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