On April 4, at the end of this period, she suddenly laughed, again ran down the hall, said she had done nothing to be kept on Ward's Island. But she quickly lapsed again into the dull state. Later, on the same day, when the doctor was near, she said, in a natural tone, "Thank God, the truth is coming out." (What do you mean?) "That I have been trusting in a false name and that Miss S. (the nurse) should not nurse me." Then she got suddenly duller, calculated slowly and with some mistakes, 3x17=41, 4x19=56, and when asked to write Manhattan State Hospital she wrote (not very slowly) "Mannahaton Hotspalne."

4. Next day it was noted that she was more stuporous, and she remained so for two weeks, now showing a decided tendency to catalepsy and more resistance than before, though not marked, except in the jaw. She lay often with head raised, sometimes with eyes partly open, or staring in a dull, dreamy way, neither soiling nor drooling, however; a few times she looked up when spoken to sharply. There was no spontaneous speech. Usually she did not answer at all, but a few times a short low response was obtained. Once she wrote slowly a simple addition, put down on paper. When, on one occasion, asked how she felt, she, as before, said, "I feel better."

5. Then, with the exception of a day at the end of the month, when the more stuporous state was again in evidence, she returned to her former condition without catalepsy or resistiveness and without staring, but essentially with inactivity or slowness. She now even dressed herself, answered slowly though not consistently, but she again denied feeling troubled or sad, "I feel better."

On July 7 she got brighter but was still rather slow. She then even began to do some work. She again denied feeling sad.

In a few weeks, while having a temperature of 102 deg. with vomiting and diarrhea, she suddenly got freer. She then said, in answer to questions, that she did not speak because she was not sure whether it would be right, again because she seemed to lose her speech. She did not move because she was tired, had a numb feeling. She said she had not been sad, "but I had different thoughts," "saw shadows on the walls of animals, living people and dead people." She was not frightened, "I just looked at them." People moved so quickly that she thought everything was moved by electricity. She thought her head had been all right.

After a few days she relapsed into a duller state again, but then got quite free and natural in her behavior. On August 28 she gave a retrospective account of her psychosis, a part of which has been embodied in the history. She had insight in so far as she knew she had been mentally ill. She claimed to remember the Observation Pavilion and her coming to the hospital, also the incidents during the manic state, when she heard cannon and thought a war was on, and voices she could not recognize nor understand. Then she became stupid, although neither sad nor happy.

Then, she claimed, she got stupid, but neither sad nor happy. She claimed to have known all along where she was, but felt mixed up at times, her thoughts wandered and she felt confused about the people. She thought she was in everybody's way, thought others wanted to get ahead of her, did not speak because she did not know if it were right or wrong, felt she might cause disturbance if she answered. (It is not clear whether she had complete insight into the morbid nature of these statements.) She also claimed again that all along she "saw shadows on the wall," "scenes from Heaven and Earth," "shadows of dead friends laid out for burial." She had insight into the hallucinatory nature of these visions. Sometimes she thought she was dead also. She claimed that she began to feel better when these shadows stopped appearing in June (the actual time of her improvement).

She was discharged recovered a month later, after having been sent to another ward.

In this case, then, we find that the two months of stupor were ushered in by a brief state in which, in addition to the usual inactivity, there was a certain bewilderment, increased by questions, while the orientation which in the preceding manic state had been good became seriously interfered with. The psychosis bordered on deep stupor for brief periods when the inactivity seemed to be complete or she lay in bed with her head raised from the pillow. On the other hand, there were occasional sudden spells of free activity even with a certain elation. She could often be persuaded to answer questions or to write, the slowness of this spoken or written speech varying considerably. Her replies revealed the fact that she was essentially affectless and that her intellectual processes were interfered with, even to the extent of paragraphic writing. We have, therefore, here again features similar to those of the preceding cases. In addition we must add as important that this patient said retrospectively that she thought she was dead, that she saw "shadows from Heaven and Earth," "shadows of dead friends laid out for burial," all this without any fear. We shall see later that this is a typical stupor content.

We will here include state 3 of Anna G. (See Chapter I, Case 1) who after the pronounced stupor was for two months merely dull, somewhat slowed and markedly apathetic. Although her orientation was not seriously affected, there was considerable interference with her intellectual processes, as shown in her wrong answers or her lack of answers when more difficult questions were asked.

