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 re
tardation. He writes, of course, mainly of dementia præcox,[28] but makes some remarks germane to our problem. In the first place he denies the existence of stupor as a clinical entity, except perhaps as the quintessence of "Benommenheit", it is the result of total blocking of mental processes. Consequently, he says, one can observe the external features of stupor in all akinetic catatonics, in marked depressive retardation, when there is a lack of interest, affect or will, in autism, with twilight states, as a result of negativism or, finally, when numerous hallucinations distract the patient's attention into a world of fancy. He notes that in all stupors (with the exception, perhaps, of "Benommenheit") the symptoms may disappear with appropriate psychic stimulation or that some reaction, no matter how larval, may be observed. He speaks, for instance, of the visits of relatives waking the patient up.
His only real group is "Benommenheit," which he separates out as a true clinical entity. This seems to correspond roughly with our "Partial Stupors." It is essentially an affectless, thinking disorder, usually acute, sometimes chronic, occurring among schizophrenics. He believes that it is the result of some organic process (intracranial pressure or toxin). Activity is much reduced or absent; they have poor understanding, answer slowly or confusedly; their actions are sometimes as ridiculous as those of people in panic (e.g., throwing a watch out
of the window when the house is on fire); the defect is best seen in writing, for large elisions are found in sentences. He was able to analyze only one case and she retained her affect; it was even labile and marked. One suspects that such a case might, perhaps, not really find a place in the "Benommenheit" group even as Bleuler himself describes it.
With the exception of Kirby, whose work has already been discussed in the introduction, we have been able to find only one author who has attempted any symptomatic discrimination of the recoverable and malignant catatonic states. Raecke[29] made a statistical study and found that 15.8% recovered, 10.8% improved, 54.4% remained in institutions, while 30% died. With the etiology mainly exogenous 20% recovered and 14.3% improved. A good outcome was seen in 30.2% of hereditary cases, while only 22.7% did well in the non-hereditary group. His most important contribution is in his formulation of good and bad symptoms. He thinks that dull, apathetic behavior with uncleanliness and loss of shame are not so unfavorable as has been thought. Malignant symptoms are grimacing with prolonged negativism but without essential affect anomaly, decided echopraxia and echolalia and protracted catalepsy. We would agree with this, although command automatisms have not been prominent either in our benign or malignant stupors.
Two writers have made special observations that should be confirmed and amplified before their significance can be established. Whitwell[30] thinks that in addition to a diminished activity of the heart there exists a pathological tension. Ziehen says that he also has frequently seen angiospastic pulse-curves in exhaustion stupor or acute dementia, but that other pulse pictures may be seen as well. Any such studies should be correlated rigorously with the clinical states before they can have any meaning. Wetzel[31] tested the psychogalvanic reflex in stupors and in normal persons who simulated stupors. He found them different.