which it seems a part, an exaggeration of some symptom of the general condition. Evidently he views stupor as a type of reaction: as a more or less complete suspension of the operation of intellectual faculties, a more or less sudden subtraction of nervous forces. This reaction can result from a fright or the memory of it, a brain lesion or trauma, the action of narcotics, exhausting fevers, excessive grief, the terrors of alcoholic hallucinations, epileptic seizures, profound anemia and nervous exhaustion consequent on sexual excess. He is careful to say that both symptoms and treatment vary with the varied etiologies.
He credits Pinel with being the first to call attention to stupor. This author claimed that some persons with extreme sensibility could be so upset by any violent emotion as to have their faculties suspended or obliterated. He noted, too, that stupors frequently terminated in manic phases of 20 to 30 days' duration. Pinel also emphasized the apathy of these cases. Esquirol called stupor "acute dementia," a term which persisted in French literature for a long time. He described an interesting circular case where alternations between mania and typical stupor took place. He mentions too the dangerous, impulsive tendencies of many patients. Georget emphasized the fact which Pinel had also noted, that retrospectively the stupor patient says his mind was a blank during the attack. In 1835 Etoc-Demazy published on the subject. He regarded stupor not as a separate form of insanity
but a complication ensuing on monomania or mania. He recognized the partial as well as complete stupor. He thought the condition was due to cerebral edema, as did other writers of that period. Dagonet remarks about this last—a lesson not learned in fifty years by the profession—that demonstrable edema does not produce the typical symptoms of stupor. Baillarger in 1843 (Annales Médico-psychologiques) was the first whose ambition to simplify psychiatric types led to denial of a separate kind of reaction. He claimed that stupor was not a form of insanity but an extension of a "délire mélancholique." As Dagonet remarks, every symptom by which he characterizes stupor is a psychiatric symptom and insanity can consist just as well in the diminution as the perversion or exaltation of normal faculties. Some of Baillarger's cases had false ideas, some apparently none at all. Dagonet thinks this justifies two types, one a dream-like state and another where no ideas are present, although he admits one may be an exaggeration of the other. Brierre de Boismont (Annales Médico-psychologique, 1851, p. 442) compares these two kinds of stupors to deep sleep when intelligence is completely suspended and to sleep with dreams. (These two types would correspond to our "absorbed mania" and true deep stupor.) He urges strongly the separation of stupor from melancholia as an entirely different type of reaction, in this connection citing the views pro and con of various authors. Of these
Delasiauve is particularly cogent in discriminating stupor from melancholia on the grounds of the difference of the emotional reactions and of the intellectual disorder and the real paucity of thought in the former psychosis.
After quoting these and other authors, Dagonet offers an explanation for the diversity of opinion. He says that stupor following another psychosis may retain some of its symptoms, so that a mixture obtains, as often in medicine. He then gives excellent descriptions of three types: the deep stupor with paralysis of the faculties, the cases that are absorbed in false ideas, and ecstatic cataleptics.
The remainder of his paper is concerned with cases and discussions about them. He cites examples of stupor following fear or other emotional shocks, following grave injuries such as the loss of a limb, following head trauma and with typhoid fever. As to the last he points out that delirious features are prominent. Many authors have assigned sexual excesses as a cause of stupor. The psychosis, Dagonet says, is not pure but more a mixture of hypochondria and depression. Relationship with mania is next considered. He says that stupor may succeed, alternate with or precede mania. His cases seem mainly to have been what we call absorbed manics or manic stupors. In fact, he uses the last term. The commonest introductory psychosis, he claims, is depression, but from his brief case reports it would seem that most of his
patients were not stuporous, in the narrow sense of the term, but severely retarded depressions. In fact, in perusing his case material comprising "stupors" in the course of many types of functional insanity, or as a complication of epilepsy or general paralysis, it is evident that in practice he does not follow the discriminative definitions of the earlier portion of his paper. For him, apparently, patients who are markedly inaccessible to examination from whatever cause are "stuporous." He closes with excellent remarks on physical and psychic treatment. As to prognosis he has nothing to say beyond the opinion that most of the cases recover.
If Dagonet be accepted as summarizing the early French work, we can conclude that their generalizations were on the whole quite sound. These were: that stupor is an abnormal mental reaction, usually psychogenic but often the result of exhaustion, that it consists in a paralysis of emotion, will and intelligence; that the prognosis is usually good; that mental stimulation may produce recovery. What remained to be done after this work was the refinement in detail of these generalizations, particularly in respect to the differentiation of prognostically benign and malignant types. But other Frenchmen did not take up this work, apparently, for the brilliant psychopathologists of the next generations attended to stupor only in so far as it was hysterical.
An Englishman, however, soon took up the task, adding more exactness to his formulations. New
ington[14] published his important paper in 1874. A nascent stage of stupor, he thinks, is a common reaction to great exhaustion, "such as hard mental work, prolonged or acute illness, dissipation, etc." Such conditions, like the grave psychotic forms, he regarded as due to physical exhaustion of the brain cells, but, since he thought psychic stress could produce this exhaustion, this "organic" view did not bias his general formulations. He makes a division into two stupors: Anergic Stupor and Delusional Stupor. The former may be primary, being generally caused by a sudden intense shock (Esquirol's "Acute Dementia"), or secondary (a) to convulsions of any kind, (b) to mania in women, (c) to any other prolonged nervous exhaustion. The delusional form results from (a) intense melancholia, (b) from general paralysis in which it may be intercurrent, (c) from epileptic seizures. When one examines his points of difference between these two types, it becomes clear that Newington really gave an excellent differentiation of benign and malignant stupor—in fact, it is the only serious attempt at such discrimination prior to this present work. What is more remarkable is the fact that, although he clearly saw the clinical differences, he failed to see that the two types differed prognostically. His description is given in a table sufficiently concise to justify its quotation in extenso.