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 praecox 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 formulae, were in the dementia praecox group, recovered. Adolf Meyer was one of the first to protest and offered categories of "Allied to Manic-Depressive Insanity" or "Allied to Dementia Praecox," 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 praecox, 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 praecox 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.

Loewenstein[21] reports an interesting case of a degenere 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 Loewenstein 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.

Froederstroem[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 seances, 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 praecox,[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 designee sous le Nom de Stupidite." 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 ueber Gefaengnisspsychosen." 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] Loewenstein: "Beitrag zur Differentialdiagnose des katatonische u. hysterische Stupors." Allg. Zeitschr. f. Psychiatrie, Bd. LXV.

[22] Gregor: "UEber die Diagnose psychischer Prozesse im Stupor." Leipzig Meeting, 1907. Reported in Neurol. Centralbl., 1907. S. 1083.

[23] Froederstroem: "La Dormeuse d'Okno. 32 ans de Stupeur, Guerison complete. Nouvelles Iconographies de la Salpetriere," 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 naera 9-arig oafbruten tvangsmatning; uppvaknande; total amnesi; helsa" (Hygiea, 1894, LVI., Part 2, No. 10, p. 355). Abstracted by Walker Berger, Neurol. Centralbl., 1895, S. 186.

[25] Leroy: "Un cas de stupeur, gueri au bout de deux ans et demi." Bull. de la Soc. Clin. de Med. Ment., III, 276, 1910. Abstracted in Zeitschr. f. d. ges. Neurol. u. Psychiatrie, Referate, Bd. II, S. 495.

[26] Myers, Charles S.: "Contributions to the Study of Shell Shock." Lancet, January 8, 1916, pp. 65-69. Lancet, September 6, 1916, pp. 461-467.

[27] Gucci, R.: "Sopra una particolarita del mutismo per stupore communicazione preventive." Archivio italiano per le malattie nervose, 1889, XXVI, 69-108. Reviewed in Neurol. Centralbl., 1889, S. 659.

[28] "Dementia Praecox oder Gruppe der Schizophrenie" Aschaffenburg's "Handbuch der Psychiatrie."

[29] Raecke: "Zur Prognose der Katatonie." Arch. f. Psychiatrie, Bd. XLVII, 1, 1910.

[30] Whitwell: "A Study of the Pulse in Stupor." Lancet, Oct. 17, 1891. Reviewed by Ziehen, Neurol. Centralbl., 1892, S. 290.

[31] Wetzel: "Die Diagnose von Stuporen." Baden-Baden Meeting of May, 1911. Reported in Neurol. Centralbl., 1911, S. 886.

[32] Vogt, Ragner: "Zur Psychologie der Katatonischen Symptome." Centralbl. fuer Nervenheilkunde, 1902, S. 433.

[33] Gnauck, R.: "Stupor nach Kohlenoxydvergiftung" (Charite-Annalen, 1883, p. 409). Reviewed by Moeli, Neurol. Centralbl., 1883, S. 237.

[34] Bonhoeffer: "Die Symptomatischen Psychosen," 1910.

[35] Knauer, A.: "Die im Gefolge des akuten Gelenkrheumatismus auftretenden psychischen Storungen." Zeitschr. f. d. ges. Neurol. u. Psychiatrie, Bd. XXI, S. 491-559.



