going to die, that there was poison in the food, that her husband was untrue to her. She became mute but continued to attend to her baby. She saw dead bodies lying around, and by the time she was taken to the Observation Pavilion was in a marked stupor.

Turning now to the symptoms of the stupor proper, we note, first, the effects of the loss of energy which regression implies. The inactivity and apathy which these patients show is too obviously evidence of this to require further comment. Another proof of the withdrawal of the libido or interest is found in the thinking disorder. Directed, accurate thinking requires effort, as we all know from the experience of our laborious mistakes when fatigued. So in stupor there is an inability to perform simple arithmetical problems, poor orientation is observed, and so on. Similarly what we remember seems to be that which we associate with the impressions received by an active consciousness. Actual events persist in memory better than those of fancy, in proof of which one thinks at once of the vanishing of dreams on waking, with its reëstablishment of extroverted consciousness. This registration of impressions requires interest and active attention. Without interest there is no attention and no registration. The patient in stupor presents just the memory defect which we would expect. Indifference to his environment leads to a poor memory of external events, while on recovery there may be such a divorce between consciousness of normal and abnormal states that the past delusions are wiped from the record of conscious memory. Withdrawal of energy then produces not only inactivity and apathy but grave defects in intellectual capacity.

The natural flow of interest in regression is to earlier types of ambition and activity. This is betrayed not merely by the thought content dealing with the youth and childhood of the patient, but also is manifested in behavior. Excluding involution melancholia there is probably no psychosis in which the patients exhibit such infantile reactions as in stupor. Except for the stature and obvious age of these patients, one could easily imagine that he was dealing with a spoiled and fractious infant. One thinks at once of the negativism which is so like that of a perverse child and of the unconventional, personal habits to which these patients cling so stubbornly. Masturbation, for instance, is quite frequent, while willful wetting and soiling is still more common. We sometimes meet with childishness, both in vocabulary and mode of expression. In one case there was evidently a delusion of a return to actual childhood, for she kept insisting that she was "in papa's house."

The frequency with which the delusion of mutual death occurs in stupor is another evidence of its regressive psychology. The partner in the spiritual marriage is rarely, if ever, the natural object of adult affection, but rather a parent or other relative to whose memory the patient has unconsciously clung for many years, reawakening in the psychosis an ambition of childhood for an exclusive possession that reaches its fulfillment in this delusion. Closely allied with this is another delusion, that of being actually dead, which the patients sometimes express in action, even when not in words. The anesthesia to pin pricks, the immobility and the refusal to recognize the existence of the world around, in patients who give evidence of some intellectual operations still persisting, are probably all part of a feigned death, with the delusion expressing itself in corpse-like behavior.

Finally we must consider the meaning of the deep stupor where no mentation of any kind can be proven and where none but vegetative functions seem to be operating. This state is either one of organic coma, in which case it marks the appearance of a physical factor not evidenced in the milder stages, or else it is the acme of this regression by withdrawal of interest. As has been stated, back of the period of primitive childish ideas there lies a hypothetical state of mental nothingness. If we accept the principle of regression we find historically an analogue to what is apparently the mental state of deep stupor in the earliest phases of infancy. This view receives justification from the study of the phenomenon of variations in symptoms. Mental faculties at birth are larval, and if such condition be artificially produced mental activity must be potentially present (as it would not be if we were dealing with coma). In Chapter IV phenomena of interruption of stupor symptoms were detailed. One case that was mentioned is now of particular importance as demonstrating that an appropriate stimulus may dispel the vacuity of complete stupor by raising mental functions to a point where delusions are entertained. This patient retrospectively recalled only certain periods of her deepest stupor, occasions when she was visited by her mother. At these times, as she claimed, she thought she was to be electrocuted and told her mother so, adding, "Then it would drop out of my mind again." Otherwise her memory for this state was a complete blank. Here we see a normal stimulus producing not normality but something on the way towards it, that is, a condition less profound than the state out of which the patient was temporarily lifted.

This case exemplifies the principle of levels in the stupor reaction which we have found to be of great value in our study. These levels are correlated with degrees of regression, as a review of the symptoms discussed above may show. In the first place, the dissatisfaction with life, the first phase of regression, leads to the quietness—the inactivity and apathy, which are the most fundamental symptoms of the stupor reaction as a whole. Initiative is lost and with this comes a tendency for the acceptance of other people's ideas. That is the probable basis for the suggestiveness which we concluded was a prominent factor in catalepsy. Indifference and stolidity may exist with those milder degrees of regression which do not conflict with one's critical sense, and hence may be present without any false ideas. The next stage in regression is that where the idea of death appears. Although not accepted placidly by the subject, its non-acceptance is demonstrated by the idea being projected—by its appearance as a belief that the patient will be killed. This notion of death coming from without has again two phases, one with anxiety where normality is so far retained that the patient's instinct of self-preservation produces fear, and a second phase where this instinct lapses and the patient so far accepts the idea of being killed as to speak of it with indifference. The next step in regression is marked by the spoiled-child conduct, interest being so self-centered as to lead to autoerotic habits and the perverse reactions which we call negativism. When death is accepted but mental function has not ceased, the latter is confined to a dramatization of death in physical symptoms or to such speech and movements as indicate a belief that the patient is dead, under the water, or in some such unreal situation. Finally, when all evidence of mentation in any form is lacking, we see clinically the condition which we know as deep stupor and which we must regard psychologically as the profoundest regression known to psychopathology, a condition almost as close to physiological unconsciousness as that of the epileptic.

Naturally we do not see individual cases in which all these stages appear successively, each sharply defined from its predecessor. To expect this would be as reasonable as to look for a man whose behavior was determined wholly by his most recent experience. Any psychologist knows that every human being behaves in accordance with influences whose history is recent or represents the habit of a lifetime. At any given minute our behavior is not simply determined by the immediate situation, but is the product of many stages in our development. Quite similarly we should not expect in the psychoses to find evidences of regression to a given period of the individual's life appearing exclusively, but rather we should look for reactions at any given time being determined preponderantly by the type of mentation characteristic for a given stage of his development. As a matter of fact, we see in psychoses, particularly in stupor, more sharply defined regressions to different levels than we ever see in normal life.

Our psychological hypothesis would be incomplete and probably unsound if it could not offer as valid explanations for the atypical features in our stupor reactions as for the typical. The unusual features which one meets in the benign stupors are ideas or mood reactions occurring apparently as interruptions to the settled quietude or in more protracted mild mood reactions, such as vague distress, depression or incomplete manic symptoms, which have been described in the chapter on affect. The interruptions are easily explained by the theory of regression. If stupor represents a complete return to the state of nothingness, then the descent to the Nirvana or the re-ascent from it should be characterized by the type of thinking with the appropriate mood which belongs to less primitive stages of development. A review of our material seems to indicate that there is a definite relationship between the type of onset and the character of the succeeding stupor. For instance, in the cases so far quoted in this book, the onsets characterized by mere worry and unhappiness and gradual withdrawal of interest had all of them typical clinical pictures. On the other hand, of those who began with reactions of definite excitement, anxiety or psychotic depression, there were interruptions which looked like miniature manic-depressive psychoses in all but one case. This would lead one to think that these patients retraced their steps on recovery or with every lifting of the stupor process, moved slightly upward on the same path on which they had traveled in the first regression. The case of Charlotte W. (Case 12), which is fully discussed in the chapter on Ideational Content, offers excellent examples of these principles.

The next atypical feature is the phenomenon of reduction or dissociation of affect, the frequency of which is mentioned in Chapter V. As the law of stupor is apathy, normal emotions should be reduced to indifference and no abnormal moods, such as elation, anxiety or depression, should occur. What often happens is that these psychotic affects appear but incompletely, often in dissociated manifestations. This looks like a combination of two psychotic tendencies, the stupor reduction process which inhibits emotional response and the tendency to develop abnormal affects which characterize other manic-depressive psychoses. There is no general psychological law which makes this view unlikely. One cannot be anxious and happy at the same instant, although one can alternate in his feelings; but one can fail to react adequately to a given stimulus when inhibited by general indifference. In fact it is because apathy is, properly speaking, not a mood but an absence of it, that it can be combined with a true affect. It is possible, therefore, to have a combination of stupor and another manic-depressive reaction, while the others cannot combine but only alternate.[11]

Finally we must discuss the psychological meaning of cases, such as those described in Chapter VIII, where we concluded that there were psychoses resembling stupors superficially. It seemed likely that these patients were absorbed in their own thoughts, rather than being in a condition of mental vacuity. It is not difficult to explain the objective resemblance. All evidence of emotion (apart from subjective feeling tone which the subject may or may not report) is an expression of contact with the outer world. There must be externalization of attention to environment before a mood becomes evident. A moment's reflection will show this to be true, for no further proof is needed than the phenomena of dreaming. The attention being given wholly to fantasies, the subject lies motionless, mute and placid, although passing through varied autistic experiences. Only when the dream becomes too vivid, disturbs sleep and re-directs attention to the environment—only then is emotion objectively betrayed. There is an appearance of apathy and mental vacuity which the dreamer can soon declare to be false. He was feeling and thinking intensely. In any condition, therefore, such as that of perplexity or of an absorbed manic state, the patient may be objectively in the same condition as a typical stupor. The histories of the two psychoses differentiate the two reactions which may be indistinguishable at one interview. The keynote of one reaction is indifference, while that of absorption is distraction, a perversion of attention to an inner, unreal world.

In summary we may recapitulate our hypotheses. Stupor represents, psychologically speaking, the simplest and completest regression. Adaptation to the actual environment being abandoned, attention reverts to earlier interests, giving symptoms of other manic-depressive reactions in the onset or interruptions, and finally dwindles to complete indifference. The disappearance of affective impulse leads to objective apathy and inactivity, while the intellectual functions fail for lack of emotional power to keep them going. The complicated mental machine lies idle for lack of steam or electricity. The typical ideational content and many of the symptoms of stupor are to be explained as expressions of death, for a regression to a Nirvana-like state can be most easily formulated in such a delusion. Other clinical conditions may temporarily and superficially resemble stupor on account of the attention being misdirected and applied to unproductive imaginations. To employ our metaphor again, in these false stupors the current is switched to another, invisible machine but not cut off as in true stupor.

As we have seen, the benign stupors are characterized by apathy, inactivity, mutism, a thinking disorder, catalepsy and negativism. All these symptoms are also found in the stupors occurring in dementia præcox. In fact this symptom complex has usually been regarded as occurring only in a malignant setting. There can be no question about the resemblance of benign to dementia præcox stupors. Even such symptoms as poverty and dissociation of affect, usually regarded as pathognomonic of dementia præcox, have been described in the foregoing chapters. Either recovery in our cases was accidental or there is a distinct clinical group with a good prognosis. If the latter be true, the symptoms must follow definite laws; if they did not, we would have to abandon our principles of psychiatric classification. Naturally, then, we seek to find the differences between the cases that recover and those that do not. There is never any difficulty in diagnosis where a stupor appears as an incident in the course of a recognized case of catatonic dementia præcox. We shall therefore consider only such clinical pictures as resemble those described in this book, in that the symptoms on admission to a hospital or shortly after are those of stupor. It should be our ambition to make a positive diagnosis before failure to recover in a reasonable time leads to a conclusion of chronicity.

