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.

CASE 1.--_Anna G._ Age: 15. Admitted to the Psychiatric
Institute July 25, 1907.

_F. H._ The mother and two brothers were living and said to
be normal. The father died of apoplexy when the patient was
seven.

_P. H._ The patient was sickly up to the age of seven, but
stronger after that. It is stated that she got on well at
school, though she was somewhat slow in her work. She was
inclined to be rather quiet, even when a child, a bit shy,
but she had friends and was well liked by others. After
recovery she made a frank, natural impression. She was
always rather sensitive about her red hair. She began to
work a year before admission and had two positions. The
last one she did not like very well, because, she alleged,
the girls were “too tough.”

Three weeks before admission she came home from work and
said a girl in the shop had made remarks about her red
hair. She wanted to change her position, but she kept on
working until six days before admission. At that time her
mother kept her at home as she seemed so quiet, and when
the mother took her out for a walk she wanted to return,
because “everybody was looking” at her. For the next two
days she cried at times, and repeatedly said, “Oh, I wish I
were dead--nobody likes me--I wish I were dead and with my
father” (dead). She also called to various members of the
family, saying she wanted to tell them something, but when
they came she would only stare blankly. For a day she
followed her mother around, clung to her, said once she
wanted to say something to her, but only stared and said
nothing.

Four days before admission she became quite immobile, lay
in bed, did not speak, eat or drink. She also had some
fever.

The patient herself, when well, described the onset of her
psychosis as follows: She knew of no cause except that her
brother, some time before the onset (not clear how long),
was run over by an automobile and had his foot hurt. She
claimed that while still working she lost her ambition,
lost her appetite, did not feel like talking to any one;
that when she went out with her mother it merely seemed to
her that people stared at her. The day before she went to
the Observation Pavilion her cousin came to see her, and
she thought she saw, standing beside this cousin, the
latter’s dead mother. She also thought there was a fire,
and that her sister was sweeping little babies out of the
room. Then, she claimed, she felt afraid (this still on the
day before going to the Observation Pavilion) because she
had repeated visions of an old woman, a witch. This woman
said, “I am your mother, and I gave you to this woman
(i.e., patient’s real mother) when you were a baby.” She
also was afraid her mother was “going away.”

At the _Observation Pavilion_ she was described as
constrained, staring fixedly into space, mute, requiring to
be dressed and fed.

_Under Observation:_ 1. For five months the patient
presented a marked stupor. She was for the most part very
inactive, totally mute, staring vacantly, often not even
blinking, so that for a time the conjunctivæ were dry. She
did not swallow, but held her saliva; did not react to pin
pricks or feinting motions before her eyes. Sometimes she
retained her urine, again wet and soiled the bed. Often
there was marked catalepsy, and the retention of very
awkward positions. As a rule she was quite stiff, offering
passive resistance towards any interference. She had to be
tube-fed at first. Later she was spoon-fed, and then would
swallow, in spite of the fact that during the interval
between her feeding she would let saliva collect in her
mouth. For a time she had a tendency to hold one leg out of
bed, and when it was put back would stick the other out.
Sometimes she walked of her own accord to the toilet chair,
but on one occasion wet the floor before she got there.

During the first month after admission, this stupor was
interrupted for two short periods by a little freer action:
she walked to a chair, sat down, smiled a little, fanned
herself very naturally when a fan was given to her, though
even then did not speak.

There was, as a rule, no emotional reaction, but after some
months she several times wept when her mother came, though
without speaking. Once when taken to the tub she yelled.

Her _physical condition_ during this stupor was as follows:
She menstruated freely on admission, then not again until
she was well. Several times she had rises of temperature to
102° or 103° with a high pulse and respiration; again a
respiration of 40, with but slight rise of temperature,
though the pulse had a tendency to go to 130 and over. She
was apt to show marked skin hyperæmia wherever touched.
With the fever there was found a leucocytosis of from
11,900 to 15,000, with marked increase of polynuclear
leucocytes (89%). She got very emaciated, so that four
months after admission she weighed 68 lbs. (height 5′ 2″).

2. About five months after admission she was often seen
smiling, and again weeping, and she began to talk a little
to the nurses, though not to the doctors. She also began to
eat excessively of her own accord, and rapidly gained
weight, so that by January she weighed 98½ lbs., a gain
of 30 lbs. in two months. Yet she continued to be sluggish.

3. For two more months she was apathetic and appeared
disinterested, often would not reply, again, at the same
interview, she would do so promptly and with natural voice.
This condition may be illustrated by the summary of a note
made on January 29, 1908, which is representative of that
period. It is stated that she sat about apathetically all
day, appeared sluggish, but was fairly neat about her
appearance and cleanly in her habits. There was at no time
any evidence of affect, except when asked by the examiner
to put out her tongue so that he could stick a pin in it
she blushed and hid her face. When asked whether she
worried about anything, she denied this. When questions
were asked, she sometimes answered promptly and in normal
voice, again simply remained silent in spite of repeated
urging. On the whole, it seemed that simple impersonal
questions were answered promptly; whereas difficult
impersonal questions or questions which referred to her
condition were not answered at all. She proved to be
oriented. Thus she gave the day of the week, month, year,
the name of the hospital, names of the doctors and nurses
promptly. She also counted quickly and did a few simple
multiplications quickly. But she was silent when asked
where the hospital was located, how long she had been here,
whether she was here one or six months, how she felt.
Questions in regard to the condition she had passed
through, or involving difficult calculations, she did not
answer. However, some questions regarding her condition
asked in such a way that they could be answered by “yes” or
“no” were again answered quite promptly. Thus when asked
whether her head felt all right she said, “Yes, sir.” (Is
your memory good?) “Yes.” (Have you been sick?) “No, sir.”
(Are you worried?) “No.”

