This may follow a period of depression or one of catatonic excitement, or it may be primary, constituting the onset of the disease.

In its true sense the term "stupor" implies the existence of a profound disorder of consciousness. In this connection, however, the word is used in a different sense. As a matter of fact lucidity is but slightly if at all impaired in the catatonic. Impressions of the external world are perceived almost normally. Very frequently the patient, though seemingly unconscious of his surroundings, relates, after the stuporous attack has passed, with surprising precision the facts which would seem to have totally escaped his observation.

1 Tschisch. Die Katatonie. A Russian work abstracted in Allgem. Zeitschr. fur Psychiatrie, 1900.

In spite of appearances catatonic stupor is therefore not the result of an intellectual disorder proper, but, like catatonic excitement, of a disorder of the will.

Automatism of the reactions is met with in three forms, which we have already mentioned: negativism, stereotypy, and pathological suggestibility.

Negativism is manifested in simple acts, such as movements of a limb, as well as in complex acts, such as eating, dressing, etc. The patient fails to react to stimuli either from the external world or from his own organism.1 An order given is not executed. Pricking, even when deep, produces no movement, not because it is not felt, but because voluntary reaction is annihilated. Hunger produces no reaction. The urine accumulates in the bladder, saliva in the mouth, faecal matter in the rectum without there being any true paralysis.

Two particularly interesting forms of negativism are mutism and refusal of food. Either symptom may persist for a long time without interruption and each may present very diverse characteristics.

Stereotypy is seen in the attitudes and in the physiognomy.

Certain patients assume very singular positions: extreme flexion of the limbs, a squatting position, the elbows upon the knees, the head drawn back, etc.

The physiognomy of the patient is often distorted by grimaces. The lips are contorted in a kind of grin, or protruded, as though the patient were making faces. The eyes may be closed tightly. These phenomena may persist for months or years. Almost always, at least in the beginning, they disappear during sleep.

1 Stoddart. Anesthesia in the Insane. The Journal of Mental Science, Oct., 1899.

Pathological suggestibility often alternates with negativism. Certain catatonics retain any attitude in which they may be placed, even the most uncomfortable (catalep-toid attitudes). Incapable of making their toilet they submissively allow themselves to be washed, combed, and dressed. Many become filthy and soil and wet themselves unless taken to the toilet at regular intervals. Sometimes a single impulse suffices to start the subject and make him accomplish in a sort of mechanical manner some habitual act or even series of acts: once seated at the table with his plate filled in front of him, he may eat like a normal person.

Echolalia and echopraxia - phenomena which are also dependent upon suggestibility - are not infrequent.

Like catatonic excitement, catatonic stupor is essentially free from emotion.

The following case is a good illustration of catatonic excitement and catatonic stupor:

Adrienne P., patient at the St. Anne Asylum, corset maker, twenty-five years old at the onset of her illness. - Heredity: paternal grandfather died at the age of sixty years of senile dementia; father is an alcoholic, has been committed twice; paternal aunt committed suicide. - The patient began to walk and speak very late in childhood; menstruation appeared at the age of seventeen, has been regular but painful. She showed no abnormality in intelligence or disposition. - At nineteen, pleurisy. At twenty-four, during a sojourn in London, a severe attack of scarlet fever with pronounced albuminuria; patient was sick three and a half months; convalescence lasted two months. Since then (fall of 1897), the relatives noticed a change in the mental condition of the patient from the letters which she wrote home. On her return to France Adrienne was gloomy, irritable, apathetic. She refused to work and often even to rise in the morning. Complete loss of appetite, headache. Much worried about her health, she consulted several physicians but with no appreciable result.

On October 20, 1898, acute symptoms set in in the form of disorders of perception. The people are "droll," the dishes served in the restaurant are "droll," life is "droll" and "absurd." At the same time hallucinations of vision appeared: the patient saw men following her, also ghosts and stars. On October 26 she started out to go to her sister who lived in the suburbs of Paris; failing to find her she walked at random and wandered around the country for two days and two nights. She was found walking along a railroad track, her hair undone, her clothes in disorder; they arrested her and took her to the Corbeil Hospital where she remained eight days in complete mutism. On her return to her mother her mutism disappeared, but she gave no explanation of what she did, telling simply that she had seen things which frightened her: terrible men and animals. For some time she remained relatively quiet, but depressed and intractable. She refused to see a physician, though her mother begged her to do so. On the night of November 24 she suddenly became greatly excited, cried, gesticulated, and uttered incoherent remarks some of which were suggestive of hallucinations: she spoke of men following her and of saints whom she saw.

She tried to throw herself out of the window.

On being brought to the clinic on November 28 she was in almost complete mutism. To all questions put to her she responded by outlandish gestures and grimaces bearing no reference to the questions. On being asked to write she tore the piece of paper which was offered her.

On December 1, at the occasion of a visit from her mother, Adrienne came out of her mutism but her remarks were incoherent. "She cannot see, she can see very clearly. ... It is Alfred, it is Martin speaking to her. . . . They are not saying anything." It was very difficult to tell whether she really had hallucinations.

Toward the evening she became totally estranged from the external world. She no longer responded to any question.

Spells of excitement and of stupor have since then followed each other without any regularity, presenting respectively the characteristic features of catatonic excitement and of catatonic stupor.

