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

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

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

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

CHAPTER XII
DIAGNOSIS OF STUPOR

In any functional psychosis an offhand diagnosis is dangerous. When one deals with such a condition as stupor, however, the problem is exacting, for, although "stupor" may be seen at a glance, what is seen is really only a symptom or a few symptoms. "Stupor," then, is more of a descriptive than a diagnostic term. The real problem is to determine the psychiatric group into which the case should be placed. This is a difficult task, for the differential diagnosis rests on the observation and utilization of minute and unobtrusive details. A correct interpretation can be only reached by obtaining a complete history of the onset and observing the behavior and speech of the patient for a long period, usually of weeks, sometimes of months. With these precautionary words in mind, it may be well to summarize briefly the diagnostic problems in connection with benign stupor.

In the first place one naturally considers the differentiation from conditions of organic stupor or coma. Since psychotic stupors never develop without some signs of mental abnormality, the history is usually a sufficient basis for final judgment. In case no anamnesis is obtainable the functional nature of the trouble may be recognized by the absence of those physical signs which characterize the organic stupors. One sees no violent changes in respiration, pulse or blood-pressure, such as are present in the intoxication comas of diabetes or nephritis. There is no characteristic odor to the breath, and the urine is relatively normal. The unconsciousness of trauma or apoplexy is accompanied by focal neurological signs. Even in aerial concussion (so frequently seen in the war) where no one part of the brain is demonstrably affected more than another, there are neurological evidences of what one might call "physiological" unconsciousness. The eyes roll independently, the pupils fail to react to light. On the other hand, there are definite symptoms characteristic of the functional state. Mental activity is evidenced by a muscular resistiveness or retention of urine. Even in states of complete relaxation the eyes move in unison, the pupils react to light, and almost universally the corneal reflex is present. The patient appears in a deep sleep rather than actually unconscious.

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

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

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

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

Great difficulties are also met with in the manic-depressive group proper. So often a stupor begins with the same indefinite kind of upset as does another psychosis that the development may furnish no clew. Any condition where there is inactivity, scanty verbal productivity and poor intellectual performance resembles stupor. This triad of symptoms occurs in retarded depressions, in absorbed manic states and in perplexities. Negativism and catalepsy are never well developed except in stupor. So if these symptoms be present the diagnosis is simplified. But they are often absent from a typical stupor. Let us consider these three groups separately.

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

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

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

CHAPTER XIII
TREATMENT OF STUPOR

In dealing with cases of benign stupor the first duty of physician and nurse is naturally the physical hygiene of the patient. More is needed to be done in the bodily care of these persons than for most of the inmates of our hospitals for the insane. It is perhaps no exaggeration to claim that a deeply stuporous patient needs as much attention as a suckling babe. In the first place, the patient must be fed. It is important for mental recovery that the individual in stupor should be stimulated to effort as much as possible. Consequently there is an economy of time in the long run in taking pains to get the patient to feed himself in so far as that is possible. He should be led to the table and assisted in handling his own spoon and cup. If this is not practicable, he should then be spoon-fed, and if this in turn is found to be out of the question, tube-feeding should be resorted to. But this last should never be looked on as a permanent necessity, but only as a method of maintaining the patient's health until such time as he may be capable of independent taking of nourishment. In exactly the same way it is of prime importance to get the patient to attend to the natural habits of excretion. He should be led to the toilet or to a chair commode, and efforts to this end should be persistent, just as are those of a good child's nurse who has the ambition of making her charge develop normal habits. Naturally those who retain urine and feces should be watched to see that this retention does not last long enough to menace health. The physical aspects of treatment are exhausted with consideration for cleanliness. On account of the stupor patients' inactivity and frequent tendency to wetting and soiling, this is a particularly important consideration. It goes without saying that the perineal region should be kept scrupulously clean. If any infections are to be avoided, eyes, nose and mouth should also be cleansed frequently. A patient who is so indifferent as to keep the eyelids open for such a long time that the sclera dry and ulcerate is also apt to let flies settle and produce serious ophthalmic disease.

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

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

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

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

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

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

CHAPTER XIV
SUMMARY OF THE STUPOR REACTION

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

It being established that stupors occur as a temporary form of insanity[12] psychiatry is faced at once with the problem of describing these conditions accurately in order to ascertain their nosological position. To this end we first examined typical cases of deep stupor and found that the clinical picture is made up of the following symptoms: In the foreground stands poverty of affect. The patients are almost unbelievably apathetic, giving no evidence by speech or action of interest in themselves or their environment, unmoved even by painful stimuli. Their faces are wooden masks; their voices as colorless when words are uttered. In some cases sudden mood reactions break through at rare intervals. The second cardinal symptom is inactivity. As a rule there is a complete cessation of both spontaneous and reactive movements and speech. So profound may this inhibition be that swallowing and blinking of the eyes are often absent. The trouble is not a paralysis, however, for reflexes without psychic components are unaffected. Possibly related to the inactivity is the preservation of artificial positions which is called catalepsy, a fairly frequent phenomenon. A tendency opposite to the inactivity is seen in negativism. This perversity is present in all gradations from outbursts of anger with blows and vituperation to sullen, or even emotionless, muscular rigidity. This last occurs most often when the patient is approached but may be seen when observations are made at a distance. Frequently wetting and soiling are due to negativism, when the patient has been led to the toilet but relaxes the sphincters so soon as he leaves it. A constant feature is a thinking disorder. On recovery memory is largely a blank even for striking experiences during the psychosis and, when accessible during the stupor to any questioning, a failure of intellectual functions is apparent. An ideational content may be gathered while the stupor is incubating, during interruptions, or from the recollections of recovered patients. Its peculiarity is a preoccupation with the theme of death, which is not merely a dominant topic but, often, an exclusive interest. Probably to be related to this is a tendency, present in some cases, to sudden suicidal impulses, that are as apparently planless and unexpected as the conduct of many catatonics. Finally the disease is prone to exhibit certain physical peculiarities. A low fever is common and so are skin and circulatory anomalies. A loss of weight is the rule, and menstruation is almost always suppressed.

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

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

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

Closely related to the apathy, and probably merely an expression of it, is the inactivity which is both muscular and mental. It exists in all gradations from that of flaccidity of voluntary muscles, with relaxation of the sphincters, and from states where there is complete absence of any evidence of mentation to conditions of mere physical and psychic slowness. After recovery the stupor patient frequently speaks of having felt dead, paralyzed or drugged.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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