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.