4. This apathy cleared up too, so that by the middle of
March she was bright, active and smiled freely. With the
nurses she was rather talkative and pleased, though this
was not marked. Towards the physician only was she natural
and free. She then gave the _retrospective account_ of the
onset detailed above. When questioned about her condition
she claimed not to remember the Observation Pavilion,
although recalling vaguely going there in a carriage. She
was almost completely amnesic for a considerable part of
her stay in the Institute. She claimed it was only in
November or December that she began to know where she was
(five months after admission). In harmony with this is the
fact that she did not recall the tube- and spoon-feeding
which had to be resorted to for about four months of this
period. No ideas or visions were remembered. As to her
mutism she said, “I don’t think I could speak,” “I made no
effort,” again “I did not care to speak.” She claimed that
she remembered being pricked with a pin but that she did
not feel it. She remembered yelling when taken to the tub
(towards end of the marked stupor) and claimed she thought
she was to be drowned.

When she went home (March 24, 1908) she got into a more
elated condition. She was talkative, conversed with
strangers on the street, said to her mother that she was
now sixteen years old and wanted “a fellow.” When the
mother would not allow her to go out, she said it would be
better if they both would jump out of the window and kill
themselves. She then was sent back to the hospital. In the
first part of this period after her return, she was
somewhat elated and overtalkative, though she did not
present a flight of ideas, and was well behaved. She soon
got well, however, and was discharged, four months after
her readmission, fully recovered.

After that, it is claimed, she was perfectly well and
worked successfully most of the time with the exception of
a short period in the spring of 1909, when she was slightly
elated.

In 1910 she had a subsequent attack, during which she was
treated at another hospital. From the description this
again seems to have been a typical stupor (immobility,
mutism, tendency to catalepsy, rigidity). According to the
account of the onset sent by that hospital (it was obtained
from the mother), this attack began some months before
admission, with complaints of being out of sorts, not being
able to concentrate and fearing that another attack would
come on. Finally the stupor was said to have been
immediately preceded by a seizure in which the whole body
jerked. She made again an excellent recovery.

The patient was seen about two years after this attack, and
described the development of the psychosis as follows: She
claimed she began to feel “queer,” “nervous,” “depressed,”
got sleepless. Then (this was given spontaneously) she
suddenly thought she was dying and that her father’s
picture was talking to her and calling her. “Then I lost my
speech.” As after the first attack, she claimed not to have
any recollection of what went on during a considerable part
of the stupor but recalled that she began to talk after her
brother visited her. It is not clear how she was during the
period immediately following the stupor.

She made a very natural impression and came willingly to
the hospital in response to a letter and was quite open
about giving information.

CASE 2.--_Caroline DeS._ Age: 21. Admitted to the
Psychiatric Institute June 10, 1909.

_F. H._ The father died of apoplexy when patient was nine.
The mother had diabetes. A paternal uncle was queer,
visionary.

_P. H._ The patient was always considered natural, bright,
had many friends, and was efficient.

Some months before admission the patient’s favorite
brother, who is a Catholic, became engaged to a Protestant
girl, and spoke of changing his religion. The family and
the patient were annoyed at this, and the patient is said
to have worried about it, but was otherwise quite natural
until seven days before admission. Then, at the engagement
dinner of the brother, the psychosis broke out. She refused
to sit down to the table, and then suddenly began to sing
and dance, cry and laugh and talk in a disconnected manner.
Among other things, she said “I hate her,” “I love you,
papa” (father is dead), “Don’t kill me.” She struck her
brother. She was in a few days taken to the Observation
Pavilion.

The patient stated after recovery that what worried her was
that the brother would marry a Protestant and that he would
leave home (favorite brother).

At the _Observation Pavilion_ she was excited, shouted,
screamed, laughed, called out “Don’t kill me,” again
“Brother, brother,” “You are my brother” (to doctor).

_Under Observation:_ 1. On admission, and for two weeks,
the patient presented a marked excitement, during most of
which she was treated in the continuous bath. She tossed
about, threw the sheets off, beat her breasts and abdomen,
put her fingers into her mouth, bit the back of her hands,
waved her arms about, sometimes with peculiar gyration,
etc., at the same time shouting, singing, again praying,
laughing or crying, sometimes fighting the nurses and
resisting them. She also talked quite a little as a rule,
but there were periods when, although excited, she would
not talk or answer questions. She was very little
influenced in her talk by the environment. When on one
occasion asked if she had any trouble, she said: “No--I
don’t want, somebody else gave me a book--all right I love
myself, Uncle Mike too--all right too--all right I am in
Bellevue--I love everybody except the Jews all right, all
right--give me water, give me milk, give me seltzer--white
horse uncle--Holy Father, he is killing me, I want my
mother,” or “Wait a minute, say, that’s a lie--oh no, Holy
water--no I didn’t wash the water away--oh, she forgets, I
am sick--mother why don’t you come--look at the baby, they
knocked my head against the wall--wait a minute, isn’t that
terrible?--I was married--I was so--I forgot--April fool--I
kiss you seven kisses and one more--I love papa and mamma,
I like others too--I am papa’s angel child--yes I confess I
love him, but I don’t want to die myself.” On another
occasion, when asked where she was, she said: “I am at the
ball--I am going to Heaven--don’t shoot me” (affectless).
(Why are you afraid?) “Because you see--high water (in the
tub)--white horse.” (What about the water?) “My name is
Caroline--if you love me, father, tickle me under my feet,”
or, rolling her eyes up, “Oh, isn’t that awful, that ring,
that diamond, that is the key to Heaven.”