The excitement is purely automatic. The same movements are constantly repeated monotonously and aimlessly. For hours at a time the patient goes through peculiar and incomprehensible gestures, striking the floor alternately with the right foot and with the left foot, and extending her arms and clinching her fists in a threatening manner but never striking anyone. She stands up in her bed in a dramatic attitude, draped with the blanket, and frozen, so to speak, in that position, uncomfortable as it is. In her attacks of excitement she displays considerable physical strength. On May 25, 1900, she made a steady, persistent attempt to leave her bed and get out of the dormitory; her eyes were shut, her, expression apathetic, and she uttered not a word or a cry. Several nurses held her back with difficulty.

Her utterances show either incoherence or verbigeration. On January 15, 1900, she stood up in her bed and sang for several hours: "The baker's wife has money," etc. On May 23, of the same year, she kept repeating during several hours without interruption "Hail Mary," etc.

She shows marked negativism. When spoken to she will give no response, showing absolute mutism; she resists systematically all attempts at passive movement: to open her mouth, to flex an extended limb, or vice versa. The command to open her eyes results immediately in a spasm of the orbicularis muscle. Refusal of food is at times complete, and then the patient has to be tube-fed; at other times it is partial, the patient taking only liquid food which is poured into her mouth by means of a feeding cup and which she then swallows readily. On November 4, without any apparent reason, she ate spontaneously a piece of bread which she took from the table. For two days she thus took bread, cheese, and chocolate, but persistently refused everything else. Later she relapsed into the former state and now takes none but liquid food which has to be poured into her mouth. Her sensibility appears to be normal, but all reaction is annihilated. Painful pricking with a pin causes slight trembling, but no cry, nor any movement of defense.

In the stuporous phases the patient lies in her bed, completely immobile. Generally this immobility is dominated by negativism which is manifested by the same traits as those observed in her excited phases. On several occasions, however, she has shown very marked suggestibility. Thus once she submitted readily, though passively, to being dressed and taken to the office of the ward physician. When standing she remains motionless, yet she will walk mechanically as soon as she is pushed. When invited to sit down, the patient slightly flexes her legs and makes a movement as though starting to sit down, showing that the command is understood; yet she will go no further, but remains standing. When taken by the shoulder and slightly pushed she sits down without trouble. Her limbs are flaccid and present no resistance to any passive movement. Negativism persists only in the muscles of the mouth and eye-lids, which remain closed and resist being opened. Cataleptoid attitudes are rare. One was, however, observed on October 30, 1900. The right arm was held for ten minutes in complete extension.

On the following day this symptom disappeared.

The patient soils and wets her bed frequently, though not constantly, both during the periods of excitement and during those of stupor.

The general nutrition is profoundly affected; the skin is discolored, the hair is falling out, and there is considerable emaciation: from December, 1898, until May, 1899, the patient's weight fell from 94 to 77 pounds

In March, 1901, the patient, considered as being completely incurable, was transferred to another institution.

Save in the rare cases in which the disease terminates in recovery, the catatonic comes out of his spell of excitement or of stupor with more or less mental deterioration.

Often some of the catatonic phenomena persist, thus disclosing the origin of the dementia: stereotyped attitude, mannerisms, verbigeration, etc.

The following case illustrates this point:

Suzanne N., patient at the Clermont Asylum, at present (1904) fifty-eight years old. The disease came on in 1894, when the patient was forty-eight years old. The clinical record in this case shows an affection developing by alternating attacks of excitement and depression, with occasional mutism and refusal of food. For the past several years the patient has been living apparently estranged from all that surrounds her. She never speaks to the physician, to the nurses, or to any of the other patients. She answers no questions, carries out no command. Negativism is very marked. Any attempt to open her mouth, shake hands with her, etc., meets with absolute resistance. The patient's gestures, actions, and utterances present all the features of stereotypy. For hours she keeps repeating certain movements, which would surely very soon tire out a normal person, and which consist in shaking both hands up and down a good deal like little children do in imitation of marionettes. When free she starts immediately for the nearest door, which she tries to open, and, when she succeeds in doing so, continues to walk straight ahead without any aim. Yet if she is tied in her chair, even though it be only with nothing stronger than a woolen thread, she will not budge.

When the door of the ward is shut she is completely mute - but the instant the door is opened, she begins mechanically, like a spring that is suddenly released, to repeat in a monotone: "Eucharist, penance, extreme unction," or "Jesus Christ, Holy Sacrament," or she recites from beginning to end: "I believe in God," etc. This is kept up as long as the door remains open, but ceases as soon as it is shut.

She is very untidy in her habits, spilling her food upon her dress and often wetting her bed or clothes.

In spite of the complete indifference which she shows, the patient is perfectly lucid. Nothing that occurs about her escapes her observation. During the visits of her relatives her mutism disappears as by magic. She converses readily and tells all the gossip of the institution: they had a feast on mid-Lent, Mrs. X. got a new dress, etc.

The disease often develops in repeated acute attacks, each, whatever be its form, leaving behind it a more advanced degree of mental deterioration. Occasionally attacks of excitement and stupor alternate with each other with a certain regularity, simulating a manic-depressive psychosis.