INDEX

absorption, 163

activity, reduction of, 36, 100, 120

acute dementia, 251

adaptation, 107, 192

adrenalin, 180

affect, 9, 22, 32, 44, 113, 116, 117, 123, 170

affect, dissociation of, 128, 201, 205, 237

affect, inappropriate, 216, 237

affect, poverty of, 234

affect, shallow, 127

affectlessness, 171, 172

affects, combination of, 245

agitation, 156

akinesis, 121

akinetic psychoses, 4, 274

albuminuria, 40

allied to dementia praecox, 236, 260

allied to manic-depressive, 236, 260

allopsychic, 135

ambivalence, 147

amnesia, 9, 24, 68, 70, 267, 269

anergic or unconscious stupor, 258

anergic stupor, 255, 256

anesthesia, 196, 212, 268

anger, 118, 139

angiospastic, 276

animal, turning into, 171

Antaeus, 190

apathy, 36, 48, 112, 122, 123, 151, 152, 163, 181, 195, 225, 237

apathy, resemblance to absorption, 202

anxiety, 122, 123, 126, 137, 153, 162, 166, 198, 226

apoplexy, 224

arteriosclerotic dementia, 80

attention, 195

atypical features, explanation of, 200

autoerotism, 199

automatism, 268

Baillarger, 252

behavior, 195

"Benommenheit," 67, 273, 274

bewilderment, 79, 112, 120, 126

Bleuler, 67, 273

blocking, 163

blood-pressure, 181

blushing, 9

Bonhoeffer, 277

boredom, 247

bowels, interest in, 217

brain tumor, 5

breath, holding, 62

Brierre de Boismont, 252

burial, 111, 192

Calculation, 23, 24

Calvary, 111

Cannon, 180

Cases Adele M. (Case 24), 220 Alice R., 135, 140, 192 Anna G. (Case 1), 6, 47, 48, 68, 74, 77, 109, 127, 136, 140, 145, 147, 183 Anna L. (Case 16), 135, 149, 158 Anna M., 135 Annie K. (Case 5), 24, 69, 72, 105, 110, 111, 136, 139, 141 Bridget B., 135 Caroline de S. (Case 2), 11, 68, 109, 141, 178, 193 Catherine H. (Case 23), 216 Catherine M. (Case 18), 158 Catherine W. (Case 25), 221 Celia C. (Case 17), 155 Celia H. (Case 19), 167 Charles O., 143, 144, 178 Charlotte W. (Case 12), 83, 106, 112, 113, 116, 127, 136, 141, 144, 166, 201 Emma K., 71, 140 Harriett C., 138 Helen M., 130 Henrietta B., 138, 140 Henrietta H. (Case 8), 42, 74, 77, 105, 106, 110, 111, 115, 136 Isabella M., 136, 144, 147 Johanna B., 135, 138 Johanna S. (Case 13), 91, 120, 127, 136 Josephine G., 138 Laura A., 71, 77, 135, 138, 140, 142, 193 Maggie H. (Case 14), 71, 96, 109, 140, 194 Margaret C. (Case 10), 55, 75, 78 Mary C. (Case 7), 39, 42, 71, 74, 77, 121, 136, 138, 178, 194 Mary D. (Case 4), 20, 47, 69, 70, 71, 74, 76, 109, 136, 145 Mary F. (Case 3), 14, 68, 105, 110, 111, 115, 140, 142, 164, 183 Mary G., 140, 141 Meta S. (Case 15), 99, 109, 127, 135 Nellie H. (Case 22), 214 Pearl F. (Case 9), 51, 75, 142 Rose S. (Case 21), 210 Rose Sch. (Case 6), 35, 74, 75, 145 Rosie K. (Case 11), 62, 75, 105, 112, 178 Winifred O'M. (Case 20), 207

catalepsy, 13, 21, 31, 32, 36, 86, 94, 95, 102, 115, 128, 143, 144, 145, 147, 209, 211, 235, 239

catatonia, 4, 5, 50, 128, 205, 236, 261

catheterization, 85, 86, 102

cemetery, 105, 112

childbirth, 159

childhood, 188, 195

Chotzen, 262

Christ, 86, 115

Christian Science, 150

circular psychosis, 5, 126

circulation, 180

Clark, 184

clouding, 67

Clouston, 258

cocoon, 109

coffin, 88, 106, 114

coma, 176, 223

concussion, aerial, 224

confusion, 163

constipation, 92

convent, 117

convulsive attacks, 15

crime, 248

crucifix, 88

crucifixion, 86, 106, 114, 161

crustaceans, 148

cut-up idea, 94

cyanosis, 32, 63, 180

Dagonet, 3, 249, 250, 253, 254, 258

death, feigned, 5, 83, 137, 196, 246

death, mutual, 192

death, projected, 198

death, relation with affect, 110

death ideas, 3, 46, 47, 50, 52, 58, 65, 83, 97, 104, 107, 109, 110, 111, 114, 115, 119, 122, 136, 137, 138, 152, 153, 156, 159, 163, 166, 187, 190, 191, 192, 199, 212, 225, 235, 240