It is probably safe to assume, on the basis of as large a series as ours, that the symptoms of stupor per se imply no bad prognosis. Further, it has been noted that a relatively pure type of reaction is seen, the symptoms appearing with tolerable consistency. In analyzing the histories of dementia præcox patients, therefore, one looks for inconsistencies among, or additions to, the stupor symptoms. We may say at the outset that we have been able to find no case of malignant stupor that showed what we regard as a typical benign stupor reaction, and it is questionable whether partial stupor as we have described it, ever occurs with a bad prognosis. Usually the discrepant symptoms in the dementia præcox cases are sufficiently marked to enable one to make a positive diagnosis quite soon after the case comes under observation.

The law of benign stupor is a limitation of energy, emotion and ideational content. In dementia præcox we have a re-direction of attention and interest to primitive fantastic thoughts and a consequent perversion of energy and emotion. In many malignant stupors one can detect evidence of this second type of reaction in symptoms that are anomalous for stupor. For instance, one meets with frequent silly and inexplicable giggling. Then, too, smiling, tears or outbursts of rage, the occasions for which are not manifest, are much more frequent than in typical stupor. Similarly, delusional ideas (not concerned with death at all) may appear or the patient may indulge in speech that is quite scattered, not merely fragmentary. Two cases may be cited briefly to illustrate these dementia præcox symptoms superadded to those of stupor.

In summary, then, we see that this patient exhibited symptoms of dementia præcox from the outset of her stupor, with scattering, genital sensations and incest ideas. The stupor symptoms gradually gave way to the typical indifference, negativism, obscenity, filthiness and inexplicable conduct of dementia præcox. At the beginning, however, the condition was superficially similar to that of a benign stupor, it being only on careful observation that other symptoms were noted.

To Recapitulate: We have here a young woman who for a year had indefinite mental symptoms and suddenly developed a stupor. This was atypical in that she sang and wrote when otherwise apparently deeply stuporous. When persuaded to talk, her utterances, even as early as ten days after admission, were of a malignant type and with such statements she giggled. This last is apparently a highly important sign. Quite frequently in our cases the first signal of a dementia præcox reaction has been giggling in a setting of what was apparently a typical benign stupor.

As has frequently been stated, symptoms of benign stupor are closely interrelated. Consequently the reaction is, when benign, a consistent one. We do not find free speech with profound apathy and inactivity, nor do we expect to meet with unimpaired intellectual functions when other evidences of deep stupor are present. The inconsistency of mental operations which characterize dementia præcox, however—the "splitting" tendency which Bleuler has emphasized in his term "schizophrenia"—is just that added factor which may produce disproportionate developments of the various stupor symptoms in the dementia præcox type of that reaction. Examples of this have been given in the two cases just quoted. The history of the following patient shows this tendency more prominently.

We see then that inconsistencies among the stupor symptoms themselves and the intrusion of definitely dementia præcox symptoms differentiate the malignant from the benign reactions. As a matter of fact, we find, as a rule, that careful examination of the onset reveals further atypical features, suggestions or definite evidences of a dementia præcox reaction before the stupor itself appears. One common occurrence is a slow deterioration of character and energy that proceeds for months or years before flagrantly psychotic symptoms appear.

Then when delusions or hallucinations are eventually spoken of by the patient, an appropriate or adequate reaction is lacking. In a benign psychosis false ideas do not appear with an equable mood unless the stupor reaction has already begun.

More important than this, although in benign stupors there may be a reduction or an insufficient affect, it is never inappropriate. This pathognomonic symptom of dementia præcox frequently occurs in the onset to malignant stupors. In fact we often find in reviewing such cases that a plain dementia præcox reaction has been in evidence, that a diagnosis has not been made simply because the stupor picture blotted out this earlier psychosis before an opinion was formed. Frequently these early symptoms are reported in the anamnesis and not actually observed by the physician.

Three cases may be cited as examples of dementia præcox onsets. It will be noted that the ensuing stupors were, like those already quoted, atypical.

In any functional psychosis an offhand diagnosis is dangerous. When one deals with such a condition as stupor, however, the problem is exacting, for, although "stupor" may be seen at a glance, what is seen is really only a symptom or a few symptoms. "Stupor," then, is more of a descriptive than a diagnostic term. 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.

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. 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. There is no characteristic odor to the breath, and the urine is relatively normal. The unconsciousness of trauma or apoplexy is accompanied by focal neurological signs. Even in aerial concussion (so frequently seen in the war) where no one part of the brain is demonstrably affected more than another, there are neurological evidences of what one might call "physiological" unconsciousness. The eyes roll independently, the pupils fail to react to light. On the other hand, there are definite symptoms characteristic of the functional state. Mental activity is evidenced by a muscular resistiveness or retention of urine. Even in states of complete relaxation the eyes move in unison, the pupils react to light, and almost universally the corneal reflex is present. The patient appears in a deep sleep rather than actually unconscious.

The post-epileptic sleep may resemble a stupor strongly. But this condition is temporary and the situation and appearance of the patient betrays the fact that he has just had a convulsion. Rarely, protracted stuporous states occur in epilepsy which closely resemble the conditions described in this book. In fact it is probable the true stupors may occur in epilepsy just as in dementia præcox or manic-depressive insanity.

There is usually little difficulty in the discrimination of hysterical stupor. Occasionally it shows, superficially, a similarity to the manic-depressive type. Fundamentally, there is a wide divergence between the two processes, in that in the hysterical form a dissociation of consciousness takes place, the patient living in a reminiscent, imaginary or artificially suggested environment, while in a true stupor there is a withdrawal of interest as a whole and a consequent diffuse reduction of all mental processes. This difference is sooner or later manifested by the appearance in the hysteric of conduct or speech embodying definite and elaborated ideas.

As has been stated fully in the last chapter (to which the reader is referred), the stupor of dementia præcox is to be differentiated from that of manic-depressive insanity by the inconsistency of the symptoms in the former and the appearance of dementia præcox features during the stupor, such as inappropriate affect, giggling, or scattering. Further, the nature of the disorder is usually manifest before the onset of the stupor as such.

Sometimes very puzzling cases occur in more advanced years when it is difficult to say whether one is dealing with involution melancholia or stupor. Such patients show inactivity, considerable apathy and wetting and soiling, and with these a whining hypochondria, negativism, and often a rather mawkish sentimental death content without the dramatic anxiety which usually characterizes the involution state. In these cases the diagnosis is bound to be a matter of taste. In our opinion it is probably better to regard these as clinically impure types. They may be looked on as, fundamentally, involution melancholias (the course of the disease is protracted, if not chronic) in whom the regressive process characteristic of stupor is present as well as that of involution.

Great difficulties are also met with in the manic-depressive group proper. 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. Let us consider these three groups separately.

The most important difference between stupor and depression lies in the affect. Although inactive and sometimes appearing dull the depressive individual is not apathetic but is suffering acutely. He feels himself wicked, paralyzed by hopelessness, and finds proof of his damnation in the apparent change of the world to his eyes and in the slowness of his mind. But he is acutely aware of these torments. The stupor patient, on the other hand, does not care. He is neither sad nor happy nor anxious. This contrast is revealed not only by the patients' utterances but by their expressions. The stuporous face is empty, that of the other lined with melancholy. The intellectual defect, too, is different. In retarded depression the patient is morbidly aware of difficulty and slowness, but on urging often performs tests surprisingly well. In the stupor, however, one is faced with an unquestionable defect, a sheer intellectual incapacity.

In Chapter VIII the differential diagnosis between perplexity and stupor has already been touched upon. Here again the affect is a point of contrast. The patient has not too little emotion but too much. The feeling of intangible, puzzling ideas and of an insecure environment causes the subject distress, of which complaint is made and which can be witnessed in the furrowed brow and constrained expression. There is also, as we have seen, a rich ideational content in these cases, if one can get at it. The mind is not a blank, as in the stupor, or concerned only with delusions of death.

Finally, there are the absorbed manic states. These are the most difficult, inasmuch as the patient is often so withdrawn and so introverted that at any given interview there may be no objective evidence of mood or ideas. Here the development of the psychosis is often an aid to diagnosis. The patient passes through phases of hypomania to great exultation, the flight becomes less intelligible, with this the activity diminishes until finally expression in any form disappears. If this sequence has not been observed, continued observation tells the tale. The patient still has his ideas and may be seen smiling contentedly over them (not vacuously as does the schizophrenic) or he may break into some prank or begin to sing. Any protracted familiarity with the case leads to a conviction that the patient's mind is not a blank, but that his attention is merely directed exclusively inward. Then, too, when his ideas are discovered, it is found that they are not exclusively occupied with the topic of death.

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. It is important for mental recovery that the individual in stupor should be stimulated to effort as much as possible. Consequently there is an economy of time in the long run in taking pains to get the patient to feed himself in so far as that is possible. He should be led to the table and assisted in handling his own spoon and cup. If this is not practicable, he should then be spoon-fed, and if this in turn is found to be out of the question, tube-feeding should be resorted to. But this last should never be looked on as a permanent necessity, but only as a method of maintaining the patient's health until such time as he may be capable of independent taking of nourishment. In exactly the same way it is of prime importance to get the patient to attend to the natural habits of excretion. He should be led to the toilet or to a chair commode, and efforts to this end should be persistent, just as are those of a good child's nurse who has the ambition of making her charge develop normal habits. Naturally those who retain urine and feces should be watched to see that this retention does not last long enough to menace health. The physical aspects of treatment are exhausted with consideration for cleanliness. On account of the stupor patients' inactivity and frequent tendency to wetting and soiling, this is a particularly important consideration. It goes without saying that the perineal region should be kept scrupulously clean. If any infections are to be avoided, eyes, nose and mouth should also be cleansed frequently. A patient who is so indifferent as to keep the eyelids open for such a long time that the sclera dry and ulcerate is also apt to let flies settle and produce serious ophthalmic disease.

Less obvious and more important are the measures undertaken for the mental hygiene of the case. On account of the tendency present in so many patients for sudden action while in the midst of an apparently deep and permanent inactivity, it is necessary that these cases be not isolated but remain under constant observation. This is particularly true of those who have demonstrated impulsive suicidal explosions.