A similar picture was presented in state 2 of Mary D. (See Chapter I, Case 4.) Here, to be sure, there were more marked stupor features in that the patient wet and soiled, in addition to occasional spells when she lay with her head raised. But she spoke and acted fairly freely (even while soiling). By her replies she showed a considerable intellectual inefficiency, although, like Anna G., her orientation was not seriously disturbed. Here again there was complete affectlessness.

This gives us, therefore, five states which may be analyzed for the symptoms of partial stupor. The pictures of all five are unusually consistent. There is inactivity, marked but not complete; poverty of affect without perfect apathy; and a marked interference with the intellectual processes. The last can be studied better than in the deep stupors because these partial cases are more or less accessible to examination. There is a tendency for the patient to think much of death either in the onset or during the psychosis. Negativism seems much less prominent than in the deep stupors.

A natural criticism is that these cases merely had retarded depressions. Although this topic will be discussed fully in a later chapter, two differential characteristics should be mentioned now. First, depression is a highly emotional state in which the sadness of the patient is as evident from his facial and vocal expression as from what he says, while these stupor reactions are by observation and confession states of indifference. Secondly, there is no such disturbance of the intellectual processes in depression as is here chronicled. Let the retardation once be overcome so that the will is exercised and no real defect is demonstrable. In our experience the cases of apparent depression with intellectual incapacity are found on closer study to be really stupors as other symptoms show.



CHAPTER III

SUICIDAL CASES

An important "catatonic" symptom is a tendency to sudden, impulsive, unexplainable acts. Such actions occur occasionally in benign stupors and, since we attempt an understanding of the reaction as a whole, an effort should be made to study these phenomena as well. The cases chosen showed persistent, quite affectless, yet very impulsive attempts at self-injury. They characterized the first of the three cases throughout, were present in one stage (the second) of the second patient, while in the last for one day there was behavior which can be similarly interpreted.

Mention has been made of the prominence, approaching universality, of the death idea in stupor. This is a subject to be discussed in length presently, but for the present we may say that there may be a delusion of death with dramatization of that state or a mere abandonment of the mental activities of life. It is but a step from corpse-like behavior to suicidal attempts, psychologically speaking, yet this transition necessarily modifies the clinical picture, since one necessitates inactivity and the other activity. Secondarily, other atypical clinical features appear, as will be seen.

CASE 9.—Pearl F. Age: 24. Admitted to the Psychiatric Institute July 26, 1913.

F. H. A paternal aunt was insane. Both parents died long ago; the mother when the patient was a baby; the father when she was a girl. She came to this country when 17. In this country she had generally been a domestic. An older brother and sister were also in America.

P. H. She was described as sociable, good-natured, bright enough, not inclined to be depressed. She had little education. There was no former attack.

Four months before admission, the patient did not menstruate but was said not to have worried about this. A month later she began to show symptoms. She said she did not want to live, had done something wrong but could not or would not say what it was. Again she said a young man was going to sue her, a young Jewish fellow whom she had seen only a few times. She talked of turning on the gas. She also complained that people were looking at her and that the food was poisoned.

The patient after recovery gave the following version of the onset: She had a position on 99th St. for 2-1/2 years. She liked the people there and often went to see them later. Her next position was in the Bronx. She was there for nine months. In the same house lived "Harry." After the work she used to talk to him in the yard and, after she left, she used to think of him and long for him. But she denied, with a very natural attitude, that she worried about him at the beginning of her psychosis. After the position in the Bronx she went to one on 96th St., where she was for four months. In the same house was a girl whom she liked and who was lively. When she left, the patient left too. This was a month before the psychosis began. When she left there, she got word that her employer on 99th St. had developed consumption and had to go out West, but did not worry over this news, she claimed. She looked for another position and had one for two weeks, but felt lonely, did not care to live. Then her sister took her to her home. She thought people were looking at her and were making remarks because she was not working. During this time she had a dream one night in which her dead mother appeared to her (in ordinary street clothes) and said to her that she (the patient) "was going away." She woke up frightened. She was worried, thought she had not prayed enough for her mother, and asked her sister to pray also and to give money to the poor. She did not recall, or at any rate denied, speaking of the young man suing her.

She was then taken to a private sanatorium, where she was for two months preceding her admission to this hospital. There she was described as quiet, mute, tube-fed, resistive.

