This case gives an excellent example of the relationship of stupor to other manic-depressive reactions. She begins with an absorbed state, showing elements of perplexity and mania. With this there are expansive ideas but, also, statements about losing everything and being in prison, which suggest abandonment of life. Next, with increasing apathy, she begins to speak of death and soon makes impulsive suicidal attempts. Evidently her mind was becoming more and more focused on death and with this there was an appropriate emotional change. She was either apathetic or the affect exhibited itself in pure impulsiveness. Then comes the stupor, when all ideas disappear and mentation is reduced or absent. When the stupor lifts, the original ideas appear not only in memory but occasion a wavering insight. It is appropriate that she recalled all of her psychosis fairly well with the exception of the pure stupor, which she remembered only as a time when her mind was a blank. FOOTNOTES: [7] Hoch, August, and Kirby, George H.: “A Clinical Study of Psychoses Characterized by Distressed Perplexity.” _Archives of Neurology and Psychiatry_, April, 1919, Vol. I, pp. 415-458. [8] Hoch, August: “A Study of the Benign Psychoses.” _Johns Hopkins Hospital Bulletin_, May, 1915, XXVI, 165. A book on “the psychology of manic-depressive insanity” will shortly appear by the editor. CHAPTER IX THE PHYSICAL MANIFESTATIONS OF STUPOR We must now discuss the most difficult of all the aspects of the stupor problem. The subject is so involved and the evidence so inconclusive that observers will probably interpret the phenomena here reported according to their individual preconceptions. What we have to say is therefore published not so much to convince as to stimulate further work. The problem is wider than that of the mere etiology of the stupors we are considering. Their relationship to manic-depressive insanity is so intimate that we must tentatively consider this affectless reaction as belonging to that larger group. A discussion of the basic pathology of manic-depressive insanity is outside the sphere of this book. The author, therefore, thinks it advisable to state somewhat dogmatically his view, as to the etiology of these affective reactions, merely as a starting point for the argument concerning stupors specifically. It is our view that the manic-depressive psychoses may be, and probably are, determined remotely but fundamentally by an inherent neuropsychic defect, but this physical and constitutional blemish is non-specific. The actual psychosis is determined by functional, that is, psychological factors. A predisposed individual exposed to a certain psychic stress develops a manic-depressive psychosis. Naturally any physical disease reduces the capacity for normal response to mental difficulties; hence physical illness may facilitate the production of a psychosis. But this intercurrent factor is also non-specific.