Not only on the basis of the psychological theory of the stupor process, but from the observed phenomena of recovery, we gather that mental stimulation is of first importance if an amelioration of the condition is to be attempted. If the stupor reaction be a regression, which is essentially a withdrawal of interest and energy rather than a fixation on a false object, then excitement is desirable and interest must be reawakened. The withdrawal is temporary (inasmuch as the psychosis is benign), but just as a normal person wakes more readily on a clear sunshiny day than when it rains, so the more cheering the environment the more rapid the recovery.

Consequently, although trying to those in charge, persistent attention should be given the patient. Feeding and hygienic measures probably have considerable value in this work. As soon as it is at all possible the patients should be got out of bed and dressed. When up, efforts should be directed towards making them do something, even if it be something as simple as pushing a floor polisher. On account of their lack of enthusiasm the stupor cases are often omitted from the list of those given occupation and amusement. Even if they go through the motions of work or play with no sign of interest, such exercise should not be allowed to lapse. Then, too, the environment should be changed when practicable. A patient may improve on being moved to another building.

Perhaps the most potent stimulus that we have observed is that of family visits. In most manic-depressive psychoses visits of relations have a bad effect. The patients become excited, treat the visitors rudely, perhaps even assault them, and all their symptoms are aggravated. But the stupor needs excitement, and an habitual emotional interest is more apt to arouse him than an artificial one. In another point the situation differs. As a rule manic-depressive patients have delusional ideas or attitudes in connection with their nearest of kin, so that contact with these stirs up the trouble. The stupor regression going beneath the level of such attachments leaves family relationships relatively undisturbed. Hence, while the visit of a husband is likely to produce nothing but vituperation or blows from a manic wife, the stuporous woman may greet him affectionately and regain thereby some contact with the world.

So many cases begin recovery in this manner that it cannot be mere chance. One patient's improvement, for instance, dated definitely from the day a nurse persuaded her to write a letter home. It is striking, too, how quickly a patient, while somewhat dull and slow, will brighten up when allowed to return home. A similar improvement under these circumstances is often seen in partially recovered cases of involution melancholia, in whom a psychological regression similar to that of stupor takes place. Such experiences make one wonder whether perhaps these alone of all our insane patients would not recover more quickly at home than in hospitals, provided nursing care could be given them.

This is a mere suggestion. Before treatment can be rational the nature of any disease process must be known, and we do not pretend to have done more as yet than outline the probable mental pathology of the benign stupors. The next step is to put theory into practice and experiment widely with various means to see if by appropriate stimulation the average duration of these psychoses cannot be reduced. It is largely with the hope of inducing other psychiatrists to carry on such work that this book is written. There is no other manic-depressive psychosis which, theoretically, offers such hope of simple psychological measures being of therapeutic value.

Having discussed in detail the various symptoms and theoretic aspects of the benign stupors, it may be well to have these observations and speculations summarized.

It being established that stupors occur as a temporary form of insanity[12] psychiatry is faced at once with the problem of describing these conditions accurately in order to ascertain their nosological position. 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. As a rule there is a complete cessation of both spontaneous and reactive movements and speech. So profound may this inhibition be that swallowing and blinking of the eyes are often absent. The trouble is not a paralysis, however, for reflexes without psychic components are unaffected. Possibly related to the inactivity is the preservation of artificial positions which is called catalepsy, a fairly frequent phenomenon. A tendency opposite to the inactivity is seen in negativism. This perversity is present in all gradations from outbursts of anger with blows and vituperation to sullen, or even emotionless, muscular rigidity. This last occurs most often when the patient is approached but may be seen when observations are made at a distance. Frequently wetting and soiling are due to negativism, when the patient has been led to the toilet but relaxes the sphincters so soon as he leaves it. A constant feature is a thinking disorder. On recovery memory is largely a blank even for striking experiences during the psychosis and, when accessible during the stupor to any questioning, a failure of intellectual functions is apparent. An ideational content may be gathered while the stupor is incubating, during interruptions, or from the recollections of recovered patients. Its peculiarity is a preoccupation with the theme of death, which is not merely a dominant topic but, often, an exclusive interest. Probably to be related to this is a tendency, present in some cases, to sudden suicidal impulses, that are as apparently planless and unexpected as the conduct of many catatonics. Finally the disease is prone to exhibit certain physical peculiarities. A low fever is common and so are skin and circulatory anomalies. A loss of weight is the rule, and menstruation is almost always suppressed.

As to the frequency of stupor no figures are available, for the simple reason that the diagnosis in large clinics has not been made with sufficient accuracy to justify any statistics. Most of these cases are usually called catatonia, depression, allied to manic-depressive insanity or allied to dementia præcox. The majority of the stupors reported in this book were in women, but this is merely the result of chance, since it has been easier in the Psychiatric Institute to study functional psychoses in the female division, while the male ward has been reserved largely for organic psychoses. The majority of the patients seem to be between 15 and 25 years of age, so that it is, presumably, a reaction of youthful years. In our experience most cases occur among the lower classes, which agrees with the opinion of Wilmanns who found this tendency among prisoners.

This gives a brief description of the deep stupor. But even our typical cases did not present this picture during the entire psychosis. They showed phases when, superficially viewed, they were not in stupor but suffered from the above symptoms as tendencies rather than states. There are also many psychoses where complete stupor is never developed. This gives us our justification for speaking of the stupor reaction, which consists of these symptoms (or most of them) no matter in how slight a degree they may be present. The analogy to mania and hypomania is compelling. The latter is merely a dilution of the former. Both are forms of the manic reaction. We consequently regard stupor and partial stupor as different degrees of the same psychotic process which we term the stupor reaction. To understand it the symptoms should be separately analyzed and then correlated.

The most fundamental characteristic of the stupor symptoms is the change in affect which can be summed up in one word—apathy. It is fundamental because it seems as if the symptoms built around apathy constitute the stupor reaction. The emotional poverty is evidenced by a lack of feeling, loss of energy and an absence of the normal urge of living. This is quite different from the emotional blocking of the retarded depression, for in the latter the patient shows either by speech or facial expression a definite suffering. The tendency to reduction of affect produces two effects on such emotions as internal ideas or environmental events may stimulate. Exhibitions of emotion are either reduced or dissociated. For instance, anxiety is frequently diminished to an expression of dazed bewilderment; or, isolated and partial exhibitions of mood occur, as when laughter, tears or blushing are seen as quite isolated symptoms. This latter—the dissociation of affect—seems to occur only in stupor and dementia præcox. It should be noted, however, that inappropriateness of affect is never observed in a true benign stupor. A final peculiarity is the tendency to interruption of the apathetic habit, when the patient may return to life, as it were, for a few moments and then relapse.

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.

By far the commonest cause of emotional expression or interruption in the inactivity is negativism. This is a perversity of behavior which seems to express antagonism to the environment or to the wishes of those about the patient. In the partial stupors it is seen as active opposition and cantankerousness. In the more profound conditions it is represented by muscular resistiveness or rigidity, or refusal to swallow food when placed in the mouth. Occasionally, too, the patient may even in a deep stupor retain urine so long that catheterization is necessary. All the explanations which one may gather from the patients' own utterances, mainly retrospective, seem to point to negativism expressing a desire to be left alone. The appearance of perverse behavior in aimless striking or mere muscular rigidity seems to be an example of dissociation of affect.

Catalepsy is an important symptom because, although it occurred in slightly less than a third of our cases, it seems to be a peculiarity of the stupor reaction found but rarely in other benign psychoses. It seems never to occur without there being some evidence of mental activity, and, consequently, we are forced to conclude that it is of mental rather than of physical origin. Just what it means psychically it is impossible to state without much more extended observations. We conjecture tentatively, however, that the retention of fixed positions is in part merely a phenomenon of perseveration, and in part an acceptance of what the patient takes to be a command from the examiner, and sometimes a distorted form of muscular resistiveness.

The intellectual processes suffer more seriously in stupor than in any other form of manic-depressive insanity. Not only do the deep stupors betray no evidence of mentation during the acme of the psychosis, but retrospectively they usually speak of their minds being a blank. Incompleteness and slowness of intellectual operations are highly characteristic features of the partial stupors and of the incubation period of the more profound reactions. The features of this defect are a difficulty in grasping the nature of the environment, a slowness in elaborating what impressions are received, with resulting disorientation, poor performance of any set tests and incomplete memory for external events when recovery has taken place. At times the thinking disorder may develop with great suddenness or improve as quickly, and a tendency to isolated evidences of mental acuity is another example of the inconsistency which is so highly characteristic of stupor. We should note, however, that these sporadic exhibitions of mentality are always associated with brief emotional awakening.

When we turn to examine the fragmentary utterances of stupor patients, we are surprised by the narrowness and uniformity of the ideational content. It seems to be confined to thoughts of death or closely related conceptions. Thirty-five out of thirty-six consecutive cases at one time or another referred literally to death. It is commonest during the onset, as all but five of these patients spoke of it during the incubation of their psychoses. Hence we conclude that death ideas and stupor are consecutive phenomena in the same fundamental process. As two-thirds of the series interrupted the stupor to speak of death or to attempt suicide, we assume that this relationship persists. Only a quarter gave any retrospective account of these fancies, so we presume that their psychotic experiences were repressed with recovery.

The usual form in which the idea appears is as a delusion of going to die or, literally, of being dead. It may appear as being in Heaven or Hell. A theoretically important group is that which includes the patients who, in addition, speak of being in situations such as under the water or underground, which we have mythological and psychological evidence to believe are formulations of a rebirth fantasy. Not rarely, preoccupation with death is expressed in sudden impulsive suicidal attempts.

The affective setting of these different formulations is important. A delusion of literal death occurs with complete apathy. The wish to die is apt to appear without the usual accompaniment of sadness or distress but still with considerable energy when impulsive suicidal attempts are made. A prospect of death, particularly when there is anticipation of being killed, is apt in manic-depressive insanity to occur in a setting of anxiety. Similarly one ordinarily observes fear in the patient who has delusions of drowning or burial. In the stupor cases, however, this painful affect seems to be reduced to a mere dazed bewilderment or feeble exhibitions of a desire for safety, such as the slow swimming movements of a patient who thought she was under the water. When these ideas of danger become allied to everyday interests—husband or child imperiled, etc.—a weak affect in the form of depression is apt to occur.

Physical symptoms are more common than in any other benign psychosis. Of these the most nearly constant is a low fever, the temperature running between 99° and 101°. Twenty-eight out of thirty-five cases had this slight elevation with a tendency for it to occur immediately at the beginning of marked stupor symptoms. Although the evidence does not positively exclude any possibility of infection, it speaks distinctly against this view. A possible explanation is that the low fever is a secondary symptom. The suprarenal glands may function insufficiently as a consequence of the emotional poverty, since all emotions which have been experimentally studied seem to stimulate the production of adrenalin. Without this normal hormone for the activity of the sympathetic nervous system, there would be a disturbance of skin and circulatory reactions that would interfere with the normal heat loss. Suggestive evidence to support this view comes from the frequency with which the extremities are cyanotic or cold, the skin greasy, sweating profuse or absent, and so on. Further observations are necessary to confirm or disprove this hypothesis, but we feel inclined to accept it tentatively because it is plausible and consistent with the view that stupor is essentially a psychogenic type of reaction. Another physical anomaly, which is presumably of endocrine origin, is the suppression of the menses. This probably results from lowered nutrition. In some cases it ensues directly on a psychic crisis before any nutritional change can have taken place. Finally, among the symptoms of possible physical origin, epileptoid attacks were described in two of our cases. This is chiefly of interest in that such phenomena are extremely rare in the benign psychoses.