2. For about ten days she was somewhat different. She
became quieter and at first lay muttering unintelligibly,
saying some things about being killed, but speaking little,
often restlessly tossing about and tremulous. She had to be
tube-fed. On one day (July 1) she smiled more and talked
more, said to the physician “You have been arrested for
me--you arrested the first man that I ever--New York
State--let me see that book” (note pad). Then she went on:
“Oh, I am all apart--diamonds--they didn’t know--must I
keep them clean?--what is your name?--that is another thing
I would like to know.” But when asked what house she was in
she said: “This is the same Ward’s Island” and then added,
“How long have I been here?--there is my picture up there
(register), who is that? (listening) it’s Ida ...” She
began to sing softly. Then again she whined. “O mamma,
mamma!” When asked how long she had been here, she said:
“Since Decoration Day, when my father went in my sister’s
house, nobody could catch up with me--somebody blackened
her eyes.” When asked whether she was sick, she said “No,
insane.”

Although, as was stated, she said at one time, “This is the
same Ward’s Island,” usually questions regarding
orientation were not answered, as she gave few relevant
replies, but she repeatedly said spontaneously that she was
in “Hoboken or Bellevue,” and called the nurse by the name
of a former teacher. A few days after this state had
developed she had a fever. Once this rose to 104°. The
fever lasted two weeks, coming down gradually. It was
associated with a leucocytosis of 15,000 on June 29 (no
differential count) and with coated tongue. No Widal (two
examinations). No diazo (July 1).

3. Then while the temperature still lasted she developed a
stupor which persisted for about a year. During this time
her temperature rose to 100° without ascertainable cause.
She lay for the most part motionless, changing her position
but rarely; her expression was stolid; she retained and
drooled saliva, wet and soiled herself. She never answered
any questions; showed no interest whatever. At times she
was quite stiff and very resistive but never cataleptic.
Her extremities were cold and cyanotic. She had to be
tube-fed throughout. During this time she lost much hair.

After some months she occasionally gazed about furtively,
or later watched everything when unaware of being observed;
at this time she also smiled occasionally at amusing
things, or perhaps said “yes” or “no” to questions, but
usually was stolid when interrogated.

Then about nine months after admission, while in the
condition just described, she developed a lobar pneumonia.
During it she remained the same. But during convalescence
she began to speak and eat.

4. A period followed lasting six months during which she
was up and about, but sat or stood around a good deal. On
the other hand, she helped the nurses a little when urged.
Her face was often stolid, again she looked about. At times
(even nearly to the end) she drooled and soiled. She said
little. At no time was she resistive. On other occasions
she smiled or laughed, not always on provocation, or she
showed little playful tendencies, such as throwing a pillow
about the room, tearing leaves from the plants, taking the
doctor’s arm and walking down the hall, asking him to kiss
her. At such times she often looked quite bright, keen,
alert and amused. Towards the end she would give at times
playful answers, such as “I came to-day,” or “This is the
Hall of Fame.” This tapered off, so that by December, 1910,
she was perfectly well.

_Retrospectively_, the patient claimed not to remember the
upset at the dinner, or what happened afterward, although
recalling the trip to the Observation Pavilion. She denied
any memory of the journey to the hospital, but could tell
what ward she came to. How well the condition after that
was recalled, was not inquired into, except that she could
or would not explain further the utterances during the
first period. For the stupor period it is stated that she
remembered many external facts, but it is not clear in
which period they occurred.

_Catamnestic Note._ May, 1913: She has worked efficiently,
and is said to have been perfectly well.

CASE 3.--_Mary F._ Age: 21. Admitted to the Psychiatric
Institute June 28, 1902.

_F. H._ The mother died when the patient was five. The
father was living, an alcoholic and reckless man. Four
brothers and sisters died in infancy.

_P. H._ The patient was the only surviving child. She was
brought up in a convent and orphan asylum until 11, when
her father remarried. At 12 she had to go to work, hence
she had but little education. She was bright, efficient,
well liked by her employers (in one position five years).
As to her peculiarities, she was thought to be, perhaps, a
little headstrong, and was also described as always very
exact, rather quick-tempered and inclined to be irritable
when crossed.

She was married six months before admission and had a _baby
three weeks before admission_. The husband stated that when
the father found out she was pregnant, he spoke of killing
him. He frequently upbraided both husband and wife, though
he lived with them. Even after the child was born he
continued to be disagreeable.

The patient was rather low spirited and quieter after her
marriage. She worried over her illegitimate pregnancy and
the scolding from her father. But nothing was thought of
all this, and it did not interfere with her activity. The
birth was normal. She had no flow, no unfavorable symptoms,
and sat up on the twelfth day. She is said to have appeared
natural mentally.

A week before admission the family returned from the
christening, having left the patient apparently well. They
now found her sitting in her chair, limp, with closed eyes,
giving no answer to questions. Only after about twenty
minutes could she be aroused. After her father had given
her milk with whiskey in it, she claimed he had poisoned
her. In the evening she was bright and lively, singing and
dancing with the others, but in the night she woke up her
husband, seemed frightened, said somebody was in the room
and that he should get a priest as she was going to die.
The husband went to sleep again. The next forenoon the
patient claimed she had been frightened all night and
thought her father was going to kill her husband.