When well, the patient said that in this sanatorium she was first spoon-fed, cup-fed, later tube-fed, "I used to be scared of them, they used to put a spoon way down my throat and I had no appetite—I did not like them around me, they were mean to me. They used to let me stand without clothes, used to spite me." "If I did not want to dress myself, they used to hit me." "I used to feel lonesome for home and I imagined my people were there and that my sister passed the place without stopping." She was afraid of the nurses, thinking they wanted to kill her.

At the Observation Pavilion the patient was described as dull, but brightening up under examination. She made few spontaneous remarks, but in answer to questions said she was melancholy, tired of life, because she was in love with a Gentile fellow who refused to marry her. She also said "I get peculiar thoughts that I am going to die."

Under Observation: The patient's condition lasted for about two years. Much of the time she lay in bed, often with the covers pulled over her, sometimes with her legs drawn up, again in a more natural, comfortable position, or she sat up with her head bowed. She obeyed almost no commands. For months she soiled and wet herself, but never drooled. For a time she refused food consistently, lost flesh and had to be tube-fed. For the most part she said very little and, when one accosted her, she was apt to turn away. A few times, when further urged, she swore at the examiner. There was also persistent marked resistance towards any interference, sometimes merely passive or quite often, especially at first, with wriggling or severe scratching of her own body. There was often with this evidence of irritation or she moaned. Again she was described as quite affectless. One of the most striking features throughout a large part of the course were her suicidal attempts. She would try to strike her head against the iron bedpost, throw herself out of bed, throw herself about generally, try to strangle herself with the sheets, try to pull out her tongue, all of which seemed to be done with great impulsiveness. Almost her only utterances had to do with death. She said she wanted to die, wanted to drop dead, did not want to live, wanted to kill herself, that she did not eat because she wanted to die. When once she was found tossing about and was asked whether she worried, she said "I know I am going to die." (You mean you will be killed?) "I don't care."

There were a few episodes which still have to be mentioned. Quite early in the course of the stupor, when she was restless, scratching herself and moaning, she once spoke quite freely. She said "Give me that fellow (Harry), I don't care, I can't help it. I must have him, even if it costs me my life." "I would feel happy if I could get him. O God, I love him—I will never get him even if I drop dead, I know I won't get him, the darling" (cries). (What if you did get him?) "I know I would lose him again." Then with shame she claimed she had had sexual relations with him (when well, denied). At the same interview, when the doctor sneezed, she said "Gesundheit." In June, 1914, she was seen smiling at times. But the first was the only episode when she spoke more freely, and the two occasions the only ones when she showed a frank affect.

The improvement commenced in April, 1915. Although still very inactive, she sometimes began to laugh and sing and talk a little to other patients. She also answered a few questions on April 22, 1915. Thus, when asked whether she wanted to go home, she said "No, I want to stay here." (Do you like it here?) "Yes" (smiles), "I can't get no other place; I have got to like it here." She smiled freely. To orientation questions, she knew the place, month, but not the year.

She continued inactive and above all diffident, but improved steadily and, when examined by the writer on November 15, she made a very natural impression and gave the retrospective account of the onset embodied in the history. She was quite frank, thanked the doctor for the interest he took in her case, and said for example, "You know I never thought I would get well. I quite gave up—I am very glad I am well now."

When questioned about her stay here, the patient evidently remembered much. She was able to say which wards she had been in and approximately how long she had been in each one. She claimed that at first it "seemed strange." "I did not eat, I did not want to eat, I used to tell them to poison me and that I wanted to die, I was disgusted, I thought I would never go home." She also says she felt angry, wanted to kill herself. She bit and scratched "because I was nervous." She remembered talking about Harry, "I said I was in love with him, I thought I wanted to die because I could not have him." She also talked of having been stubborn. Sometimes she felt like running to the river. She also claimed she imagined people were false to her.

In one of the wards she said she thought people were there on her account, were waiting for her death. She did not care for a time whether she died or not. She knew she tried to choke herself occasionally. Asked how she behaved, she first said she was quiet. (Were you not restless?) "I used to get tired and have backache and roll around in bed." She also felt like running away sometimes, wanted to get out of bed and wanted to walk about. (What about going to the river?) "I used to say that." She claimed not to have been mixed up at any time and to remember everything. Remarkable is the fact that she claimed she did not worry at all, "I felt I was lost and would not worry. I used to worry at home and at Dr. M.'s (the private sanatorium) but not here. Here I never worried, I did not care where I went." She said she did not talk because she was bashful in the presence of doctors, sometimes she felt afraid of them, afraid they would kill her, put poison in her food when they fed her. "When my people came, I said I did not want to live, wanted to kill myself. I used to cry." Again asked why she did not talk, she admitted she really did not know. Once she said she was bashful because she soiled her bed. She did not want to go to the closet because she was afraid of the nurse. She denied hearing voices.

