baum included stupor with "Catatonia," the situation was not changed, for he did not claim a hopeless prognosis for this group. But when Kraepelin made catatonia a subdivision of dementia præcox, all stupors (except obvious phases of manic-depressive insanity) had to be hysterical or malignant. Faced with this dilemma psychiatrists have either called recoveries "remissions" or, like E. Meyer, claimed that one-fifth or one-fourth of catatonics really get well.
As a matter of fact it seems clear that stupor is a psychobiological reaction that can occur in settings of quite varied clinical conditions. It is not necessary to detail publications describing stupors in hysteria, epilepsy, dementia præcox or in the organic psychoses. It may be of interest, however, to cite some examples of acute, benign stupors and the discussion of them which appear in the literature of recent years.
An important group is that of stupors occurring as prison psychoses. Stern[16] mentions that acute stupors are found in this group. Wilmanns[17] examined the records for five years in a prison and discovered that there were two forms of psychotic reaction, a paranoid and a stupor type. It is interesting psychologically that the former appeared largely among prisoners in solitary confinement,
while the stupors developed preponderantly among those who were not isolated. The stupors recovered more quickly. He describes the psychosis thus: The prisoner becomes rather suddenly excited, destructive and assaultive; then soon passes into an inactive state, where he lies in bed, mute, with open expressionless eyes. He is clean, however; eats spontaneously and attends to his own hygienic needs. Some cases are roused by transport from the jail to the hospital but sink into lethargy again when they reach their beds. Physically, they show disturbances of sensation which vary from analgesia to hypesthesia. There are a rapid pulse, positive Romberg sign, exaggerated reflexes, fibrillary twitching of the tongue and tremor of the hands. Recovery takes place gradually. They begin to react to physical stimuli and to answer questions, although still inhibited, until consciousness is quite clear. When speech begins, it is found that they are usually disoriented for place and time as the result of an amnesia which sets in sharply with the excitement. This memory defect gradually improves pari passu with the other symptoms.
Two attacks in the same prisoner of what seem to have been typical stupor are reported by Kutner[18] and Chotzen.[19] The patient was a recidivist of unstable mental make-up. At the age of 34 he was sent
to prison for three years. Shortly after confinement began, he became stuporous, being mute and negativistic, soiling, refusing food and showing stereotypy. On being shifted to another institution he appeared suddenly much better, although he remained apathetic and dull for some months. A striking feature was a complete amnesia, not merely for the stupor but also for his trial and entrance to the prison. At the age of 42, he was again incarcerated. A practically identical picture again developed, with recovery when his environment was changed, and with a similar amnesia. Recovery seemed to be complete and there were no hysterical stigmata. The interesting features of this case are that a typical stupor seems to have been precipitated by imprisonment, while the retroactive amnesia covering a painful period of the patient's life reminds one of hysteria.
A case which is more difficult to interpret is reported briefly by Seelig.[20] A man of 20 with bad inheritance tried to steal 100 marks. When sent to jail he became ill shortly before his trial was due and was sent to a hospital. There he seemed anxious, was shy, and gave slow answers, with initial lip motions and had to be urged to take hold of objects. All this sounds more like a pure depression than a stupor. But he also had paralogia. This might make one think of a Ganser reaction on the background of depression. S., however, calls it an
hysterical stupor, although he agreed with Moeli that it was hard to differentiate from a catatonic state.
Löwenstein[21] reports an interesting case of a dégénéré who had had hysterical attacks. He suddenly developed stupor symptoms, which lasted with interruptions for nearly two years. After recovery and during the interruptions the patient explained his mutism, refusal to swallow, his filthiness and general negativism as all occasioned by delusions. He was commanded by God to act thus, the attendants were devils, and so on. He spoke, too, of being under hypnotic influence. In addition there were other delusions such as that he had killed his brother. The attack came on with the belief that he was going to die, otherwise none of the ideas were typical of the stupors we have studied. Another incongruous symptom was that he did not seem to be really apathetic, he reacted constantly to the environment. The author comments on the absence of senseless motor phenomena, such as would be expected in a "catatonic." His complete memory of the psychosis also speaks against the usual form of stupor. It seems possible that this psychosis was neither hysterical nor a benign stupor in our sense, but, rather, an acute schizophrenic reaction such as one occasionally sees. From the account which Löwenstein gives, one gathers that the patient was absorbed in a wealth of imaginations.