We believe that the mental symptoms summarized above constitute a specific psychotic type of reaction capable of appearing in any severity from mere lethargy and indifference to profound stupor. Since the prognosis is good, we feel obliged to classify this with the manic-depressive reactions. Further justification for this grouping is found in the occurrence of the stupor reaction as a phase in many manic-depressive psychoses. A patient may swing from mania to stupor as from mania to depression, and when the partial stupors are recognized as milder forms of the same process, it seems to be a frequent type of reaction.

If stupor be a reaction type, its laws must be psychological. According to the view of modern psychopathology, the essence of insanity is regression with indolent thinking as opposed to progressive and energetic mentation. One can look on stupor as being a profound regression. Effort is abandoned (apathy and inactivity), while the ideational content expresses a desire for a retreat from the world in death. It is possible to think of this regression as a return to the mental habit of the suckling period, when spontaneous effort is at its minimum. This, too, is the time when petulance and tantrums are frequent expression of a wish to be left alone, which may account for the negativism as a consistent symptom of the same regressive progress.

Just as we regress in sleep, to rise refreshed for a new day's duties, so the stupor case often shows excessive energy in a hypomanic phase before complete normality is reached. This corresponds again to the age-old association of the ideas of death and rebirth which we see together so frequently in stupor. It is the psychology of wiping the slate clean for a fresh start.

The development and symptoms of stupor furnish evidence in support of the hypothesis of this type of regression. Dissatisfaction of any kind is the setting in which the psychosis begins and the commonest precipitating factor is some reminder of death. That loss of energy appears with the stupor is evident from the inactivity and apathy, while the thinking disorder can be shown to be the result of the same loss. The different "levels" of the stupor reaction also conform to a theory of regression. First there is mere indifference and quietness; then appear false ideas when normality is so far abandoned as to mean a loss of the sense of reality; withdrawal of interest from the environment, with its consequent centering of self, leads to the next stage—that of the spoiled child reaction; then follows the exclusion of the world around in the dramatization of death; finally, in the deepest stupor, mentation is so far abandoned that we can gather no evidence of even this delusion being present.

Atypical features in stupor have to do mainly with interruptions, interludes as it were, of elation, anxiety or perplexity. These are explicable as awakenings from the nothingness of stupor into imaginations such as characterize the other manic-depressive psychoses. When such tendencies are present, the co-existence of the stupor process may tone down the emotional response or prevent its complete repression so that insufficient or dissociated affects appear. A combination of the stupor tendency to apathy with the mood of another reaction is probably the only combination of affects to be met with in psychiatry.

The stupor reaction, then, is a simple regression, with a limitation of energy, emotion and ideational content, the last being confined to notions of death. All functional psychoses are regressions. How do the others differ from this? We need only answer this question in so far as it concerns the clinical states resembling benign stupors. Stupors occur frequently in catatonic dementia præcox. In this disease there is a regression of interest to primitive fantastic thoughts, and with this a perversion of energy and emotion. This corrupts the purity of the stupor picture so that inconsistencies, such as empty giggling, atypical delusions and scattered speech, occur. Other impurities are to be found in the frequent orientation of the dementia præcox stupor patient which is discovered to be astonishingly good, or in free speech associated with apathy and inactivity. Such symptoms usually appear quite early and should enable one to make a positive diagnosis within a short time after patient comes under observation. As a matter of fact, in many if not most cases there is a slow onset characterized by the pathognomonic symptoms of dementia præcox before the actual stupor sets in.

Other psychoses superficially resembling stupor are the perplexity and absorbed manic (manic stupor) states. We have reason to believe that both these conditions are essentially the result of absorption in kaleidoscopic ideas. Their appearance is that of inactivity and indifference to the outside world, just as a dreamer seems placid and apathetic. But these reactions are not without emotion which may sometimes be obvious, and the richness of the mental content is sooner or later manifest.

Finally, from a practical standpoint, an important peculiarity of benign stupor is the tendency for response to stimulation in amelioration of the process. Close attention to these patients is advisable, therefore, not merely for the sake of their physical health, but also because any attention tends to keep them mentally alive or revive their waning energy. Visits of relations often initiate recovery in a striking way. From occurrences such as these, psychiatrists should gain hints for valuable therapeutic experiments.

So much for the technical, psychiatric aspects of the stupor problem. We have frequently spoken of it, however, as a psychobiological reaction. If this be a sound view, similar tendencies should appear in everyday life, the psychotic phenomena being merely the exaggerations of a fundamental type of human and animal behavior. Shamming of death in the face of danger and animal catalepsy come to mind at once, but since we know nothing of the associated affective states we should be chary of using them even as analogies. We are on safer ground in discussing problems of human psychology.

It is evident that there are psychological parallels between the stupor reaction and sleep, while future work may show physiological similarities as well. Apathy towards the environment, inactivity and a thinking disorder are common to both. But sleep reactions do not occur in bed alone. Weariness produces indifference, physical sluggishness, inattention and a mild thinking disorder such as are seen in partial stupors. The phenomena of the midday nap are strikingly like those of stupor. The individual who enjoys this faculty has a facility for retiring from the world psychologically and as a result of this psychic release is capable of renewed activity (analogous to post-stuporous hypomania) that cannot be the result of physiological repair, since the whole affair may last for only a few minutes.

In everyday life there are more protracted states where the comparison can also be made. When life fails to yield us what we want, we tend to become bored—a condition of apathy and inactivity, forming a nice parallel to stupor inasmuch as external reminders of reality and demands for activity are apt to call out irritability. A form of what is really mental disease, although not called insanity, is permanent boredom, a deterioration of interest, energy and even intelligence by which many troubled souls solve their problems. A sudden withdrawal from the world we call stupor. When the same thing happens insidiously, the condition is labeled according to the financial and social status of the victim. He is a bum, a loafer, a mendicant or, more politely, a disillusioned recluse. Frequently this undiagnosed dement has satisfied himself with a weak, cynical philosophy that life is not worth while.

It is but a step from valueless life to death and the same tendency which makes the patient fancy he is dead, leads the tired man to sleep, the poet to sigh in verse for dissolution, and the myth maker to fabricate rebirth. The religions of the world are full of this yearning, which reaches its purest expression in the belief and philosophy of Nirvana. The ideational content of stupor has also its analogue in crime. The desire for perpetuation of relationships unprosperous in this world is not seen only in the delusion of mutual death. One can hardly pick up a newspaper without reading of some unhappy man or woman who has slain a disillusioned lover and then committed suicide.

The cases of benign stupor which we report here are not clinical curiosities. Taking the symptoms as the products of a reaction type, the latter is really quite common. One, therefore, asks what other psychiatrists have done with this material. How have they described these stupors, how classified them? This chapter, essentially an appendix, attempts to give a brief answer to this inquiry. No attempt is made to catalogue all that has been written on or around this subject but only to mention typical reports and viewpoints.

The French, beginning with Pinel in the 18th Century, were the first to write extensively of stupor. An excellent paper by Dagonet[13] appeared in 1872, in which such literature as had appeared up to that time is discussed. He defines "Stupidity" as a form of insanity in which "delirious" ideas may or may not be present, which has for its characteristic symptoms a state of more or less manifest stupor and a greater or less incapacity to coördinate ideas, to elaborate sensations experienced and accomplish voluntary acts necessary for adaptation. This would seem to include our "partial stupor," as well as the more marked cases.

He quotes an excellent definition from Louyer Villermay (Dict. des sc. méd. t. LIII, p. 67). "Stupor is a term applied to stupefaction of the brain. It is recognizable by the diminution or enfeeblement of internal sensation and by a greater difficulty in exercising memory, judgment and imagination. It is accompanied by a general numbness and a weakness of feeling and movement. The patient, then, has an indefinite and stupid expression, he understands questions put to him with difficulty, and answers them with effort or not at all. He seems overwhelmed with sleep, he forgets to withdraw his tongue after showing it to the doctor, he complains of no uncomfortable sensation, of no illness, he seems to take no interest in what goes on about him.... The stupor patient is a fool who does not speak, in this being more tolerable than the one who speaks [delightful naiveté!]. One who is dumbfounded by surprise or fright is also to be called stuporous."

Dagonet says stupor results from various causes, such as exhaustion, or emotional and intellectual factors. Clinically it varies in kind and degree according to the situation in which it develops. When it develops during normal mental health, it disappears when its cause does. In insanity it appears in the course of a psychosis of some duration, of which it seems a part, an exaggeration of some symptom of the general condition. Evidently he views stupor as a type of reaction: as a more or less complete suspension of the operation of intellectual faculties, a more or less sudden subtraction of nervous forces. This reaction can result from a fright or the memory of it, a brain lesion or trauma, the action of narcotics, exhausting fevers, excessive grief, the terrors of alcoholic hallucinations, epileptic seizures, profound anemia and nervous exhaustion consequent on sexual excess. He is careful to say that both symptoms and treatment vary with the varied etiologies.

He credits Pinel with being the first to call attention to stupor. This author claimed that some persons with extreme sensibility could be so upset by any violent emotion as to have their faculties suspended or obliterated. He noted, too, that stupors frequently terminated in manic phases of 20 to 30 days' duration. Pinel also emphasized the apathy of these cases. Esquirol called stupor "acute dementia," a term which persisted in French literature for a long time. He described an interesting circular case where alternations between mania and typical stupor took place. He mentions too the dangerous, impulsive tendencies of many patients. Georget emphasized the fact which Pinel had also noted, that retrospectively the stupor patient says his mind was a blank during the attack. In 1835 Etoc-Demazy published on the subject. He regarded stupor not as a separate form of insanity but a complication ensuing on monomania or mania. He recognized the partial as well as complete stupor. He thought the condition was due to cerebral edema, as did other writers of that period. Dagonet remarks about this last—a lesson not learned in fifty years by the profession—that demonstrable edema does not produce the typical symptoms of stupor. Baillarger in 1843 (Annales Médico-psychologiques) was the first whose ambition to simplify psychiatric types led to denial of a separate kind of reaction. He claimed that stupor was not a form of insanity but an extension of a "délire mélancholique." As Dagonet remarks, every symptom by which he characterizes stupor is a psychiatric symptom and insanity can consist just as well in the diminution as the perversion or exaltation of normal faculties. Some of Baillarger's cases had false ideas, some apparently none at all. Dagonet thinks this justifies two types, one a dream-like state and another where no ideas are present, although he admits one may be an exaggeration of the other. Brierre de Boismont (Annales Médico-psychologique, 1851, p. 442) compares these two kinds of stupors to deep sleep when intelligence is completely suspended and to sleep with dreams. (These two types would correspond to our "absorbed mania" and true deep stupor.) He urges strongly the separation of stupor from melancholia as an entirely different type of reaction, in this connection citing the views pro and con of various authors. Of these Delasiauve is particularly cogent in discriminating stupor from melancholia on the grounds of the difference of the emotional reactions and of the intellectual disorder and the real paucity of thought in the former psychosis.