In addition to the activity incidental to her attempts at self-injury, this patient showed an unusual degree of resistiveness and with this some affect, for she appeared to be irritated and at times moaned. Still more unusual were the appearances of delusions not associated with death but with a vivid form of life, namely, a love affair. Occasionally she spoke of her imaginary lover "Harry." Another atypical feature was a fair memory for the period when she was in stupor. She claimed to remember much of her movements and this claim was substantiated by her answers to questions after recovery.

CASE 10.—Margaret C. Age: 23. Single. Admitted to the Psychiatric Institute November 13, 1913.

F. H. Heredity was absolutely denied. The mother is living and made a natural impression. The father died at 65, nine months before patient's admission, of cardio-renal disease. Two brothers and one sister died of acute diseases. One sister died in childbirth. Three brothers and one sister were said to be well.

P. H. The patient was bright and passed successfully through high school. For seven years prior to the psychosis she worked for the same company as clerk. She was described as efficient, conscientious, systematic, though sometimes upset by her work; as lively, talkative, cheerful, with somewhat of a temper and easily hurt, also as quite religious. She was more attached to her mother than to her father, but still more to her older sister, whose death precipitated her psychosis. She never had any love affair and was said not to have cared for men. Two months before admission, when her favorite sister was confined, the patient was quite worried about her, but relieved when she heard good news. A few hours later, however, the sister died suddenly. When the patient learned of the sister's death, she screamed, and screamed several times at the funeral. She did not cry, said she could not. After this she slept poorly, seemed nervous, went to church more, but there was no other change. She continued to work and, according to the employer, worked well.

Nine days before admission she would not get out of bed in the morning, said little and refused food. A few days later she was induced to take a walk, but she seemed to have no interest in anything. When she talked at all it was about her sister and of wanting to go to a convent. When asked to do anything she said she would if it were God's will. She did not menstruate after her sister's death. When practically recovered, the patient attributed her breakdown to this tragedy. She added to the description above given that, soon after losing her sister, she had a fright at home. "It was the house in which my father died and one day when I was in bed I thought somebody came in." But she denied a vision and could not further explain.

At the Observation Pavilion she was very inactive, so that she had to be fed and cared for in every way, mute, often covering her head with a sheet, turning away when questioned and resistive when the physical examination was attempted. But at times she smiled or laughed.

Under Observation: 1. For two months the patient was generally inactive, sometimes lying in bed with her eyes tightly closed, or with her face covered by the sheets or buried in the pillow; or she sat inactive, staring, or with eyes closed, or her head buried in her arms. On one visit she had to be brought into the examining room in a wheel chair and lifted into another seat. A few times she was observed holding herself very tense with her head pressed against the end of the bed. But this inactivity was often interrupted by her going quickly into various rooms to kneel down, though she was never heard praying. Or she ran down the hall for no obvious reason. Or, again, she was found lying on the floor face down. She ate very poorly and had to be tube-fed a considerable part of the time. When this was done, she sometimes resisted severely, as she did in fact most nursing attentions. Thus she soon began to struggle when her hair was combed. She also resisted being taken to the toilet or being brought back. She did not soil or drool, however, but sometimes seemed to be in considerable distress before she finally literally ran to the closet. This resistance just spoken of consisted chiefly in making herself stiff and tense. Sometimes at the feeding she pulled up the cover when preparations were made and held to it tightly. Quite striking was the fact that with such resistance she sometimes, though by no means always, laughed loudly, as she did occasionally when she was talked to, or even without any external stimulation. This laughter always was one of genuine merriment and quite contagious, and by no means shallow or silly.