On the second day, while sitting at breakfast, she groped
about for the bread plate for some time and then said she
had been blind for a short time. During the day she had
frequent spells in which she would close her eyes, become
perfectly quiet and difficult to rouse. Sometimes at the
beginning of these spells she would say “I am going.” She
was then taken to her aunt and walked there, a distance of
a few blocks. She was there for two days before going to
the Observation Pavilion. In this time she is said to have
been quiet for the most part, often apparently sleeping or
staring. Once she said she was “rather dirty, filthy.” Once
she tried to get out of the window, said it was a door and
that she wanted to get out and take a walk. Above all, she
had, in these two days, repeated peculiar seizures which
the aunt and the husband described as follows: When sitting
on a chair she would close her eyes, clench her fists,
pound the side of the chair, get stiff, slide on the floor,
then thrash her arms and legs about and move the head to
and fro. She frothed at the mouth. After the attack, which
lasted a few minutes, she breathed heavily for a while.
Once she wiped off the froth with a handkerchief and gave
the latter to the aunt, saying “Burn that, it is poison.”
Before the attack she sometimes said that it got dark over
her eyes and that her face felt funny, again that she had a
pain in the stomach which worked towards her right
shoulder. There was no cry in the beginning of the attack,
but once she wet herself.

After recovery the patient herself told the development of
her psychosis thus:

There was trouble between the father and the husband, and
she was afraid of her father. On the day of the christening
she took sick: a queer feeling came over her and she
wondered whether she was going to die, “Then I seemed to
lose myself, and when I came to I found my family standing
around me.” Her father gave her whiskey and she thought it
was poison. “That night I had spells of dancing and
singing, it must have been something I took, perhaps the
liquor.” The same night she was frightened, thought her
father might do some harm, and had a vision of a person in
white standing at her bed. After that she had repeated
spells in which she knew nothing until “I came to again.”
“It was a queer trembling.”

At the _Observation Pavilion_ she was described as in a
state of “intense mental depression,” taking no interest in
things going on about her. She spoke, however; said she
wanted to die, that she had imagined her father had given
her poison, that every one was against her, and that people
were talking about her.

1. _On admission_ the patient had a slightly elevated
temperature, which soon subsided, full breasts but without
inflammation. Sordes were not mentioned.

For a few days she was essentially somewhat restless,
getting out of bed, disarranging her clothes, wandering
about--all in a rather deliberate, aimless way, sometimes
vaguely resistive, again with free movements. She looked,
dazed, sometimes stared straight ahead and looked “dreamy.”
Occasionally there was a tendency to close her eyes. With
the restlessness she looked at times “a little
apprehensive,” or shrank away when approached. She spoke
slowly, with initial difficulty, but answered quite a
number of questions. The mental content of this period was
displayed in the following utterances: She would ask for a
priest, or say “Have I done something?” or “Do people want
something?” or, when asked why she was here, she said “I
have done damage to the city, didn’t I?” (What have you
done?) “I don’t know.” Or she spoke of people watching her.
When asked the day, she said “Judgment Day,” yet she knew
the month. Once when asked what the place was she said,
“This is the hereafter.” When asked what had happened at
home, she said: “Voices told me I was to be killed.” She
was not clearly oriented, called the place Bellevue, asked
“Isn’t this a hospital?” yet again said, “Ward’s Island,
where they work.” On the day of admission she thought she
came “the day before,” but knew she had come in a boat.
When asked her address, she said slowly, “Didn’t I live at,
etc.,” giving the address correctly. To the physician she
said, “Are you my brother?” And on another occasion, “My
God! You are Charlie” (brother). It was difficult to get
her to eat, and she had to be spoon-fed.

2. Then she became more preoccupied, the restlessness was
much less in evidence, it became necessary to tube-feed
her, she retained her urine, answered a few questions, and
when asked where she was, she said, “Calvary, ain’t it?”
(What house?) “Heaven, ain’t it?” She still called the
physician by the name of her brother. After a few days this
gave way to a more marked stupor which lasted nearly two
years. This was characterized most frequently by a complete
inactivity. She usually lay or sat motionless, sometimes
with mouth partly open, letting the flies crawl over her
face, gazing in one direction, soiling, wetting, resisting
moderately or markedly any interference, and had to be
tube-fed. But this was not the invariable state. The most
constant feature was her mutism, but even that was a few
times interrupted. Thus, when after a visit from her uncle
(towards the end of July, 1902) she tried to get out of the
window and was prevented, she swore at the nurse. Or in
August, 1902, when she got into another patient’s bed and
was taken out, she resisted and said promptly: “I think it
is a damned shame I can’t get into my own bed.” But this
was the extent of her talk for a year and a half. Nor was
she always totally inactive. In the middle of July, 1902,
she sometimes tried to get out of bed, wandered about, got
into other patients’ beds. It was on such an occasion that
the above incident happened. In August, 1902, she sometimes
tried to get out when the door was opened, and we have
seen that she tried to get out of the window, but she did
not change her placid expression at such times. Her motive
was not known. On two occasions towards the end of 1902,
when she was taken to a dance and was made to take part,
she waltzed with considerable animation but did not speak.
This was quite striking in that these incidents occurred in
a setting of marked inactivity (i.e., a condition in which
she had to be pushed to the table, pushed to the closet).
She did not soil any more, but she sometimes drooled and
had to be spoon-fed. However, on a third occasion when this
was tried, she had to be dragged around. Finally, though
her facial expression showed at times a preoccupied
staring, she more often looked around, sometimes quite
freely and often looked up promptly enough when accosted.
But there was very little evidence of any affect at any
time. We have seen that twice she swore a little when
opposed. On another occasion she slapped a patient when the
latter helped her. Twice she was seen crying a little
without apparent provocation, but she did not laugh, and
the only suggestion of pleasurable emotion was that at the
two dances mentioned she could be led into a certain
animation. Usually, even when she got less resistive
towards the end, she was essentially apathetic.