After quoting these and other authors, Dagonet offers an explanation for the diversity of opinion. He says that stupor following another psychosis may retain some of its symptoms, so that a mixture obtains, as often in medicine. He then gives excellent descriptions of three types: the deep stupor with paralysis of the faculties, the cases that are absorbed in false ideas, and ecstatic cataleptics.

The remainder of his paper is concerned with cases and discussions about them. He cites examples of stupor following fear or other emotional shocks, following grave injuries such as the loss of a limb, following head trauma and with typhoid fever. As to the last he points out that delirious features are prominent. Many authors have assigned sexual excesses as a cause of stupor. The psychosis, Dagonet says, is not pure but more a mixture of hypochondria and depression. Relationship with mania is next considered. He says that stupor may succeed, alternate with or precede mania. His cases seem mainly to have been what we call absorbed manics or manic stupors. In fact, he uses the last term. The commonest introductory psychosis, he claims, is depression, but from his brief case reports it would seem that most of his patients were not stuporous, in the narrow sense of the term, but severely retarded depressions. In fact, in perusing his case material comprising "stupors" in the course of many types of functional insanity, or as a complication of epilepsy or general paralysis, it is evident that in practice he does not follow the discriminative definitions of the earlier portion of his paper. For him, apparently, patients who are markedly inaccessible to examination from whatever cause are "stuporous." He closes with excellent remarks on physical and psychic treatment. As to prognosis he has nothing to say beyond the opinion that most of the cases recover.

If Dagonet be accepted as summarizing the early French work, we can conclude that their generalizations were on the whole quite sound. These were: that stupor is an abnormal mental reaction, usually psychogenic but often the result of exhaustion, that it consists in a paralysis of emotion, will and intelligence; that the prognosis is usually good; that mental stimulation may produce recovery. What remained to be done after this work was the refinement in detail of these generalizations, particularly in respect to the differentiation of prognostically benign and malignant types. But other Frenchmen did not take up this work, apparently, for the brilliant psychopathologists of the next generations attended to stupor only in so far as it was hysterical.

An Englishman, however, soon took up the task, adding more exactness to his formulations. Newington[14] published his important paper in 1874. A nascent stage of stupor, he thinks, is a common reaction to great exhaustion, "such as hard mental work, prolonged or acute illness, dissipation, etc." Such conditions, like the grave psychotic forms, he regarded as due to physical exhaustion of the brain cells, but, since he thought psychic stress could produce this exhaustion, this "organic" view did not bias his general formulations. He makes a division into two stupors: Anergic Stupor and Delusional Stupor. The former may be primary, being generally caused by a sudden intense shock (Esquirol's "Acute Dementia"), or secondary (a) to convulsions of any kind, (b) to mania in women, (c) to any other prolonged nervous exhaustion. The delusional form results from (a) intense melancholia, (b) from general paralysis in which it may be intercurrent, (c) from epileptic seizures. When one examines his points of difference between these two types, it becomes clear that Newington really gave an excellent differentiation of benign and malignant stupor—in fact, it is the only serious attempt at such discrimination prior to this present work. What is more remarkable is the fact that, although he clearly saw the clinical differences, he failed to see that the two types differed prognostically. His description is given in a table sufficiently concise to justify its quotation in extenso.

	ANERGIC STUPOR	DELUSIONAL STUPOR
Etiology—	Hereditary and individual liability to sudden loss of vis nervosa.	Hereditary.
Onset—	Rapid.	Usually insidious, may be almost instantaneous.
Symptoms—	Intellect greatly impaired.	Conduct shows reasoning power.
Memory—	Seems to be swept away as far as possible.	Found after recovery to have been preserved to a great extent.
Emotional Capacity—	Nil or almost so. Tears frequent but due to relaxation of sphincter muscles. Features relaxed, eyes vacant and not constantly fixed.	Evidence of grief, fear, etc., in facial expressions and wringing and clasping of hands. Tears rare. Great contraction of features [grimacing?]. Eyes fixed on one point, usually upwards or downwards, or else obstinately closed.
Volition—	Almost absent.	Frequently great stubbornness, refusal to do what is wanted. On the other hand, intense determination in following out own plan.
Motor System—	Weak and uncertain. Patient has to be led about and if placed on a seat or in some position does not move. ("Cataleptoid" condition.)	But little interfered with, independently of sheer asthenia, produced by patient's conduct. May stand behind door or kneel on floor in constrained position even for days.
Sensory System Reflex System—	} Both dull.	Ditto. There seems to be a much greater ability to bear severe pain.
Pupils—	Dilated.	Tendency to contraction.
Sleep—	Generally good.	Intense sleeplessness.
General bodily condition—	Emaciation, sometimes extreme, usually rapid, with rapid recovery of flesh. Often not much loss of weight, though whole tone is lowered.	Affected pari passu with mental state and seems governed by it.
Vascular System—	Pulse slow, sometimes almost imperceptible. Cyanotic appearance, edema and iciness of extremities. Great decrease of vitality in peripheral structures, as shown by asthenic eruptions and production of vermin.	Pulse weak and often quick and thready. Complexion anemic and sallow. The other appearances may be present but come on later and are less marked.
Digestive System—	Tongue clean or if furred it is moist. Appetite apathetic, bowels not irregular, but habits very dirty.	Tongue dry, small and furred. Refusal of food. Great constipation. Dirtiness of habits rare.

If one compares these data with those given in the chapter on Malignant Stupors, it is seen that in the main Newington has made the same discrimination as we have. He is certainly wrong in denying "negativism" to his anergic type. Probably, too, he attempts too fine a distinction between the physical symptoms of the two groups. His conclusions are interesting: that in the anergic cases there is an absence of cerebration, while amongst the delusional there is an abnormal presence of intense but perverted cerebration. This is not unlike our own view. He thinks the difference in memory is the most important differential point. Sex is important in determining the nature of the stupor, for he found the anergic type following mania in females only. He observed such an end to manic attacks in 6 out of 36 cases. All his cases were under 30 and he regards the prognosis as good on the whole. As to treatment he emphasizes the necessity for "moral pressure" as a stimulus and cites a case of rapid improvement after a change of scene.

Since 1874 very little advance has been made by British psychiatrists, as seen by a perusal of Clouston's[15] summary in 1904. He regards sex exhaustion as a highly frequent cause, although Dagonet had shown 32 years before that sex abuse does not produce a true stupor. He thinks stupor usually follows depression or mania and says that "the 'Confusional Insanity' of German and American authors is just a lesser degree of stupor." Omitting his stupors in general paralysis and epilepsy he makes three clinical divisions: melancholic or conscious stupor, which is not a product of delusions, although delusions of death or great wickedness may be present, impulsiveness and fits may be observed; anergic or unconscious stupor, which corresponds roughly to our deep, benign stupor; and secondary stupor after acute mental disease, which resembles our partial stupor. He warns against a rash diagnosis of dementia in this last group. His views on the importance of mental causation and the relation to manic-depressive insanity may be gathered from these sentences: "The condition of the mental portion of the convolutions in stupor is probably analogous to the stupidity of a nervous child when terrified or bullied." "Stupor is frequently one of the stages of alternating insanity following the exalted condition. It is more apt to occur in those where the exalted period is acutely maniacal. The stupor is usually melancholic in form." Since he claims that the anergic is a "very curable form of mental disease," while only 50% of the melancholic cases recover, it seems clear that this division is not prognostically final. The "melancholic" is evidently Newington's "delusional" without his more accurate discrimination of symptoms.

From the standpoint of accurate description the opinion may be ventured that there is a gap in the literature from the early French writers and Newington up to the paper by Kirby, which has been discussed in the first chapter. This gap is filled by literature of the German schools and their adherents in other countries. German psychiatry has been concerned mainly with classification or the elaborate examination of certain symptoms. Inevitably such a program militates against detached objective clinical description. It is hard to record symptoms that interfere with classification. German psychiatry has tended to make the insane patient a type rather than an individual. Hence the gap in the descriptive literature of stupor.

The necessity of establishing the possibility of some stupors having a good prognosis has arisen from Kraepelin's work. He can rightly be viewed as the father of modern psychiatry because he introduced a classification based on syndromes and taught us to recognize these disease groups in their early stages. Inevitably with such an ambitious scheme as the pigeon-holing of all psychotic phenomena some mistakes were made. Most of these appear in the border zone between dementia præcox and manic-depressive insanity. The latter group being narrowly defined, the former had to be a waste basket containing whatever did not seem to be a purely emotional reaction. Clinical experience soon proved that many cases which, according to Kraepelin's formulæ, were in the dementia præcox group, recovered. Adolf Meyer was one of the first to protest and offered categories of "Allied to Manic-Depressive Insanity" or "Allied to Dementia Præcox," as tentative diagnostic classifications to include the doubtful cases.

Difficulties with stupor furnish an excellent example of the confusion which results from the adoption of rigid terminology. The earlier psychiatrists were free to regard a patient in stupor as capable of recovery as well as deterioration. When Kahlbaum included stupor with "Catatonia," the situation was not changed, for he did not claim a hopeless prognosis for this group. But when Kraepelin made catatonia a subdivision of dementia præcox, all stupors (except obvious phases of manic-depressive insanity) had to be hysterical or malignant. Faced with this dilemma psychiatrists have either called recoveries "remissions" or, like E. Meyer, claimed that one-fifth or one-fourth of catatonics really get well.

As a matter of fact it seems clear that stupor is a psychobiological reaction that can occur in settings of quite varied clinical conditions. It is not necessary to detail publications describing stupors in hysteria, epilepsy, dementia præcox or in the organic psychoses. It may be of interest, however, to cite some examples of acute, benign stupors and the discussion of them which appear in the literature of recent years.

