Chapter 17

THE LITERATURE OF STUPOR[C]

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 Hereditary. individual liability to sudden loss of _vis nervosa_.

_Onset_--Rapid. Usually insidious, may be almost instantaneous.

_Symptoms_--Intellect greatly Conduct shows reasoning power. impaired.

_Memory_--Seems to be swept Found after recovery to have away as far as possible. been preserved to a great extent.

_Emotional Capacity_--Nil or Evidence of grief, fear, etc., in almost so. Tears frequent facial expressions and wringing but due to relaxation of and clasping of hands. sphincter muscles. Features Tears rare. Great contraction relaxed, eyes vacant and not of features [grimacing?]. constantly fixed. 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. But little interfered with, Patient has to be independently of sheer led about and if placed on a asthenia, produced by seat or in some position does patient’s conduct. May stand not move. (“Cataleptoid” behind door or kneel on floor condition.) in constrained position even for days.

_Sensory System_}--Both dull. Ditto. There seems to be a _Reflex System_ } much greater ability to bear severe pain.

_Pupils_--Dilated. Tendency to contraction.

_Sleep_--Generally good. Intense sleeplessness.

_General bodily condition_-- Affected _pari passu_ with Emaciation, sometimes extreme, mental state and seems usually rapid, with governed by it. rapid recovery of flesh. Often not much loss of weight, though whole tone is lowered.

_Vascular System_--Pulse slow, Pulse weak and often quick sometimes almost imperceptible. and thready. Complexion Cyanotic appearance, edema anemic and sallow. The and iciness of extremities. other appearances may be Great decrease of vitality present but come on later in peripheral structures, and are less marked. as shown by asthenic eruptions and production of vermin.

_Digestive System_--Tongue Tongue dry, small and furred. clean or if furred it is moist. Refusal of food. Great Appetite _apathetic_, bowels constipation. Dirtiness of not irregular, but habits habits rare. very dirty.

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.

FOOTNOTES:

[C] This chapter has been written mainly from material in Dr. Hoch’s notes which was manifestly incomplete. No claim is made for its exhaustiveness.

_The Editor._

[13] Dagonet, M. H.: “De la Stupeur dans les Maladies Mentales et de l’Affection mentale désignée sous le Nom de Stupidité.” _Annales Medico-Psychologiques_, T. VII, 5e Serie, 1872.

[14] Newington, H. Hayes: “Some Observations on Different Forms of Stupor, and on Its Occurrence after Acute Mania in Females.” _Journal of Mental Science_, Vol. XX, 1874, p. 372.

[15] Clouston: “Mental Diseases.” J. & A. Churchill, 1904.

[16] Stern: “Ueber die akuten Situations-psychosen der Kriminellen.” Abstracted, _Zeitschr. f. d. ges. Neurol. u. Psychiatrie_, Referate Bd. V, S. 554.

[17] Wilmanns, K.: “Statische Untersuchungen über Gefängnisspsychosen.” _Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 847.

[18] Kutner: “Ueber katatonischer Zustandsbilder bei Degenerierten.” _Allgemeine Zeitschr. f. Psychiatrie_, Bd. LXVII, S. 375.

[19] Chotzen: “Fall von degenerativem Stupor.” Abstracted, _Zeitschr. f. d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 1077.

[20] Seelig: “Psychiatrischer Verein in Berlin, 1904.” _Neurol. Centralbl._, 1904, S. 421.

[21] Löwenstein: “Beitrag zur Differentialdiagnose des katatonische u. hysterische Stupors.” _Allg. Zeitschr. f. Psychiatrie_, Bd. LXV.

[22] Gregor: “Über die Diagnose psychischer Prozesse im Stupor.” Leipzig Meeting, 1907. Reported in _Neurol. Centralbl._, 1907. S. 1083.

[23] Froederström: “La Dormeuse d’Okno. 32 ans de Stupeur, Guérison complète. Nouvelles Iconographies de la Salpétrière,” 1912, No. 3. Reviewed by E. Bloch, _Neur. Centralbl._, 1913, S. 852, and by Forster, _Zeitschr. f. d. ges. Neur. u. Psychiatrie_, Referate, Bd. VI, S. 510.

[24] Gadelius: “Ett ovanligt fall af stupor med nära 9-arig oafbruten tvangsmatning; uppvaknande; total amnesi; helsa” (_Hygiea_, 1894, LVI.,