Once in January, 1903, she could be made to write her name
but wrote her maiden name. In the end of 1903 she improved
gradually (a condition not well observed), so that by
December she answered some questions in a low tone. Even in
April, 1904, she was still described as apathetic, though
she had begun to do some work.

3. Then she improved markedly and began to work, looked
after herself in a natural way, spoke freely, was entirely
oriented and her mood generally presented nothing striking.
But her mental attitude was still peculiar when she was
questioned. She seemed somewhat inattentive, sulky,
sneering. Thus, when asked why she was here, she said, “You
will have to ask those who brought me here.”

She denied ever having been pregnant, said the nurses on
the ward had spoken of her having had a child and that they
had showed her a child (one was born on that ward about
August, 1903) but that it was not hers. She thought it was
wrong for the nurses to speak on the ward of her having
been pregnant. Again questioned about her marriage, she
first said she had not been married, again that she was
married “a year ago” (was in the hospital then). Again she
spoke of her husband as her “gentleman friend,” claimed she
called herself Mary M. (maiden name) until a girl friend
wrote her a letter addressed to Mrs. F. From then on, she
called herself by her married name. But she thought that
probably they sometimes spoke of her marriage in fun. If
she were Mrs. F. she would be living in Mr. F.’s house.

On June 29, when again asked about her marriage, she said
she was to have been married in December (correct date).
(Were you?) “So they say.” (Do you remember it?) “In a
way.” (When was the baby born?) “You will have to ask
somebody more superior to me, more experienced.” Then, when
further questioned about the age of the baby, she said,
“The baby I saw in the ward was about a year old,” and she
claimed not to remember ever having a baby. When asked why
she had come here she said, “Well, I don’t know, perhaps
you know better, through sickness I guess,” and later:
“Well, don’t you ever get a cold and want doctors to
examine you?” (What kind of a place?) “This is a nice place
for sensible people who have enough knowledge to know and
realize what they come for.” But she knew the name of the
place, the date, the names of persons.

Questioned about the trouble with her father or her
husband’s trouble with him, she denied it, “If he did (sc.
have any trouble), I don’t remember.” About her not
speaking, she said, in answer to questions, “I didn’t know
what I was here for, what was the object in keeping me
here”; and to other questions about her condition, “I don’t
know, those who examined me can tell you more about that.”
Finally, she said in reply to the question, why she came
here, “I don’t remember _unless it was through fire_,” but
would not explain what she meant.

In the beginning of July, she again said that she had no
recollection of her marriage.

She then improved a great deal and finally appeared very
natural, gave the retrospective account noted in the
history, had a clear appreciation of the fact that she was
married and had a child. She claimed that she had
previously forgotten about her marriage and thought she was
still merely keeping company with Mr. F. She claimed not to
remember coming to the hospital, did not know what ward
she came to, who the doctor and nurses were, in fact
claimed that it was about a year before she knew where she
was. But she remembered having been tube-fed. She could not
say why she did not speak. But she appreciated that she had
been ill.

Ten years after discharge the husband, in answer to an
inquiry, stated that she had been perfectly well and had
had no trouble at three successive childbirths.

CASE 4.--_Mary D._ Age: 20. Admitted to the Psychiatric
Institute September 17, 1907.

_F. H._ The grandfather and the father of the patient were
alcoholics. The father died three years before the
patient’s admission; he was killed in an accident. The
mother stated that she herself was nervous, but she made a
normal impression.

_P. H._ The patient was described as bright at school and
efficient in her work as a dressmaker, but she was rather
quiet, inclined to stay at home and had not much
inclination to consort with the other sex. She was rather
proud. As an example of this is stated the fact that she
was always somewhat sensitive, because the family lived in
the basement of the house in which her mother was
janitress. She did not menstruate until 16. It was about
this time that her father was killed in an accident. She
was considerably upset by this, talked a good deal about
the way he was killed, but did not break down. The patient
on recovery stated that it worried her because the father
died without having any chance to get a priest.

Six weeks before admission the patient was given a
vacation, as there was not work enough in the shop, but she
worked at home.

Two or three weeks before admission her appetite failed
somewhat, and ten days before admission, without any
appreciable cause, she began to sleep badly, seemed
somewhat nervous, became a little “fidgety” and said she
worried because her mother had to work so hard. Later she
began to speak about people saying that the ambulance would
come for her and she heard voices saying “You will be
dead.” It is not known in what emotional setting these
remarks were made. Her mother took her to a dispensary. On
the way she asked the mother where she was going and said
“I can’t tell the number and I don’t know where I am going.
I think I am losing my mind.” She also said she could not
understand any more what she read. She was put to bed. She
then talked less, appeared stupid, and was inclined to
refuse food.

Four days before admission she claimed that she could see
her dead father beckoning to her, again she said a certain
young man was God. She was sent to the Observation
Pavilion. On the day she went there she was reported to
have shown a slight jaundice.

The patient, after her recovery, added to the above account
of the mother, that about two weeks before admission, for
no reason which she could state, she began to feel quiet,
and that after that her father’s death began to prey on her
mind, and that later she had a vision of her father. She
claimed that in this period she had no fear but that her
head felt dizzy and her vision seemed dim.

At the _Observation Pavilion_ the patient was described as
constrained, refusing food, mute, resistive of attention,
sometimes muttering to herself and having the appearance of
uneasiness.

_Under Observation:_ 1. On admission the patient had a
slight jaundice, which disappeared in a few days, and the
bile test in the urine was negative on admission. She was
rather thin, but otherwise in good physical condition. Her
temperature was 99.2°.