An important group is that of stupors occurring as prison psychoses. Stern[16] mentions that acute stupors are found in this group. Wilmanns[17] examined the records for five years in a prison and discovered that there were two forms of psychotic reaction, a paranoid and a stupor type. It is interesting psychologically that the former appeared largely among prisoners in solitary confinement, while the stupors developed preponderantly among those who were not isolated. The stupors recovered more quickly. He describes the psychosis thus: The prisoner becomes rather suddenly excited, destructive and assaultive; then soon passes into an inactive state, where he lies in bed, mute, with open expressionless eyes. He is clean, however; eats spontaneously and attends to his own hygienic needs. Some cases are roused by transport from the jail to the hospital but sink into lethargy again when they reach their beds. Physically, they show disturbances of sensation which vary from analgesia to hypesthesia. There are a rapid pulse, positive Romberg sign, exaggerated reflexes, fibrillary twitching of the tongue and tremor of the hands. Recovery takes place gradually. They begin to react to physical stimuli and to answer questions, although still inhibited, until consciousness is quite clear. When speech begins, it is found that they are usually disoriented for place and time as the result of an amnesia which sets in sharply with the excitement. This memory defect gradually improves pari passu with the other symptoms.

Two attacks in the same prisoner of what seem to have been typical stupor are reported by Kutner[18] and Chotzen.[19] The patient was a recidivist of unstable mental make-up. At the age of 34 he was sent to prison for three years. Shortly after confinement began, he became stuporous, being mute and negativistic, soiling, refusing food and showing stereotypy. On being shifted to another institution he appeared suddenly much better, although he remained apathetic and dull for some months. A striking feature was a complete amnesia, not merely for the stupor but also for his trial and entrance to the prison. At the age of 42, he was again incarcerated. A practically identical picture again developed, with recovery when his environment was changed, and with a similar amnesia. Recovery seemed to be complete and there were no hysterical stigmata. The interesting features of this case are that a typical stupor seems to have been precipitated by imprisonment, while the retroactive amnesia covering a painful period of the patient's life reminds one of hysteria.

A case which is more difficult to interpret is reported briefly by Seelig.[20] A man of 20 with bad inheritance tried to steal 100 marks. When sent to jail he became ill shortly before his trial was due and was sent to a hospital. There he seemed anxious, was shy, and gave slow answers, with initial lip motions and had to be urged to take hold of objects. All this sounds more like a pure depression than a stupor. But he also had paralogia. This might make one think of a Ganser reaction on the background of depression. S., however, calls it an hysterical stupor, although he agreed with Moeli that it was hard to differentiate from a catatonic state.

Löwenstein[21] reports an interesting case of a dégénéré who had had hysterical attacks. He suddenly developed stupor symptoms, which lasted with interruptions for nearly two years. After recovery and during the interruptions the patient explained his mutism, refusal to swallow, his filthiness and general negativism as all occasioned by delusions. He was commanded by God to act thus, the attendants were devils, and so on. He spoke, too, of being under hypnotic influence. In addition there were other delusions such as that he had killed his brother. The attack came on with the belief that he was going to die, otherwise none of the ideas were typical of the stupors we have studied. Another incongruous symptom was that he did not seem to be really apathetic, he reacted constantly to the environment. The author comments on the absence of senseless motor phenomena, such as would be expected in a "catatonic." His complete memory of the psychosis also speaks against the usual form of stupor. It seems possible that this psychosis was neither hysterical nor a benign stupor in our sense, but, rather, an acute schizophrenic reaction such as one occasionally sees. From the account which Löwenstein gives, one gathers that the patient was absorbed in a wealth of imaginations.

Gregor[22] tells of a stupor which is unusual in that it consisted only of symptoms connected with inactivity, which did not affect the intellectual processes. The patient was a rubber worker who suddenly developed a depression with self-accusation and convulsions. She was soon admitted to a clinic and then showed mutism and catalepsy. Later she became totally immobile with no apparent psychic reactions, and soiled. Gregor studied pulse, respiration and respiratory volume in their reflex manifestations and found nothing unusual. Next he tried to discover if there were voluntary alterations in respiration. He discovered that the respiratory curve could be changed by calling out words to her, by odors associated with suggestions, menaces, etc. [This is suggestive of the dissociation of affect, which we have discussed.] After two months she recovered, with complete recollection of the stupor period. It was then proven that the absence of reactions was not the same as the lack of perception of stimuli.

Froederström[23] reports a case that suggests hysteria, where the stupor lasted for 32 years. A girl at the age of 14 fell on the ice, had a headache, went to bed and stayed there for 32 years. She lay there immobile, occasionally spoke briefly and took nourishment, when it was put at a definite place at the edge of the bed. At first (according to a late statement of her brothers) this consisted only of water but was soon changed to two glasses of milk a day. After being in this state for ten years she was placed in a hospital for two weeks, where she was mute, did not react to pin pricks and had to be fed. It seems that at home she secretly looked after herself, for she kept her hair and nails in condition. Sometimes she sat up and stared at the ceiling.

After attending to the patient for 30 years, her mother died. The patient cried for several days when told of it, and after this she took nourishment of her own accord. Two years later a brother died. Again she cried on hearing the news. Her father, who looked after her when the mother was dead, also died. Then a governess came into the home, who noticed that furniture was moved about when she was alone.

At the age of 46 she suddenly woke up and asked at once for her mother. She claimed total amnesia for the period of her stupor, including the stay at the hospital. She could summon memories of her childhood, however. Her brothers she did not recognize and said, "They must be small." She recalled the fall on the ice and coming home with headache, toothache and pain in the back. Her general knowledge was limited but she could read and write. Her expression and appearance was that of a young person, only her atrophic breasts and the fat on her buttocks betraying her age. She had been well for four years at the time the report was made.

He thinks that a certain tendency to exaggeration and simulation speak for hysteria. We would be more inclined to view the fact that she looked after herself in spite of complete amnesia as evidence of hysteria.

Another protracted case suggestive of hysteria is that reported by Gadelius.[24] The patient was a tailor, 32 years old, who had always been rather taciturn and slow. A year before admission he began to have ideas of persecution and to shun people. Then he developed a stereotyped response, "It is nice weather," whenever he was addressed. A month before admission inactivity set in. He would sit immobile in his chair with closed eyes and relaxed face; he resisted when an attempt was made to put him to bed. His color was pale.

He was taken to hospital on November 1, 1882, where he was observed to be immobile and to have little reaction to pin pricks. When a limb was raised, it fell limply. However, he would leave bed to go to the toilet. Tube-feeding became necessary, but when the tube was inserted in his nose, he woke up. He then showed an amnesia not merely for his illness but for his whole life: he did not know his father, that he was married or that he had a mother. Towards the end of November, he became limp again and answered, "I don't know" to most questions. In December, however, he improved again and for a few months these variations occurred. From April, 1883, to May, 1886, he was in deep stupor, almost absolutely immobile and close to being completely anesthetic even with strong Faradic currents. Towards the end of this period he walked about whenever he thought he was not watched. He was very cautious about this and became motionless any time he became aware of observation. (Gadelius thinks this was not simulation but the expression of an automatism on the basis of a vague fixed idea.)

This condition persisted apparently for five years more, by the end of which time the anesthesia had turned into a hyperesthesia. A year later he began to eat. It was now found that he had an amnesia for his illness and former life, so that he did not even recognize a needle or pair of scissors. He knew that he was born in the month of February and retained some facility in calculation, in speech, walking and usual motions. Then he regained all his memories and resumed his trade as tailor. He was discharged in June, 1893, nearly eleven years after admission.

It seems safe to say that elements at least of hysteria appear in this history, such as the profound retroactive amnesia and appearance of simulation in the conduct of the patient. Accurate and rapid grasp of the environment is necessary for such a watch as he kept on the eye of his attendants. Mental acuity of this grade combined with amnesia looks more like an hysterical than a manic-depressive process.

Leroy[25] describes a case much like ours which is interesting from a therapeutic standpoint. The patient was a woman who passed from a severe depression with hallucinations and anxiety into a long stupor, from which she recovered completely. There was no negativism and no affect, although the latter appeared so soon as contact began to be established. When well she had a complete amnesia for the onset of the psychosis. Leroy attributed the recovery, in part at least, to the thorough attention given the patient. Kraepelinian rigidity is seen, however, in the author's refusal to regard the case as "circular" because of the lack of all cyclic symptoms. He takes refuge in the meaningless label "Mental Confusion."

An important group of cases is that of the stupors occurring during warfare. Considering stupor as a withdrawal reaction, it is surprising there were so few of them, although partial stupor reactions as functional perpetuation of concussion were very common. The editor saw several typical cases in young children in London who passed into long "sleeps" apparently as a result of the air raids. Myers[26] has given us the best account of stupors in actual warfare. A typical case was that of a man who was found in a dazed condition and difficult to arouse. He could give little information about himself, could neither read nor write and never spoke voluntarily. A week later his speech was still limited and labored and no account of recent events could be obtained from him. Under hypnosis he was induced to talk of the accident which had precipitated this disorder. He became excited in telling his story, evidently visualizing many of the events. In several successive séances, more data were obtained and a cure effected. Myers points out that in all his cases there was a mental condition which varied from slight depression to actual stupor, all had amnesias of variable extent and all had headaches. The mental content seemed to be confined to thoughts of bombardment, with a tendency for the mind always to wander to this topic. The author thinks that pain is a guardian protecting the patient from too distressing thoughts. An effort to speak would cause pain in the throat of a case of mutism and, sometimes, when a distressing memory was sought after under hypnosis, physical pain would wake the sleeper. 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 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.] Myers believes that in nearly every instance mutism follows stupor and is merely an attenuation of the latter process. When deafness is associated with mutism, he thinks it is often due merely to the inattention of the stuporous state.

In this connection we should mention that Gucci[27] points out that stupor patients with mutism of long duration may, when requested, read fluently and then relapse again into complete unreactiveness towards auditory impressions. This, we would say, is probably an example of a more or less automatic intellectual operation occurring when the patient is sufficiently stimulated, although he cannot be raised to the point of spontaneous verbal productivity.

As these scattered reports about benign stupors are so unsatisfactory, one naturally turns to text-books. Little more appears in them. Kraepelin treats stupors occurring in manic-depressive insanity as falling into two groups, the depressive and manic. The former seems to be nearer to our cases, judging by the statements in his rather sketchy account. He regards stupor as being the most extreme degree of depressive retardation. [This possibility has been discussed in the chapter on Affect.] His description seems perhaps to include cases which we would regard as perplexity states or absorbed manias. Activity is reduced, they lie in bed mute, do not answer, may retract shyly at any approach, but on the other hand may not ward off pin pricks. Sometimes there is catalepsy and lack of will, again there may be aimless resistance to external interference. They hold anything put into their hands, turning it slowly as if ignorant of how to get rid of it. They may sit helpless before food or may allow spoon-feeding. Not rarely they are unclean. As to the mental content, he says they sometimes utter a few words, which give an insight into confused delusions that they are out of the world, that their brains are split, that they are talked about, or that something is going on in the lower part of the body. The affect is indefinite except for a certain bewilderment about their thoughts and an anxious uncertainty towards external interference. Intellectual processes suffer. They are disoriented and do not seem to understand the questions put to them. An answer "That is too complicated" may be made to some simple command. Kraepelin thinks that the disorder is sometimes more in the realm of the will than of thinking, for one patient could do a complicated calculation in the same time as a simple addition. After recovery the memory for the period of the psychosis is poor and quite gone for parts of it. Occasionally there may be bursts of excitement, when they leave the bed; they may scold in a confused way or sing a popular song.