death of others, 192

deep stupor, 1, 6, 41, 199

deep stupor, explanation of, 197

Delasiauve, 253

delirium, 176

delusional stupor, 255, 256

delusions, 165

delire melancholique, 252

dementia praecox, 4, 5, 62, 123, 127, 128, 205, 225

depression, 5, 117, 123, 137, 156, 236, 253

depression, differentiation of, 48, 124, 226

dermatographia, 102, 180

deterioration, 210

diabetes, 224

diarrhea, 45, 64, 178

dissociation, 225

distress, 119, 122, 154, 156, 162

dreams, 161, 190

drooling, 132, 181

drowning, 87, 192

Earth, 107, 111, 190

echolalia, 275

echopraxia, 275

ecstasy, 91, 162, 191

elan vital, 123

elation, 44, 91, 123, 127, 151, 157

electric chair, 85, 110, 119

electricity, 150

emaciation, 8, 32, 58

emotion, 62

emotion, inconsistency of, 126

emotions and contact with reality, 164

energy, 187, 194

epilepsy, 5, 183, 199, 224, 242, 254

epileptic aura, 184

epileptic confusion, 80

epileptic deterioration, 80

erotic, 161

erotic ideas, 90

Esquirol, 251

Etoc-Demazy, 251

Euripides, 2

excretion, habits of, 230

extroversion, 195

family visits, 232

father, 104, 109, 110

fear, 111

fever, 8, 13, 26, 32, 38, 40, 45, 64, 102, 160, 176, 235, 241

filthiness, 210

fire, 151, 157

flippancy, 129

flushing, 27, 127, 128, 180

food, refusal of, 99, 104

Forel, 182

Froederstroem, 265

Gadelius, 267, 268

Ganser reaction, 263

Georget, 251

German psychiatry, 259

Gnauck, 277

giggling, 206

God, 115, 160, 162

Golden Age, 187

Gregor, 265

Gucci, 271

guilt, 157

hair, loss of, 32, 58, 180

heat production and loss, 179, 181, 242

Heaven, 87, 88, 104, 106, 108, 109, 111, 114, 115, 117, 118, 160, 162, 166, 171, 191, 240

Hell, 240

Hoch, 164

hyperaemia, 8

hyperesthesia, 268

hypochondria, 225, 253

hypomania, 243

hypnotism (see mesmerism), 145, 213

hysteria, 3, 135, 184, 225, 264, 267, 269

ideational content, 82, 235

immobility, 85, 94, 196

immorality, 150

impulsiveness, 50, 113, 128, 172

impurities in stupor reaction, 66

inaccessibility, 141

inactivity, 17, 30, 40, 48, 56, 62, 88, 97, 102, 123, 132, 152, 163, 194, 225, 234, 238