Usually the patient was totally mute. The exceptions occurred mostly when her resistance was called forth. Thus one day when fed she said, "I wish you people would have more to do," or on another occasion, when she had resisted being brought into the examining room, she said, "I will get out of here if I break a leg." But once when the nurse accidentally tickled her, she said, "Since I am ticklish, I must be jealous—I should worry." She also answered very few questions and such responses as she made were chiefly expressions of resentment. Thus, when one kept urging her, she finally would say "stop," or after much urging "I am going to hurt you pretty quick." Sometimes she said "Go away," or "Let me alone." She was just as silent with the mother and the priest as with the physicians. On one occasion she told the nurse that the priest had told her to talk to the doctors, but that she had nothing to say. Sometimes she did not even look at the visitors, but turned away from them, as she did from the physicians, but at one visit from a priest, though she scarcely said anything, she held on to him when he was about to depart and would not let him go. Throughout this period, since scarcely any answers were given, nothing was known about her orientation, except when on admission she gave a few answers. She then thought she was at the Observation Pavilion, seemed unable to tell even that the physician was a doctor, but knew the date. When asked how she came to Ward's Island, she said "By ambulance." The physical condition presented nothing of note, except for a certain sluggishness of the skin with marked comedones.

2. By January, 1914, the picture changed somewhat and she then presented the following state for an entire year: The mutism persisted and indeed became even more absolute, and she began to wet and soil constantly. This commenced as what seemed to be an act of spite as a part of her resistiveness, for the first time she soiled she seemed to do it deliberately when the nurses insisted that she allow them to put on a dress. Later this explanation no longer held. Tube-feeding too was for the most part necessary, the resistiveness continuing as before. But the inactivity was broken into much more than before by constant impulsive attempts to hurt herself in every conceivable way—by bumping her head against the wall, putting her head under the hot water faucet, trying to pound the leg of the bedstead on her foot, striking herself, pinching her eyelids, pulling out her hair, trying to pick her radial artery, throwing herself out of bed, knocking her head against the bed rail, etc. This was done in silence but with what appeared a great determination that occasionally showed itself in her face. She also sometimes scowled and frowned. With the difficulty in feeding her and the constant impulsive excitement in which bruises could not always be avoided (once an extensive cellulitis developed in the arm which had to be lanced), the patient got weak, emaciated and exhausted; much of her hair fell out, although some she pulled out. It should be stated that during this entire impulsive state she could not be taken care of in the Institute ward, but was sent to a special ward in the Manhattan State Hospital, where suicidal patients are under constant watch. These impulsive attempts at self-injury lessened only towards the end of the period. Her laughter, which had been such a prominent trait, disappeared almost entirely during this entire phase. With all this, the general resistiveness, as has been stated, remained towards feeding or any other interference. It was only in the beginning associated with laughter as in the previous stage.

Although there were, as a rule, no spontaneous remarks and no replies, she on one occasion said spontaneously, probably referring to her unsuccessful attempts to kill herself: "I can't do it, I have no will." During the same period she once said: "I don't want to eat, I don't want to get well, I want to do penance and die."

By January, 1915 (i.e., a year after the second phase had commenced), she began to dress herself and eat, and also became clean. But she remained for the most part very inactive, sitting stolidly about all day and still without interest in her environment. The impulsive attempts at killing herself disappeared. Although she remained for months to come still inactive, she gradually began to talk a little, began to play a little on the piano, but said little to any one.

By August, 1915, she still was inactive, shy, standing about, or sitting picking her fingers, occasionally going to the piano, but evidently unable to finish anything. She had to be coaxed to come to the examining room and talked in a low tone. Often she commenced vaguely to speak and then stopped and could not be made to repeat what she had been saying. Affectively she was remarkably frank, sometimes a little surly, or she showed a slight empty uneasiness. She could, however, be made to laugh heartily at times, or did so spontaneously on very slight provocation.

Some of her utterances were in harmony with her apparent indifference. It was difficult to get her to say how she felt even when thorough inquiries were made. Once she said, when asked about worrying, "I don't worry," or again "I get angry sometimes," or "I used to worry about my health, I don't now," or, when asked what her plans were, she said directly: "I don't care what happens." Again she said "I guess I am disagreeable," or "I guess I am a crank." Another interesting indication of her state was expressed in her repeated statement, "I don't know what I want." But she was oriented in a way, though not sure of her data. She would give most of her answers with a questioning inflection, "This is the Manhattan State Hospital, isn't it?" or she would say, "I don't know exactly where I am, it's Ward's Island, isn't it?" and in the same way she gave the day, date and year correctly. But she did not know the names of the physicians. At that time she could give many data about her family correctly, but was slow, even if correct, in calculation, and, though she got the gist of a test story, she left out some important details.

