If one compares these data with those given in the chapter on Malignant Stupors, it is seen that in the main Newington has made the same discrimination as we have. He is certainly wrong in denying "negativism" to his anergic type. Probably, too, he attempts too fine a distinction between the
physical symptoms of the two groups. His conclusions are interesting: that in the anergic cases there is an absence of cerebration, while amongst the delusional there is an abnormal presence of intense but perverted cerebration. This is not unlike our own view. He thinks the difference in memory is the most important differential point. Sex is important in determining the nature of the stupor, for he found the anergic type following mania in females only. He observed such an end to manic attacks in 6 out of 36 cases. All his cases were under 30 and he regards the prognosis as good on the whole. As to treatment he emphasizes the necessity for "moral pressure" as a stimulus and cites a case of rapid improvement after a change of scene.
Since 1874 very little advance has been made by British psychiatrists, as seen by a perusal of Clouston's[15] summary in 1904. He regards sex exhaustion as a highly frequent cause, although Dagonet had shown 32 years before that sex abuse does not produce a true stupor. He thinks stupor usually follows depression or mania and says that "the 'Confusional Insanity' of German and American authors is just a lesser degree of stupor." Omitting his stupors in general paralysis and epilepsy he makes three clinical divisions: melancholic or conscious stupor, which is not a product of delusions, although delusions of death or great wickedness may be present, impulsiveness and fits may be observed; anergic or
unconscious stupor, which corresponds roughly to our deep, benign stupor; and secondary stupor after acute mental disease, which resembles our partial stupor. He warns against a rash diagnosis of dementia in this last group. His views on the importance of mental causation and the relation to manic-depressive insanity may be gathered from these sentences: "The condition of the mental portion of the convolutions in stupor is probably analogous to the stupidity of a nervous child when terrified or bullied." "Stupor is frequently one of the stages of alternating insanity following the exalted condition. It is more apt to occur in those where the exalted period is acutely maniacal. The stupor is usually melancholic in form." Since he claims that the anergic is a "very curable form of mental disease," while only 50% of the melancholic cases recover, it seems clear that this division is not prognostically final. The "melancholic" is evidently Newington's "delusional" without his more accurate discrimination of symptoms.
From the standpoint of accurate description the opinion may be ventured that there is a gap in the literature from the early French writers and Newington up to the paper by Kirby, which has been discussed in the first chapter. This gap is filled by literature of the German schools and their adherents in other countries. German psychiatry has been concerned mainly with classification or the elaborate examination of certain symptoms. Inevitably such a program militates against detached objective clini
cal description. It is hard to record symptoms that interfere with classification. German psychiatry has tended to make the insane patient a type rather than an individual. Hence the gap in the descriptive literature of stupor.
The necessity of establishing the possibility of some stupors having a good prognosis has arisen from Kraepelin's work. He can rightly be viewed as the father of modern psychiatry because he introduced a classification based on syndromes and taught us to recognize these disease groups in their early stages. Inevitably with such an ambitious scheme as the pigeon-holing of all psychotic phenomena some mistakes were made. Most of these appear in the border zone between dementia præcox and manic-depressive insanity. The latter group being narrowly defined, the former had to be a waste basket containing whatever did not seem to be a purely emotional reaction. Clinical experience soon proved that many cases which, according to Kraepelin's formulæ, were in the dementia præcox group, recovered. Adolf Meyer was one of the first to protest and offered categories of "Allied to Manic-Depressive Insanity" or "Allied to Dementia Præcox," as tentative diagnostic classifications to include the doubtful cases.
Difficulties with stupor furnish an excellent example of the confusion which results from the adoption of rigid terminology. The earlier psychiatrists were free to regard a patient in stupor as capable of recovery as well as deterioration. When Kahl