For three months the patient was very inactive, moving very
little. She had to be dressed and undressed, when taken out
of bed. She often was markedly constrained, either lying
with her head raised from the pillow, or for long periods
of time holding her arms or hands in rather constrained
positions on her body. But there was at no time any
catalepsy when tested by moving her arms. In the beginning,
however, before she lay so persistently with her head
raised, she was found holding it up from the pillow after
her hair had been fixed. Again, she did not correct other,
rather uncomfortable, positions in which she had been left.
There was also at times a slight or occasionally a somewhat
more marked resistance in her arms and neck, but this never
amounted to a pronounced resistance. She sometimes did not
react to pin pricks, sometimes flinched a little, never
warded off the pin, indeed she would put out her tongue
repeatedly when asked to do so in order to have a pin stuck
into it. She very often wet and soiled, once even
immediately after she had been taken to the closet, on
which occasion she did not urinate. Her face was usually
dull, vacant and immobile, but sometimes, when questioned
or when something obtrusive happened, a little puzzled.
Occasionally she looked slowly about or followed people
with her eyes. There was no evidence of any affect as a
rule, but not infrequently she smiled, even quite freely at
times, when the physician came to her or on other
appropriate occasions. For example, once when a nurse came
into the ward whom she had known outside she flushed and
smiled a little. Once when the mother came to see her a few
tears appeared, the only time this occurred.

Although for the most part immobile, when she did move, she
was distinctly slow. When asked to do certain things, she
usually did not comply, but now and then, after urging,
would show her tongue after delay, or merely open her
mouth; or she would bring the hand forward slowly when the
physician offered his hand in greeting. Once she fumbled
with her braids slowly. When out of bed, she stood about
aimlessly or sometimes walked somewhat slowly.

She was almost entirely mute, but a few times she returned
a greeting quite promptly, or on another occasion
(September 23) she said quite promptly, when asked how she
felt, “I feel better. I took off my clothes” (correct--she
had been up and put to bed again). Again she sometimes
answered simple questions by “yes” or “no,” though
sometimes in a contradictory and rather aimless manner, but
promptly enough. Once she said to her mother, “I can’t, I
have to remain here.” There were some other replies which
we shall presently take up. Several times it was possible
to make her write. On these occasions she wrote her name
promptly, or might write only after much delay or stopping
in the middle of a word.

This leads us to her capacity to think, the defect of which
was perhaps most clear in her writing. Thus, though having
been told to write her name, and having written it quickly
enough, when, immediately after it, she was asked to write
her address or the name of the hospital, she had to be
urged much, and then wrote each time merely a repetition of
her name, this time much more slowly. On October 13, when
she was asked to write her name, she wrote it correctly;
then for the address she wrote the house number correctly,
but for 90th street she wrote “90theath”; and, urged again
for the address, she added “Dr. Wyeth.” Again when asked to
write the word “watch” she was slow, and finally put down
“10.” When on October 23 she was asked to write “Manhattan
State Hospital,” she wrote “Manhatt Hhospshosh,” and for
“Ward’s Island” (which she was told), “Ww Iland.” Then she
was asked to write “I wish to go home.” She wrote “I wish
to go home, go West.” Here again the first part was written
promptly.

We now can add some of the other replies which she gave.
Once she was asked “Do you know where you are?” She
promptly said, “Yes.” (Where?) No reply. On another
occasion, at the initial examination, she said she was home
or “in papa’s house.” Once when asked “Do you know me?” she
said “Yes.” (What is my name?) “Miss D.” (her name). On the
occasion on which she had stated that she had taken off her
clothes, she was asked “Where have you taken off your
clothes?” She made the irrelevant reply, “That was the girl
the one I had.”

2. Then she improved somewhat. On January 5 she walked
about a little more, though slowly, and still looked
slightly puzzled when questioned. She spoke more readily,
counted promptly though once stopped in the middle of the
exercise. In calculation she multiplied correctly 3 × 7,
but for 4 × 9 repeated the 21, and when given 9 × 9 she did
not answer. A few days later, though she lay again
motionless with her head raised as before, and, as she had
sometimes done, smiled brightly when accosted, she gave few
replies, but when asked to write down the month she slowly
wrote “December.” Asked to write it the second time, she
did it promptly. She also replied promptly by saying “Yes”
when asked whether Christmas, and again whether New Year’s,
had passed, but did not reply to the questions how long ago
Christmas, or how long ago New Year’s, had occurred. On
January 23 she was decidedly more free and prompt in her
replies, yet she still wet and soiled (in fact this did not
cease until the end of the month, when great improvement
occurred). At this time she gave quite a number of
calculations promptly, about an equal number wrongly. She
knew where she was, knew the names of a number of people
about her, but thought she had been here about two weeks
(four months), and gave the year and the date, the latter
as the 28th of January. When then told that it was
Thursday, January 23, and that she must remember it, and
asked five minutes later what she had been told, she again
said “January 28” and left out Thursday. To some questions
to which she did not know the answers, since she had an
amnesia for the time of their occurrence (the incidents of
coming here), she simply remained silent. Even on February
7, when she was much freer, helped the nurses, and said
herself she was “smarter,” she had difficulty in thinking,
said she was 17 (21), gave the date of her birth correctly,
but the current year as 1909 (1908) and still insisted she
was 17. She then did the calculations on paper, and with
considerable difficulty got correctly “22.” But she could
not straighten out the discrepancy. At that time, also, she
still wrote “Hospitital,” calculated even simple
multiplications with some mistakes, could not get the point
of a story, and to retention tests gave poor results.
Indeed, even seven days later, when she wrote a very
rational letter and appeared quite natural, she made some
omissions in her writing, and a few mistakes in spelling.