His manic stupor is a "mixed condition," a combination of retardation with elated mood. The condition is different from the depressive stupor in that activity is more frequent, either in constant fumbling with the bed clothes or in spasmodic scolding, joking, playing of pranks, assaultiveness, erotic behavior or decoration. The affect is usually apparent in surly expression or happy, or erotic, demeanor. They are usually fairly clear and oriented and often with good memory for the attack but with evasive explanations for their symptoms. One cannot make any classification of the ideas he quotes, but it is apparent from all his description that the minds of these "manic stupors" are not a blank but rather that there is a fairly full mental content.

Wernicke, unhampered by classifications of catatonia and manic-depressive insanity with inelastic boundaries, calls all stupor reactions akinetic psychoses with varying prognosis. He does not make Kraepelin's mistake of confusing the apathy of stupor with the retardation of depression, stating distinctly that the processes are different.

Bleuler also has grasped this discrimination. He points out that the thinking disorder in what he terms "Benommenheit" (dullness) differentiates such conditions from affectful depression with retardation. He writes, of course, mainly of dementia præcox,[28] but makes some remarks germane to our problem. In the first place he denies the existence of stupor as a clinical entity, except perhaps as the quintessence of "Benommenheit", it is the result of total blocking of mental processes. Consequently, he says, one can observe the external features of stupor in all akinetic catatonics, in marked depressive retardation, when there is a lack of interest, affect or will, in autism, with twilight states, as a result of negativism or, finally, when numerous hallucinations distract the patient's attention into a world of fancy. He notes that in all stupors (with the exception, perhaps, of "Benommenheit") the symptoms may disappear with appropriate psychic stimulation or that some reaction, no matter how larval, may be observed. He speaks, for instance, of the visits of relatives waking the patient up.

His only real group is "Benommenheit," which he separates out as a true clinical entity. This seems to correspond roughly with our "Partial Stupors." It is essentially an affectless, thinking disorder, usually acute, sometimes chronic, occurring among schizophrenics. He believes that it is the result of some organic process (intracranial pressure or toxin). Activity is much reduced or absent; they have poor understanding, answer slowly or confusedly; their actions are sometimes as ridiculous as those of people in panic (e.g., throwing a watch out of the window when the house is on fire); the defect is best seen in writing, for large elisions are found in sentences. He was able to analyze only one case and she retained her affect; it was even labile and marked. One suspects that such a case might, perhaps, not really find a place in the "Benommenheit" group even as Bleuler himself describes it.

With the exception of Kirby, whose work has already been discussed in the introduction, we have been able to find only one author who has attempted any symptomatic discrimination of the recoverable and malignant catatonic states. Raecke[29] made a statistical study and found that 15.8% recovered, 10.8% improved, 54.4% remained in institutions, while 30% died. With the etiology mainly exogenous 20% recovered and 14.3% improved. A good outcome was seen in 30.2% of hereditary cases, while only 22.7% did well in the non-hereditary group. His most important contribution is in his formulation of good and bad symptoms. He thinks that dull, apathetic behavior with uncleanliness and loss of shame are not so unfavorable as has been thought. Malignant symptoms are grimacing with prolonged negativism but without essential affect anomaly, decided echopraxia and echolalia and protracted catalepsy. We would agree with this, although command automatisms have not been prominent either in our benign or malignant stupors.

Two writers have made special observations that should be confirmed and amplified before their significance can be established. Whitwell[30] thinks that in addition to a diminished activity of the heart there exists a pathological tension. Ziehen says that he also has frequently seen angiospastic pulse-curves in exhaustion stupor or acute dementia, but that other pulse pictures may be seen as well. Any such studies should be correlated rigorously with the clinical states before they can have any meaning. Wetzel[31] tested the psychogalvanic reflex in stupors and in normal persons who simulated stupors. He found them different.

Only one publication has come to our attention in which an attempt is made at psychological interpretation of various symptoms in stupor. Vogt[32] derives much from a restriction of the field of consciousness. Only one idea is present at a time, hence there is no inhibition and impulsiveness occurs. Similarly, if the idea appear from without, it, too, is not inhibited, which produces the suggestibility that in turn accounts for catalepsy. Stereotypy and perseveration are other evidences of this narrowness of thought content. Negativism is a state, he says, of perseverated muscular tension. [This would apply only to muscular rigidity.] So far as it goes, this view seems sound. Of course it leaves the problem at that interesting point, Why the restriction of consciousness?

If stupor be a psychobiological reaction, it should occur, occasionally, in organic conditions just as the deliria of typhoid fever may contain many psychogenic elements. Gnauck[33] reports such a case. The patient, a woman, was poisoned by carbon dioxide. At first there was unconsciousness. Then, as she became clearer, it was apparent that she was clouded and confused. She soiled. Neurological symptoms were indefinite; enlargement of the left pupil, difficult gait and exaggerated tendon reflexes. Months later she was still apathetic, although her inactivity was sometimes interrupted by such silly acts as cutting up her shoes. After five months she recovered with only scattered memories of the early part of her psychosis. What seems like a typical stupor content was recalled, however. She thought she was standing in water and heard bells ringing.

Stupor-like reactions are not infrequent in connection with or following fevers. Bonhoeffer[34] describes a type that follows a febrile Daemmerzustand of a few hours or a day at most. The affect suddenly goes, disorientation sets in. Although outbreaks of anxiety may be intercurrent, the dominant picture is of stupor. Reactions are slowed, often there is catalepsy. Sometimes there is a retention defect and confabulation to account for the recent past. Again the retention may be good. In the foreground stands a strong tendency to perseveration. This may affect speech to the point of an apparent aphasia or produce paragraphia. Plainly organic aphasia and focal neurological symptoms are sometimes seen.

As Knauer[35] has gone thoroughly into the question of the febrile stupors, the reader is referred to his paper for a digest of the literature on this topic. Mention has already been made in Chapter IX to this publication, where the close resemblance of these rheumatic, to our benign functional, stupors has been noted. Discrimination seems to be possible only on the basis of delirium-like features being added in the organic group.

• absorption, 163
• activity, reduction of, 36, 100, 120
• acute dementia, 251
• adaptation, 107, 192
• adrenalin, 180
• affect, 9, 22, 32, 44, 113, 116, 117, 123, 170
• affect, dissociation of, 128, 201, 205, 237
• affect, inappropriate, 216, 237
• affect, poverty of, 234
• affect, shallow, 127
• affectlessness, 171, 172
• affects, combination of, 245
• agitation, 156
• akinesis, 121
• akinetic psychoses, 4, 274
• albuminuria, 40
• allied to dementia præcox, 236, 260
• allied to manic-depressive, 236, 260
• allopsychic, 135
• ambivalence, 147
• amnesia, 9, 24, 68, 70, 267, 269
• anergic or unconscious stupor, 258
• anergic stupor, 255, 256
• anesthesia, 196, 212, 268
• anger, 118, 139
• angiospastic, 276
• animal, turning into, 171
• Antæus, 190
• apathy, 36, 48, 112, 122, 123, 151, 152, 163, 181, 195, 225, 237
• apathy, resemblance to absorption, 202
• anxiety, 122, 123, 126, 137, 153, 162, 166, 198, 226
• apoplexy, 224
• arteriosclerotic dementia, 80
• attention, 195
• atypical features, explanation of, 200
• autoerotism, 199
• automatism, 268

• Baillarger, 252
• behavior, 195
• "Benommenheit," 67, 273, 274
• bewilderment, 79, 112, 120, 126
• Bleuler, 67, 273
• blocking, 163
• blood-pressure, 181
• blushing, 9
• Bonhoeffer, 277
• boredom, 247
• bowels, interest in, 217
• brain tumor, 5
• breath, holding, 62
• Brierre de Boismont, 252
• burial, 111, 192

• Calculation, 23, 24
• Calvary, 111
• Cannon, 180
• Cases
  • Adele M. (Case 24), 220
  • Alice R., 135, 140, 192
  • Anna G. (Case 1), 6, 47, 48, 68, 74, 77, 109, 127, 136, 140, 145, 147, 183
  • Anna L. (Case 16), 135, 149, 158
  • Anna M., 135
  • Annie K. (Case 5), 24, 69, 72, 105, 110, 111, 136, 139, 141
  • Bridget B., 135
  • Caroline de S. (Case 2), 11, 68, 109, 141, 178, 193
  • Catherine H. (Case 23), 216
  • Catherine M. (Case 18), 158
  • Catherine W. (Case 25), 221
  • Celia C. (Case 17), 155
  • Celia H. (Case 19), 167
  • Charles O., 143, 144, 178
  • Charlotte W. (Case 12), 83, 106, 112, 113, 116, 127, 136, 141, 144, 166, 201
  • Emma K., 71, 140
  • Harriett C., 138
  • Helen M., 130
  • Henrietta B., 138, 140
  • Henrietta H. (Case 8), 42, 74, 77, 105, 106, 110, 111, 115, 136
  • Isabella M., 136, 144, 147
  • Johanna B., 135, 138
  • Johanna S. (Case 13), 91, 120, 127, 136
  • Josephine G., 138
  • Laura A., 71, 77, 135, 138, 140, 142, 193
  • Maggie H. (Case 14), 71, 96, 109, 140, 194
  • Margaret C. (Case 10), 55, 75, 78
  • Mary C. (Case 7), 39, 42, 71, 74, 77, 121, 136, 138, 178, 194
  • Mary D. (Case 4), 20, 47, 69, 70, 71, 74, 76, 109, 136, 145
  • Mary F. (Case 3), 14, 68, 105, 110, 111, 115, 140, 142, 164, 183
  • Mary G., 140, 141
  • Meta S. (Case 15), 99, 109, 127, 135
  • Nellie H. (Case 22), 214
  • Pearl F. (Case 9), 51, 75, 142
  • Rose S. (Case 21), 210
  • Rose Sch. (Case 6), 35, 74, 75, 145
  • Rosie K. (Case 11), 62, 75, 105, 112, 178
  • Winifred O'M. (Case 20), 207
• catalepsy, 13, 21, 31, 32, 36, 86, 94, 95, 102, 115, 128, 143, 144, 145, 147, 209, 211, 235, 239
• catatonia, 4, 5, 50, 128, 205, 236, 261
• catheterization, 85, 86, 102
• cemetery, 105, 112
• childbirth, 159
• childhood, 188, 195
• Chotzen, 262
• Christ, 86, 115
• Christian Science, 150
• circular psychosis, 5, 126
• circulation, 180
• Clark, 184
• clouding, 67
• Clouston, 258
• cocoon, 109
• coffin, 88, 106, 114
• coma, 176, 223
• concussion, aerial, 224
• confusion, 163
• constipation, 92
• convent, 117
• convulsive attacks, 15
• crime, 248
• crucifix, 88
• crucifixion, 86, 106, 114, 161
• crustaceans, 148
• cut-up idea, 94
• cyanosis, 32, 63, 180