A retrospective account at that time showed she was uncertain about the Observation Pavilion, that she was not certain how she came to Ward's Island, "On a boat, I believe." It was clear that she did not remember the admission ward, about the Institute ward (in which she had been for the first two and a half months and in which she was again examined); she said it was familiar to her, but she was not certain that she had been in it. About the physician who saw most of her in these first two and a half months, she said that his voice seemed familiar, and she asked him whether he had tube-fed her (she had been tube-fed by him many times), but she again said, "No, you are not the one," and described as the man who had fed her the one who did it on the second ward where she was for a year. But she knew that she had been sent to the second ward, because she constantly tried to injure herself. These injuries she recalled but was unable to say why she attempted them, "I suppose I didn't know what I was doing." She claimed she heard voices and had "all sorts" of imaginations, but could not be gotten to tell about them. When it was difficult for her to give an answer, she was apt to keep silent and then could be prodded without much success.

In October, 1915, there was further improvement, inasmuch as she began to converse some with other patients, played the piano and seemed able to carry a piece through. She was put in the occupation class and did quite well. At the interview with the physician she was still apt to laugh boisterously at slight provocation. Even now she had great difficulty in describing her condition and at the examination was often still quite vague. Thus, when asked how she felt, she said, "I do know I feel ridiculous—sometimes I feel kind of angry—I don't know—they say I am crazy but I am not, but I am hungry—I don't know whether I am or not, I don't know what I can do well," etc. This is quite characteristic. When asked whether she was worried, she said: "I don't know, am I worried?—yes, a little sometimes, I am to-day—I am so untidy—don't know what is the matter with me." Again: "Sometimes I lose my speech—I can't say what I feel, I don't know what it was." Later, half to herself: "I don't know what is the matter with me—I don't care anyway."

In December, 1915, there was still further improvement, and on the ward and in superficial conversation she made, towards the end of the month, in many ways a natural impression, though the laughter before described was still somewhat in evidence. It usually came not without occasion, but was, as a rule, quite out of proportion to the stimulus. She again said she could not explain why she tried to injure herself, claimed she did not feel it, and even claimed she did not remember doing it in the Institute but only in the second ward.

The defect in thinking which still remained is very difficult to formulate. She was now entirely oriented, no longer with any hesitation about the correctness of her information. She subtracted 7 from 100 very quickly and could from memory write a long poem, but there was a certain vagueness about her which partly may have been due to a still existing indifference. This vagueness consisted chiefly in a difficulty of attention or in her capacity to grasp fully what was wanted. It is best illustrated by a few examples: After she had been asked about the onset of her sickness and she had said that what was on her mind then were prayers for the salvation of her relatives, she was asked exactly when it was that she thought of this; she answered "Now?" (What period were we talking of, the present or past?) "The present." (What did I ask you?) "About this period of my sickness." (Which one?) "What sickness?" She said herself at this point, "I am rather stupid" (quite placidly). Or again she said she did not know why she pounded her head, but finally said, "To get better and go home." (Do you think if you pounded your head against the wall you would go home sooner?) "I don't know—maybe." (How would it help you?) "You mean to go to the city?" (Yes.) "I don't know." Again when asked how her mind worked, she said, "Pretty quickly sometimes—I don't know." (As good as it used to?) "No, I don't think so." (What is the difference?) This had to be repeated several times, at which she said, "There is no difference." (What did I ask you?) "The difference." (The difference between what?) "You did not say." Equally striking was the fact that when she was jokingly told "If it snows to-night, we shall have a black Christmas," she did not grasp the absurdity at once, but in a rather puzzled way asked, "Why?"

She was then discharged on parole, two years and one month after admission. Soon after discharge her menstruation, which had been absent throughout her psychosis, returned. On her discharge she had regained her normal weight, and during the two subsequent months gained fifteen pounds.

She then recovered completely, so that three months after discharge she made a very natural impression. She said, on looking back over her state with impulsive excitement, that she constantly had the idea that she wanted to punish herself, but that she did not know why, and did not think she was sad or worried.

Considering only the second phase of the psychosis, this deep stupor showed many interruptions, due not merely to her suicidal efforts but also to her resistiveness. The condition, too, was not so completely affectless as one expects a deep stupor to be. In the first stage there was much sudden laughter, reminding one of dementia praecox (except for its never being shallow or silly) and this persisted into the first part of the second phase. The actual attempts at self-injury brought out emotion, for with them she scowled and frowned as well as showing considerable energy.