inactivity, patients' explanation of, 134

incest ideas, 209

inconsistency of reaction, 134, 214, 215, 245

incontinence (see wetting and soiling), 52, 57

indifference, 123, 124, 142

infantile reactions, 196

infections, 5, 178, 241

insight, 157

insomnia, 39

instinct of self-preservation, 188, 191, 198

interest, 99, 195

internal secretions, 178

internal thoughts, 163

interruptions of stupor, 130, 197, 238, 244

introversion, 164, 227

involuntary nervous system, 178, 180

involution melancholia, 129, 195, 225, 226

jaundice, 21

Jung, 107

Kahlbaum, 4, 260

Kirby, 4, 6, 164, 234

Knauer, 175, 278

Kraepelin, 4, 260, 269, 271, 272, 273

Kutner, 262

laughter, 56, 141

Leroy, 269

leucocytosis, 8, 13, 40, 64, 178

levels, principle of, 198, 244

Loewenstein, 264

MacCurdy, 2, 184

make-up, mental, 5

malignant stupors, 205

mania (or manic), 5, 126, 137

mania, absorbed, 125, 226, 245

manic content, 166

manic-depressive insanity, 149, 167

manic-depressive insanity, mixed conditions in, 202

manic-depressive insanity, pathology of, 174

manic episodes, 191

manic stupor, 125, 245, 253

marriage, 160, 169

masturbation, 196, 209, 219

melancholic or conscious stupor, 258

memory (see thinking disorder), 40, 67, 168, 195

menstruation, 8, 56, 61, 100, 168, 182, 236, 242

mesmerism, 86, 114, 117, 141, 144

Meyer, Adolf, 260

Meyer, E., 261

midday nap, 247

mixed conditions, 202, 273

Moeli, 264

Moses, 108

mother's body, 108

movement, spontaneous, 133

muscular resistiveness, 224

mutism, 10, 22, 31, 57, 62, 88, 104, 124, 134, 209, 271

mutual death, 165, 192, 196, 248

Myers, 270, 271

mystics, 3

mythology, 107, 108, 190, 240

negativism, 5, 31, 52, 56, 65, 128, 138, 139, 199, 209, 225, 235, 238, 243, 276

negativism, explanation of, 196

nephritis, 224

neuropsychic defect, 174

neurotic, 150

nervous, 159

Newington, 3, 254, 255, 257

Nirvana, 166, 188, 200, 248

nourishment, 229, 242

OEdipus, 165

oestrous cycle, 182

onset, 96

onset, depressive, 99

ophthalmic disease, 230

Orestes, 2

organic delirium, 175

organic dementia, 67

organic stupor, 223

orientation (see thinking disorder), 9, 53, 154, 156, 159, 170, 245

Osiris, 108

pain, 133

Papanicolaou, 182

paragraphia, 80

paralysis, feeling of, 105

paralysis, general, 5, 254

partial stupor, 34, 206

perplexity, 125, 152, 153, 154, 155, 156, 160, 162, 164, 165, 169, 172, 208, 226, 245

perplexity, differentiation of, 227

perseveration, 145, 148, 276

personality, 1

perversity, 138

physical disease, 175

physical symptoms, 174, 176

Pinel, 249, 251

poison, 97, 172

primitive ideas, 108

prison, 105, 169

prognosis, 4, 5, 206

prostitution, 157, 161

psychoanalysis, 161

psychobiological reaction, 246

psychogalvanic reflex, 276

psychological explanation, 186

psychological factors, 175

pulse, 63, 92, 128, 180

Rank, 107

reality, 107, 187

recuperation, 189

rebirth, 107, 110, 114, 115, 119, 120, 121, 122, 187, 189, 190, 191, 240

regression, 187, 188, 191, 192, 194, 198, 199, 243

religious visions or ideas, 2, 162

resentment, 98

resistiveness, 54, 97, 102, 112, 127, 129, 133, 141, 147, 156, 211, 225

respiration, 180

resurrection, 159

restlessness, 53, 120, 169

retention of urine, 224, 230

rheumatism, 175

rigidity, muscular, 142, 179

Romberg sign, 262

rousing, 176

sadness, 111, 113, 121, 122, 124

St. Catherine of Siena, 2

St. Paul, 2

saliva, 30, 63, 181

scattered speech, 207, 208

schizophrenia, 67, 214

seclusiveness, 207

secondary stupor, 259

Seelig, 263

self-injury, 50, 57

sexual excess, 251, 253, 258

sexual ideas, 209, 219

sexual sensations, 209

ship, 87, 106, 118

sick, 136

skin, dry, 180

skin, greasy, 43, 180

sleep, 188, 189, 247

slowing of thought, 125

slowness, 85, 119, 160

smearing of feces, 142

smiling, 127

social status, 236

soiling, 30, 132, 172, 196, 225, 230, 235

somatopsychic, 135

sphincters, control of, 133

spirits, 89

spoiled child reaction, 129, 139

starvation, 182

stereotypy, 276

Stern, 261

stimulation, mental, 231, 246

Stockard, 179, 182

stubbornness, 142

stupidity, 93

stupor, diagnosis of, 223 hysterical, 225 malignant, 205, 206 organic, 223 reaction, 35, 236 relation to manic-depressive insanity, 173