However, she now improved rapidly, and by March 31 she made
a very natural impression, was frank, free, had good
insight, calculated well, etc., understood a story,
retention was good.

She then gave the retrospective account embodied in the
history, and in addition told that she had no recollection
of going to the Observation Pavilion, the coming here, or
the first part of her stay, including presentation of the
case at a staff meeting, a physical examination and a blood
examination, and she claimed for a long time not to know
where she was, “I was in a kind of dazed condition.” She
also said she could not understand the questions which were
asked her. This probably refers, however, to the second
part, i.e., the partial stupor lasting for two months. She
did not “feel like talking,” the limbs “felt stiff-like.”

CASE 5.--_Annie K._ Age: 22. Admitted to the Psychiatric
Institute January 7, 1907.

_F. H._ The father was an alcoholic, who died when patient
was a child. A paternal aunt had a nervous breakdown, with
recovery. The mother appeared to be normal.

_P. H._ The mother stated that the patient was a rather
delicate child. She attended school irregularly, never felt
much interest in it, and was always glad to be at home and
help the mother take care of the other children. On the
other hand, she is said to have been quite lively, rather a
tomboy, with a temper. She left school at 14; learned
dressmaking for a year, but did not get along well. Then
she took several other positions, which she held for about
a year, getting on pretty well.

She married at 20. Her husband never supported her well and
often beat her. She had to borrow money to get along and
worried much. During pregnancy she seemed to worry more,
had crying spells, and often seemed absorbed in thought.

Three weeks before admission she gave birth to a child. The
labor was somewhat difficult, but she had no fever. She got
up on the tenth day, and then seemed to lose all interest,
did not attend to the baby, said she was not strong enough.
She sat about, appearing depressed. The mother then took
her and the baby to her house. There she sat or walked
about, said very little. But she repeatedly came to her
mother, said she had something to tell her, or that she had
“done something,” although she could never be induced to
say what. Once she came to her and said, “You are not going
to die.” She often moaned. Finally, she claimed a neighbor
had been saying she was poisoning the baby.

The patient herself gave, after recovery, the onset as
follows: When she married she knew her husband was not what
he should be, but not that he was so bad as he proved to
be. He was a gambler, did not support her, and this caused
her much worry. When she became pregnant, eight months
after marriage, this increased her worry, and throughout
the pregnancy she spoke much to a neighbor about her
worries, and said she did not know how she could manage,
pay the doctor, and the like, but she did not say much
about it to her mother (because the latter would have made
such a fuss about it, or would have said, “It serves you
right”). Then the childbirth came. This further accentuated
her worries. She felt her difficult circumstances, wondered
how she could get the necessary money, “I lay there
worrying.” And she claimed she did not sleep at all. About
her statement, mentioned by the mother, that she had done
something, she said that she thought she had poisoned the
child by giving it fennel tea, and that she thought a
neighbor who visited her said she had poisoned it. She was
then put to bed again, and one night she had a vision of
her father. This frightened her. She thought this meant he
had come for her and she wanted to die.

At the _Observation Pavilion_ she was dull, staring,
resisting attempts at passive motions.

_Under Observation:_ 1. There was nothing noteworthy in her
physical condition, except for a rise of temperature to
100° occasionally during the first month of her admission.
For the first four months she was often found lying in bed
with her head half raised from the pillow, or standing or
sitting about in constrained positions, immobile,
frequently she let saliva collect in her mouth. She usually
wet and sometimes soiled the bed. Sometimes, when sitting
in a constrained position, she let herself gradually slide
on the floor. She often began to feed herself when urged,
but would not finish, and had to be spoon-fed, as a rule.
She was never tube-fed. She was often quite stiff and
showed marked resistance. This was manifested either when
passive motions were tried, at which times she usually
resisted passively, i.e., she became more tense; or when
there broke through a more active aggression and she would
strike. Above all, the opposition showed itself towards the
nurses’ attention; in this she also showed either a
passive, aimless opposition and stiffness, or a more active
one; but even in the latter an open show of angry affect,
or plain irritation, though present at times, was by no
means constant. When it was present, she would strike quite
aimfully; once she struck the nurse and said, “You are the
cause of it all,” and once, when the nurse tried to give
her some milk, she said, in an irritated tone, “I wonder
people would not let me alone some time.” Again, she bit a
patient who tried to hold her. On another occasion she
quickly jumped up and pulled the hair of a patient who
evidently disturbed her by her noisy shouting. As was
stated, she usually wet the bed, resisted being taken to
the toilet, or when taken there, would not urinate or
defecate, but would do so as soon as she was returned to
bed; or she urinated while standing. The same perverse
opposition was seen when she would refuse a glass of milk,
but grab it when it was taken away and then refuse to let
go. She often would grasp the bedclothes or other things
and hold on aimlessly.

She rarely spoke, answered almost no questions, complied,
as a rule, not even with the simplest commands. To pin
pricks she did not react except at times by flushing. But
she did not stare, rather looked about, and was at times
easily attracted by noises or happenings about her, and
would then look in that direction not without some
interest. Often there was then an expression of
bewilderment. Her mood, however, was, as a rule, apathetic,
but at times, as stated, she showed some anger. Once she
wept, and a few times she smiled or snickered. As a rule,
this happened without appreciable cause. But once, when a
cheering remark was made, she smiled; or, when her picture
was taken (to show the peculiar constrained attitude with
the head raised from the pillow), she laughed loudly.

Although she spoke rarely, she made a few utterances in the
first few days. Thus she suddenly said: “I want to see Mr.
N.--what I said to him was not right,” or “Listen! there
are the priests calling,” or “You are all faking--it is me
that done it--they are all dressing up downstairs,” or “I
told you she was not able to nurse the baby,” or “I have
nobody, I am lost--I want to know the truth--my mamma,” or
she called her sister, “They are dead since last night.”