To these may be added the following case. It is not unlike the ordinary stupor in the fact that there was intense inactivity and mutism with great tenseness. The remarkable trait was, however, that for a whole day she forcibly held her breath until she got blue in the face. The case in detail is as follows:

CASE 11.—Rosie K. Age: 18. Admitted to the Psychiatric Institute January 24, 1907.

F. H. Both parents were living. The father was a loafer. Nine brothers and sisters were said to be well, with the exceptions of one brother who had an irritable temper, and of a markedly inferior sister.

P. H. The patient was a Galician Hebrew, a shirtwaist operator. Not much was known about her make-up, but it is certain that she was a bright girl. The patient herself said after recovery that her father was nagging her constantly with complaints that she was not making enough money, although he himself did not work and she contributed much to the support of her family. She disliked him very much and claimed that all her relatives worried her, except her mother.

Nine weeks before admission a messenger came into the shop where she worked and said, "Rosie, your father is dead" (the message was intended for a fellow worker). In spite of the fact that the matter was explained, she was upset and nervous enough to be taken home. Though she continued to work for over two weeks, she worried over many trivial matters and talked much about this. She also said that everything looked queer at her home and complained of having difficulty in concentrating her mind. Finally she became elated and talkative. Nothing is known of any special ideas.

At the Observation Pavilion she appeared to be typically manic.

Then she was sent to an institution where she remained for six weeks. The report from there stated that she was for ten days "elated, excited, talkative, with flight of ideas." Then her condition suddenly changed to a marked reduction of activity, in which she neither spoke spontaneously nor answered questions. She "appeared to sleep," but was said to have talked to her people. When interfered with, she was resistive and sometimes let herself fall out of bed. On the other hand, she occasionally wandered about at night. It should be added that during the stupor an alveolar abscess developed which discharged pus. It was washed out and healed.

Then she was sent to the Manhattan State Hospital and admitted to the service of the Psychiatric Institute.

Under Observation: 1. On the first day she lay in bed with cyanotic extremities, weak pulse, grunting, moaning and not responding in any way when examined. After this the moaning and grunting ceased and she was essentially indifferent, and for the most part kept her eyes closed. Often she wet and soiled herself. She was resistive to any care or examination. She would not eat, as a rule, but again gulped down milk offered her. For a considerable time she had to be tube-fed. During the early part of this stupor she once took a paper from the doctor, examined it, and then gave it back without saying anything, or again she peered around silently, or asked to go home, or again, on a few occasions, answered a question or two or spoke some unintelligible words. Orientation could not be established.

2. After a few weeks she became more rigid, a condition which continued for six months. She let saliva collect in her mouth, and drooled. She had to be tube-fed. She lay very rigid, with very pronounced general tension, with her lips puckered, hands clenched, sometimes holding her eyes tightly closed, and often with marked perspiration. For one day she held her breath until she was blue in the face. On the same day she was extremely rigid, so that she could be raised by her head with only her heels resting on the bed. Her eyes were tightly shut and she was in profuse perspiration. Sometimes she interrupted this by a deep breath, only again to resume the forcible holding of her breath. On another day towards the end of the period, while quite stiff, she kept grunting and screaming "murder." The soiling continued. She never spoke.

Physical condition during the stupor: At first she had a coated tongue, foul breath and a fetid diarrhea. The latter was treated with high colonic flushing and mild diet. Urine normal—gynecologically normal. General neurological and physical examination not possible. At the same time she had for two weeks a temperature which often reached 100 deg. or a little above, a weak, irregular but not rapid pulse, a leucocytosis of 17,500 and 80% hemoglobin. When she began to refuse food and before she was tube-fed regularly, she twice had syncopal attacks and lost considerable flesh which was gradually regained under tube-feeding. After the diarrhea she was habitually constipated. Cyanosis of the extremities seemed to have been present only at first.