• Dagonet, 3, 249, 250, 253, 254, 258
• death, feigned, 5, 83, 137, 196, 246
• death, mutual, 192
• death, projected, 198
• death, relation with affect, 110
• death ideas, 3, 46, 47, 50, 52, 58, 65, 83, 97, 104, 107, 109, 110, 111, 114, 115, 119, 122, 136, 137, 138, 152, 153, 156, 159, 163, 166, 187, 190, 191, 192, 199, 212, 225, 235, 240
• death of others, 192
• deep stupor, 1, 6, 41, 199
• deep stupor, explanation of, 197
• Delasiauve, 253
• delirium, 176
• delusional stupor, 255, 256
• delusions, 165
• délire mélancholique, 252
• dementia præcox, 4, 5, 62, 123, 127, 128, 205, 225
• depression, 5, 117, 123, 137, 156, 236, 253
• depression, differentiation of, 48, 124, 226
• dermatographia, 102, 180
• deterioration, 210
• diabetes, 224
• diarrhea, 45, 64, 178
• dissociation, 225
• distress, 119, 122, 154, 156, 162
• dreams, 161, 190
• drooling, 132, 181
• drowning, 87, 192

• Earth, 107, 111, 190
• echolalia, 275
• echopraxia, 275
• ecstasy, 91, 162, 191
• élan vital, 123
• elation, 44, 91, 123, 127, 151, 157
• electric chair, 85, 110, 119
• electricity, 150
• emaciation, 8, 32, 58
• emotion, 62
• emotion, inconsistency of, 126
• emotions and contact with reality, 164
• energy, 187, 194
• epilepsy, 5, 183, 199, 224, 242, 254
• epileptic aura, 184
• epileptic confusion, 80
• epileptic deterioration, 80
• erotic, 161
• erotic ideas, 90
• Esquirol, 251
• Etoc-Demazy, 251
• Euripides, 2
• excretion, habits of, 230
• extroversion, 195

• family visits, 232
• father, 104, 109, 110
• fear, 111
• fever, 8, 13, 26, 32, 38, 40, 45, 64, 102, 160, 176, 235, 241
• filthiness, 210
• fire, 151, 157
• flippancy, 129
• flushing, 27, 127, 128, 180
• food, refusal of, 99, 104
• Forel, 182
• Froederström, 265

• Gadelius, 267, 268
• Ganser reaction, 263
• Georget, 251
• German psychiatry, 259
• Gnauck, 277
• giggling, 206
• God, 115, 160, 162
• Golden Age, 187
• Gregor, 265
• Gucci, 271
• guilt, 157

• hair, loss of, 32, 58, 180
• heat production and loss, 179, 181, 242
• Heaven, 87, 88, 104, 106, 108, 109, 111, 114, 115, 117, 118, 160, 162, 166, 171, 191, 240
• Hell, 240
• Hoch, 164
• hyperæmia, 8
• hyperesthesia, 268
• hypochondria, 225, 253
• hypomania, 243
• hypnotism (see mesmerism), 145, 213
• hysteria, 3, 135, 184, 225, 264, 267, 269

• ideational content, 82, 235
• immobility, 85, 94, 196
• immorality, 150
• impulsiveness, 50, 113, 128, 172
• impurities in stupor reaction, 66
• inaccessibility, 141
• inactivity, 17, 30, 40, 48, 56, 62, 88, 97, 102, 123, 132, 152, 163, 194, 225, 234, 238
• inactivity, patients' explanation of, 134
• incest ideas, 209
• inconsistency of reaction, 134, 214, 215, 245
• incontinence (see wetting and soiling), 52, 57
• indifference, 123, 124, 142
• infantile reactions, 196
• infections, 5, 178, 241
• insight, 157
• insomnia, 39
• instinct of self-preservation, 188, 191, 198
• interest, 99, 195
• internal secretions, 178
• internal thoughts, 163
• interruptions of stupor, 130, 197, 238, 244
• introversion, 164, 227
• involuntary nervous system, 178, 180
• involution melancholia, 129, 195, 225, 226

• jaundice, 21
• Jung, 107

• Kahlbaum, 4, 260
• Kirby, 4, 6, 164, 234
• Knauer, 175, 278
• Kraepelin, 4, 260, 269, 271, 272, 273
• Kutner, 262

• laughter, 56, 141
• Leroy, 269
• leucocytosis, 8, 13, 40, 64, 178
• levels, principle of, 198, 244
• Löwenstein, 264

• MacCurdy, 2, 184
• make-up, mental, 5
• malignant stupors, 205
• mania (or manic), 5, 126, 137
• mania, absorbed, 125, 226, 245
• manic content, 166
• manic-depressive insanity, 149, 167
• manic-depressive insanity, mixed conditions in, 202
• manic-depressive insanity, pathology of, 174
• manic episodes, 191
• manic stupor, 125, 245, 253
• marriage, 160, 169
• masturbation, 196, 209, 219
• melancholic or conscious stupor, 258
• memory (see thinking disorder), 40, 67, 168, 195
• menstruation, 8, 56, 61, 100, 168, 182, 236, 242
• mesmerism, 86, 114, 117, 141, 144
• Meyer, Adolf, 260
• Meyer, E., 261
• midday nap, 247
• mixed conditions, 202, 273
• Moeli, 264
• Moses, 108
• mother's body, 108
• movement, spontaneous, 133
• muscular resistiveness, 224
• mutism, 10, 22, 31, 57, 62, 88, 104, 124, 134, 209, 271
• mutual death, 165, 192, 196, 248
• Myers, 270, 271
• mystics, 3
• mythology, 107, 108, 190, 240

• negativism, 5, 31, 52, 56, 65, 128, 138, 139, 199, 209, 225, 235, 238, 243, 276
• negativism, explanation of, 196
• nephritis, 224
• neuropsychic defect, 174
• neurotic, 150
• nervous, 159
• Newington, 3, 254, 255, 257
• Nirvana, 166, 188, 200, 248
• nourishment, 229, 242

• Œdipus, 165
• œstrous cycle, 182
• onset, 96
• onset, depressive, 99
• ophthalmic disease, 230
• Orestes, 2
• organic delirium, 175
• organic dementia, 67
• organic stupor, 223
• orientation (see thinking disorder), 9, 53, 154, 156, 159, 170, 245
• Osiris, 108

• pain, 133
• Papanicolaou, 182
• paragraphia, 80
• paralysis, feeling of, 105
• paralysis, general, 5, 254
• partial stupor, 34, 206
• perplexity, 125, 152, 153, 154, 155, 156, 160, 162, 164, 165, 169, 172, 208, 226, 245
• perplexity, differentiation of, 227
• perseveration, 145, 148, 276
• personality, 1
• perversity, 138
• physical disease, 175
• physical symptoms, 174, 176
• Pinel, 249, 251
• poison, 97, 172
• primitive ideas, 108
• prison, 105, 169
• prognosis, 4, 5, 206
• prostitution, 157, 161
• psychoanalysis, 161
• psychobiological reaction, 246
• psychogalvanic reflex, 276
• psychological explanation, 186
• psychological factors, 175
• pulse, 63, 92, 128, 180

• Rank, 107
• reality, 107, 187
• recuperation, 189
• rebirth, 107, 110, 114, 115, 119, 120, 121, 122, 187, 189, 190, 191, 240
• regression, 187, 188, 191, 192, 194, 198, 199, 243
• religious visions or ideas, 2, 162
• resentment, 98
• resistiveness, 54, 97, 102, 112, 127, 129, 133, 141, 147, 156, 211, 225
• respiration, 180
• resurrection, 159
• restlessness, 53, 120, 169
• retention of urine, 224, 230
• rheumatism, 175
• rigidity, muscular, 142, 179
• Romberg sign, 262
• rousing, 176

• sadness, 111, 113, 121, 122, 124
• St. Catherine of Siena, 2
• St. Paul, 2
• saliva, 30, 63, 181
• scattered speech, 207, 208
• schizophrenia, 67, 214
• seclusiveness, 207
• secondary stupor, 259
• Seelig, 263
• self-injury, 50, 57
• sexual excess, 251, 253, 258
• sexual ideas, 209, 219
• sexual sensations, 209
• ship, 87, 106, 118
• sick, 136
• skin, dry, 180
• skin, greasy, 43, 180
• sleep, 188, 189, 247
• slowing of thought, 125
• slowness, 85, 119, 160
• smearing of feces, 142
• smiling, 127
• social status, 236
• soiling, 30, 132, 172, 196, 225, 230, 235
• somatopsychic, 135
• sphincters, control of, 133
• spirits, 89
• spoiled child reaction, 129, 139
• starvation, 182
• stereotypy, 276
• Stern, 261
• stimulation, mental, 231, 246
• Stockard, 179, 182
• stubbornness, 142
• stupidity, 93
• stupor, diagnosis of, 223
  • hysterical, 225
  • malignant, 205, 206
  • organic, 223
  • reaction, 35, 236
  • relation to manic-depressive insanity, 173
• sudden mental loss, 71
• suggestibility, 145, 198, 276
• suicidal impulses, 50, 84, 104, 116, 118, 128, 172, 230, 235, 240
• suicide, 188
• sulkiness, 129
• sullenness, 142
• suprarenals, 242
• swallowing, 133
• sweating, 63, 102, 179, 180
• swimming movements, 94
• syncopal attacks, 64

• tears, 95, 98, 117, 128, 153
• tense of ideas, 116
• thinking disorder, 22, 31, 37, 39, 41, 45, 48, 59, 67, 75, 124, 125, 148, 152, 157, 235, 239, 247
• thinking disorder, explanation of, 195
• tongue, coated, 13
• toxins, 175
• trauma, 5, 224
• treatment, 229

• ulceration of eyes, 133
• unconscious ideas, 163
  • motives, 186
• unconsciousness, physiological, 199, 224, 277
• underground, 240
• understanding, 67
• uneasiness, 93, 94, 95, 121
• unfaithfulness, 97
• unhappiness, 192
• urine, retention of, 31

• Villermay, 250
• Vogt, 276
• vomiting, 45

• water, 94, 95, 106, 107, 114, 120
• weakness, 137, 160
• wealth, 169
• wedding ring, 117
• weight (see emaciation), 38, 52, 61
• Wernicke, 3, 273
• wetting, 30, 40, 132, 151, 170, 172, 196, 225, 230, 235
• Wetzel, 276
• whining, 171, 225
• Whitwell, 276
• Wilmanns, 261
• womb, 108
• worry, 110
• writing, 27

• Ziehen, 276