Since his paper is the foundation for this present study, it should be reviewed carefully. He first points out that Kraepelin's "Dementia præcox"
includes much more than it should with its inevitably bad prognosis. He shows how others have found patients with catatonic symptom complexes proceed to recovery and speaks of these symptoms occurring in epilepsy and even in frankly organic conditions, such as brain tumor, general paralysis, trauma and infections. Kirby's first claim is that there are probably fundamentally different catatonic processes, deteriorating and non-deteriorating. Lack of knowledge has prevented us from understanding the meaning of the symptoms and hence making the discrimination. He points out that stupor seems to represent an attitude of defense, similar to feigned death in animals, and that in a number of his cases it was clear that the stupor symbolized the death of the patient. Apparent negativism, he found to be often a consciously assumed attitude of aversion towards an unpleasant emotional situation. In cases where there had been no prodromal symptoms pointing definitely to dementia præcox the outcome was almost always good. To discriminate the cases with good outlook from those with bad, he discerned no difference in the stupors themselves, but observed that the mental make-up and initial symptoms differed sufficiently for diagnosis to be made. His most important point is, perhaps, that these benign stupors showed a definite relationship to manic-depressive insanity in that some patients passed directly from stupor to typical manic excitement, while in others a "catatonic" attack replaced a depression in a circular psychosis.
Kirby introduces, then, the idea of stupor being a type of reaction which can occur either in dementia præcox or in manic-depressive insanity. The matter cannot be left there, in fact it raises new problems: what constitutes the reaction? how are the various symptoms interrelated? are they different in deteriorating and acute cases? what is the teleological significance of the reaction? if it be an integral part of the manic-depressive group, how does it affect our conceptions of what manic-depressive insanity is? More than five years have been spent in endeavors to answer these questions and the results of the study are now presented.
Naturally the first point to be settled is: what constitutes the stupor reaction itself. We can say at the outset that it is seen in the purest form in benign cases, hence they make up the material of this book. To discover the symptoms of the disorder one cannot do better than to study them in their most glaring form in deep stupors, where consistently recurring phenomena may be assumed to be essential to the reaction.
Case 1.—Anna G. Age: 15. Admitted to the Psychiatric Institute July 25, 1907.
F. H. The mother and two brothers were living and said to be normal. The father died of apoplexy when the patient was seven.
P. H. The patient was sickly up to the age of seven, but stronger after that. It is stated that she got on well at school, though she was somewhat slow in her work. She was inclined to be rather quiet, even when a child, a bit shy, but she had friends and was well liked by others. After recovery she made
a frank, natural impression. She was always rather sensitive about her red hair. She began to work a year before admission and had two positions. The last one she did not like very well, because, she alleged, the girls were "too tough."
Three weeks before admission she came home from work and said a girl in the shop had made remarks about her red hair. She wanted to change her position, but she kept on working until six days before admission. At that time her mother kept her at home as she seemed so quiet, and when the mother took her out for a walk she wanted to return, because "everybody was looking" at her. For the next two days she cried at times, and repeatedly said, "Oh, I wish I were dead—nobody likes me—I wish I were dead and with my father" (dead). She also called to various members of the family, saying she wanted to tell them something, but when they came she would only stare blankly. For a day she followed her mother around, clung to her, said once she wanted to say something to her, but only stared and said nothing.