sudden mental loss, 71

suggestibility, 145, 198, 276

suicidal impulses, 50, 84, 104, 116, 118, 128, 172, 230, 235, 240

suicide, 188

sulkiness, 129

sullenness, 142

suprarenals, 242

swallowing, 133

sweating, 63, 102, 179, 180

swimming movements, 94

syncopal attacks, 64

tears, 95, 98, 117, 128, 153

tense of ideas, 116

thinking disorder, 22, 31, 37, 39, 41, 45, 48, 59, 67, 75, 124, 125, 148, 152, 157, 235, 239, 247

thinking disorder, explanation of, 195

tongue, coated, 13

toxins, 175

trauma, 5, 224

treatment, 229

ulceration of eyes, 133

unconscious ideas, 163 motives, 186

unconsciousness, physiological, 199, 224, 277

underground, 240

understanding, 67

uneasiness, 93, 94, 95, 121

unfaithfulness, 97

unhappiness, 192

urine, retention of, 31

Villermay, 250

Vogt, 276

vomiting, 45

water, 94, 95, 106, 107, 114, 120

weakness, 137, 160

wealth, 169

wedding ring, 117

weight (see emaciation), 38, 52, 61

Wernicke, 3, 273

wetting, 30, 40, 132, 151, 170, 172, 196, 225, 230, 235

Wetzel, 276

whining, 171, 225

Whitwell, 276

Wilmanns, 261

womb, 108

worry, 110

writing, 27

Ziehen, 276



[Transcriber's Note:

The following corrections have been made:

p. 1: antequated to antiquated (antiquated methods)

p. 11, 97, 100: period to colon (Under Observation:)

p. 53: extra "when" removed (from "In June, 1914, when she was seen smiling at times." to "In June, 1914, she was seen smiling at times.")

p. 64: period to colon (Physical condition during the stupor:)

p. 84: 24 italicized to match other dates (October 24)

p. 91: missing blank line added between Case 12 and 13

p. 93: aswer to answer (in answer to questions)

p. 150: fatiguable to fatigable (nervous and fatigable)

p. 153: phenomenom to phenomenon (unusual phenomenon for a stupor patient)

p. 159: comma added (correcting his grammar, and cried easily.)

p. 161: missing "in" added (appeared in the statement that her father)

p. 171: missing open quote added (she wants to go "to the river,")

p. 198: funadmental to fundamental (most fundamental symptoms)

p. 211: salivia to saliva (drooling saliva)

p. 220: inaccesibility to inaccessibility (disinterestedness and inaccessibility)

p. 252: dimunition to diminution (just as well in the diminution)

p. 256: or to of (relaxation of sphincter muscles)

p. 262, Footnote 19: v. to u. (Zeitschr. f. d. ges. Neur. u. Psychiatrie)

p. 265, Footnote 23: Zeitsch. to Zeitschr. to match other instances (Zeitschr. f. d. ges. Neur. u. Psychiatrie)

p. 271, Footnote 27: Archivo to Archivio (Archivio italiano per le malattie nervose)

p. 280, Index: catherization to catheterization

p. 282, Index: ophtalmic to ophthalmic (ophthalmic disease)

Irregularities in capitalization (e.g. Dementia vs. dementia) and hyphenation (e.g. off-hand vs. offhand) have not been corrected. A repetitive sentence on p. 46 (Then she became stupid, although neither sad nor happy. Then, she claimed, she got stupid, but neither sad nor happy.), and two spaced em-dashes on p. 87 have also been retained. Minor punctuation errors (e.g. missing period, missing close or open quote where intended placement is clear) have been corrected without note. The abbreviations "p.m.", "e.g." and "i.e." have been standardized, with no space.

In the Latin-1 and ASCII versions, oe/OE ligatures have been changed to oe/OE. In the ASCII version, the following characters were changed: mid-dots to periods (in front matter); degree signs to deg.; multiplication symbols to x; half fractions to -1/2; ae ligatures to ae; o diaeresis/umlaut to o (e.g. cooperation) or oe (e.g. Loewenstein) depending on context; u umlaut to ue/UE; a umlaut to ae; e diaeresis to e; o circumflex to o; e acute to e; e grave to e; and a acute to a.]

THE END