Even during the more stuporous state she could, a few
times, be made to write a little. Then she either wrote
very slowly and not more than a letter, or if she wrote
more, it was remarkably mixed up. Thus when asked to write
the date, she wrote, “Jane (mother’s name) to me to
Chrichst,” or when asked to write her name: “Annie take you
ktusto.”

As to her orientation, nothing could be made out as a rule.
At first, however, a few weeks after admission, she spoke
correctly of the month as January and spoke of the Island.
When at that time she was asked if she had a baby, she
said, in an annoyed tone, “I don’t know.”

2. In the beginning of May, i.e., four months after
entrance, her condition changed somewhat, and for two
months she presented the following state: She stood about,
or walked around slowly, usually with her arms folded. She
had a tendency to stand near the door. She had to be
assisted in dressing, pushed rather than led to her meals,
and urged to eat. For the most part, she would not answer
questions, but would either smile in a sneering way, or
just walk away, or say, “Oh, don’t bother me,” or “I don’t
want to talk,” and generally her attitude was rather sulky.
Nor was this only towards the physicians but towards the
husband, sister and child as well. When on May 17 the
sister came, she would not speak to her but said “Go away.”
The baby she simply pushed away sulkily when it was brought
to her. To the husband she said on May 31, “Go away, you
stink.” In the first part of this period, she presented
some bursts of elation, on one occasion turned somersaults,
indulged in a few pranks with laughter, or once, when a
knock at the door was heard, she called out “Holy gee,
cheese it, the cop.” But these occurred only in the first
part of the period. On June 1 she spoke to the nurse, said,
“What is the matter with these people, they must be crazy,”
asked to go home, and was then by the nurse found to be
oriented, and to know the names of people around her. But
when she was asked about the baby she would not answer, and
questioned whether she was not married, she said “I don’t
know.” Yet when the physician desired to talk to her, she
was just the same as before and remained so for two more
weeks. Another somewhat isolated occurrence was when on
June 18 she spoke a little to the physician, but she sat in
a constrained position when taken into the office and
answered many questions by “I don’t know,” namely, those
regarding her condition and feelings, the questions about
orientation, about her mother’s address, and her child’s
age; but when asked how long she had been married she said
correctly “Two years.”

At the beginning of July she improved quite rapidly, and on
July 5 appeared fairly free and gave a fair retrospective
account, with some urging, and it was thought that she
smiled somewhat too freely. However, on July 27, she seemed
perfectly well, had normal insight, and then gave the
second retrospective account, which, together with the
first, will now be taken up.

_Retrospectively:_ She claimed to remember things at home,
and at both interviews said she recalled being taken to the
Observation Pavilion. While there she thought she knew
where she was, remembered that she did not talk. She had a
feeling she was going to die and said “I thought I would
die if I kept still.” However, the transfer to this
hospital was vague in her mind, as was the entrance on the
ward, and she claimed not to have known for quite a while
where she was. She added that she used to wonder where she
was, how she had gotten here, and how she could get out,
and thought the questions which were asked were queer.
Individual occurrences, too, specifically inquired into
were not recollected, such as an examination in a special
room. Of the mixed-up writing at the end of the second
week, she had no recollection even when it was shown to
her. She did not recall having her picture taken (with eyes
open) two months after entrance. Yet a sudden angry
outburst ten weeks after admission was remembered. She
stated that she struck the patient because the latter
annoyed her by her shouting. She had a general recollection
of being stiff, having her head raised, and of soiling and
drooling, but could not account for it. She felt stubborn.
She also claimed not to have been hungry and not to have
felt pin pricks.

In regard to ideas which she had, she claimed to be afraid
at first that she would be cut up. She remembered repeated
visions of her father at night, also once of her dead aunt,
who said “Come to me.” She thought she was in a cemetery,
all the family were dead, the baby dead. In the beginning,
too, she sometimes heard a priest whom she had known, say
“Be good and God will look after you.”

In regard to the later period, she recalled that she got up
in May and felt cross. She did not answer because she did
not want to be bothered. She pushed the baby away because
she did not think it belonged to her, the husband because
she did not like him. (She did not think she was not
married.) She evidently remembered the visits, thought she
knew where she was, knew she stood near the door “because I
wanted to go home.” Besides the idea that the baby was not
hers, she recalled none, and thought she had no
hallucinations.

She was discharged perfectly well six months after
admission to the hospital. Soon after that, she left the
husband, once had him arrested in 1908 and sent to the
workhouse. She was again examined in 1913, and was found to
be perfectly well, and she stated she had been well since
the discharge.

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.

FOOTNOTES:

[1] MacCurdy has discussed the psychological phenomenon of a dramatist depicting a psychosis correctly in “Concerning Hamlet and Orestes.” _Journal of Abnormal Psychology_, Vol. XIII, No. 5.

[2] Many of these states seem to be hysterical rather than manic-depressive stupors, but so far as the unconsciousness goes, there is probably as much psychological as symptomatic resemblance between the two types of reaction.

[3] Kraepelin recognizes, of course, the occurrence of stupor symptoms or states in the course of manic-depressive psychoses. It is stupor as a clinical entity, as a separate psychosis, that he regards as one form of the catatonic, and therefore of the dementia præcox, reaction.

[4] Kirby, George H.: “The Catatonic Syndrome and Its Relation to Manic-Depressive Insanity.” _Jour. of Nervous and Mental Disease_, Vol. 40, No. 11, 1913.