Rose Sch. (Case 6) was remarkable, in connection with the present problem, in her unusually poor answers. She either merely repeated the questions, or made irrelevant superficial replies, or said she did not know, this even with very simple questions. When better, too, though not quite well, she showed striking discrepancies in time relations and incapacity to correct them. It would seem that in this case there was something more than an acute interference with the intellectual processes, such as we are here discussing. As a matter of fact, we have the statement in the history that the patient herself said she was slow at learning in school and had not much of an education. A congenital intellectual defect
and the attitude which it creates may, however, as my experience has repeatedly shown me, very greatly exaggerate an acute thinking disorder. The case, therefore, while it shows us an unquestionably acute interference with the intellectual processes, does not give us useful information about its nature. More information can be gathered from Mary D. (Case 4). Even toward the end of her marked stupor some replies were obtained chiefly by making her write. When asked to write Manhattan State Hospital, she wrote Manhatt Hhospshosh, and for Ward's Island, Ww. Iland. Again, instead of writing 90th Street, she wrote 90theath Street. These are plainly reactions of the path of least resistance or, in these instances, of perseveration. Of the same nature are some of her other replies in writing or speaking. After she had been asked to write her name, she was requested to add her address, or the name of the hospital; she merely repeated the name. Similarly, when asked whether she knew the examiner, she said "Yes," but when urged to give his name, she gave her own. In the partial stupor at a time when she knew where she was, knew the names of some people about her, the year and approximately the date, she made mistakes in calculation and could not get the point of a test story. Moreover, she failed in retention tests without there being any evidence of anything like a marked fundamental retention disorder, such as we find in Korsakoff psychosis. It seems that these results are best termed defects in attention, which chiefly interfere
with the apprehension of more difficult tasks. As we shall see later, this seems to be rather characteristic of these cases. Another point which should be mentioned is the fact that her reaction to questions which she was unable to answer (such as matters which referred to her amnesic periods) was peculiar, inasmuch as she did not only not try to think them out, but seemed indifferent to her incapacity, simply leaving the question unanswered. This too, as we shall see later, is characteristic. Laura A., at a time when she could be made to reply, merely repeated the question, again a reaction of least resistance. The same patient sometimes asked, "Where am I?" Mary C. (Case 7) made similar queries. Although she was at times approximately oriented, she would say, "I don't know where I am," or "I can't realize where I am," or more pointedly, "I can't take in my surroundings." She often did not answer and sometimes seemed bewildered by the questions. Henrietta H. (Case 8) again showed some defect of orientation and mistakes in calculation, and above all, marked mistakes in writing (for Manhattan State Hospital—Manhaton Hotspal). A special feature here is that this occurred immediately after she had been quite talkative, but suddenly had relapsed into a dull state. Anna G. (Case 1), during the third phase of her psychosis, showed the following: Although she was approximately oriented and answered promptly simple questions; e.g., about orientation or simple calculation, she, like these other patients, simply remained silent when more
difficult intellectual tasks were required of her (more difficult calculations); or when she was asked how long she had been here (which involved data that could not be available to her, owing to her amnesia); or when questions were put to her regarding her feelings or the condition she had passed through. On the other hand, she sometimes gave appropriate replies in the words "yes" or "no," but it was difficult to say whether these answers did not also represent the path of least resistance.
We will finally take up the last phase of Margaret C. (Case 10). Although she was entirely oriented, there was a certain vagueness about her answers which is difficult to formulate. She was telling about the onset of her sickness and said that at that time her mind was taken up with prayers about the salvation of her relatives. She was asked exactly when it was that she thought of this and she answered "Now?" (What period are we talking about?) "The present." (What did I ask you?) "About this period of my sickness." (Which one?) "What sickness?" She said herself at this point, "I am rather stupid." Again when asked how her mind worked, she said, "Pretty quickly sometimes—I don't know." (As good as it used to?) "No, I don't think so." (What is the difference?) "There is no difference." (What did I ask you?) "The difference." (The difference between what?) "You did not say." In this the shallowness of her comprehension and thinking is well shown, and it seems here again perhaps justifiable to formulate the main
defect as one of attention, which prevents completion of a complicated process of comprehension. A feature of further interest in this case is that automatic intellectual processes, such as those necessary for the writing of a long poem from memory, were not interfered with.
Summary
In the most pronounced stupor we have evidently a more or less complete standstill in thinking processes. Practically no impressions are registered and consequently nothing is remembered except events that occurred in some short periods when some affective stimulus, or a brief burst of elation, lifts the patient temporarily out of the deep stupor. It is impossible to say whether the statement of a complete standstill has to be qualified. In some stupors repeated environmental stimuli sometimes make at least a vague impression, so that while spontaneous recollection is impossible a feeling of familiarity is present when the patient is again confronted with this environment. This might be an exception to the dictum of complete mental vacuity, or it may be that there are somewhat less pronounced stupor reactions. When more is perceived, there is often a retrospective statement of having felt mixed up, being unable to take in things, or, directly under observation, the patient may say, "I cannot realize where I am," "I cannot take in my surroundings." In harmony with this is the fact that questions often produce a certain bewilderment.
In quite pronounced states in which some replies can still be obtained, we find that the intellectual processes may be interfered with to the extent of a paragraphia, i.e., a remarkably mixed-up writing in which perseveration (one form of following the path of least resistance) plays a prominent part. This same principle is also seen in such reactions as the repetition of the question or the senseless repetition of a former answer. These phenomena remind us of what we see in epileptic confusions, in epileptic deterioration and in arteriosclerotic dementia.
In milder cases difficulties in orientation may be more or less marked; or there may be incapacity to think out problems, although the orientation is perfect. The more automatic mental processes may run smoothly (memory and calculation may be excellent) and there may yet be a certain shallowness in thinking, a defect of attention (a purely descriptive term) which is most obvious in the patient's inability to grasp clearly the drift of what is going on or the meaning of complicated questions. I am inclined to think that poor results in retention tests are entirely due to this attention disorder, for we have no evidence of any fundamental retention defect such as we find in the totally different organic stupors. From a practical point of view it is important at this place to call attention to the fact that such mild changes are particularly seen in end stages. Even when pronounced negativistic tendencies do not play a prominent rôle, the patient is then apt to be silent chiefly as a result of the residual