3. Six months after admission she began to make very free facial movements—winking, raising the eyebrows—and soon developed an excitement with marked elation. She had to be kept in the continuous bath, talked continuously, whistled, sang, was markedly erotic towards the physician, careless in exposing herself and often obscene in her talk. Most of her productions were determined by the environment. She was therefore quite distractible, very alert; sometimes she was meddlesome, again irritable, irascible. The following illustrates her productions: "Send for my husband, S.—He had one sister as big as that. She likes candy.... My father is underneath and my mother is on top because she is fat and he is skinny.... Wait till the sun shines, Nellie—we will be happy, Nellie—don't you sigh, sweetheart, you and I—wait till the sun shines by and by.... Come in (as noise is heard)—I bet that is my husband—my name is Regina K. (mother's name)—my mother's name is the same—I got a little sister named Regina—she is my husband." When she heard the word pain, she said, "Who says paint, Pauline used paint, I used paint," etc.

Towards the end of August she had pneumonia, which did not change her condition.

By October she was well, having gradually settled down. She had good insight.

Retrospectively: She laid very little stress on the false report of the father's death. She claimed to remember being at the Observation Pavilion, but to recall very little of the other hospital. Unfortunately an inquiry was not made regarding her memory during the stupor period under observation with the exception of the fact that she said she wanted to die and therefore refused food.

She was seen in March, 1913, appeared perfectly well, and stated she had been well during the entire interval.

If this forced holding of the breath had been the only anomaly, one would, perhaps, not be justified in drawing any conclusions as to its significance. But the deep stupor was interrupted again for a day by grunting and screaming of "murder." This is certainly indicative of a compulsive death idea and retrospectively she spoke of having refused food in order to die. The latter seems to indicate some connection between her negativism and death. Consequently, even if we regard the breath holding as resistiveness, it would still be related to her idea of dissolution. Her negativism went beyond ordinary limits in that it affected the expression of the face.

When we consider these three cases together, we see that what would otherwise have been deep stupors with profound inactivity, were modified by activity in two directions: suicidal and resistive. Presuming that the symptoms of stupor are all interrelated, we can see a reason why the affect should also have been altered. When one is modified, this should influence the other. When the activity is increased, the emotional concomitants of impulsive acts tend to break through as well. Hence the changes observed in these cases in facial expression and tone of voice. It is noteworthy, too, that all three showed a tendency for laughter to appear, as if, the emotions once stirred, it was possible for them to be exhibited in other than unpleasant forms. So, too, it was possible for ideas unrelated to the stupor picture, such as those of lovers, to occur sporadically. Finally, since activity must imply some contact with environment, the first of these cases at least showed less interference with the intelligence than is usual. In general, one may conclude that any aberration from the pure type of stupor tends to allow other impurities to appear.



CHAPTER IV

THE INTERFERENCES WITH THE INTELLECTUAL PROCESSES

This is one of the most interesting and important of the stupor symptoms. We are accustomed to think of the functional psychoses having symptoms to do with emotions and ideas in the main, and, conversely, that disorientation, etc., observed in such cases is merely the result of distraction, poor attention or cooperation. But in stupor the deficit in understanding, incapacity to solve simple problems and failure of memory seem deep-rooted and fundamental symptoms. So far is this true that Bleuler[5] looks on "schizophrenic" cases with this symptom of "Benommenheit" as organic in etiology. It may be said at the outset that we do not share this view for many reasons. One at least may now be stated as it seems to be final. In benign stupor purely mental stimuli may change the whole clinical picture abruptly and with this produce a change in the intellectual functioning such as we never see in organic dementias or clouded states. We find it more satisfactory to attempt a correlation of this with the other symptoms on a purely functional basis, as will be explained later.

For the study of the interferences with the intellectual processes during stupor reaction, we have two sources of information: The first is derived from the account which the patient is able to give in regard to what he remembers as having taken place around him or in his mind during the stupor period; the second is the direct observation of partial stupor reactions.

1. Information Derived from the Patient's Retrospective Account

We will start with the cases of marked stupor mentioned in Chapter I. Anna G.'s (Case 1) psychosis commenced at home, and under observation lasted with great intensity for five months. She remembered only vaguely the carriage going to the Observation Pavilion, had no recollection of the latter, nor of her transfer to the Manhattan State Hospital and of most of the stay at the Institute ward, including the tube- or spoon-feeding which had to be carried on for four months. She also claimed that she did not know where she was until four or five months after admission. She was amnesic for her delusions and hallucinations. Of Caroline DeS. (Case 2) we have no information. Of Mary F. (Case 3), whose stupor began at home and under observation lasted two years, we find that she had no recollection of coming to the hospital, what ward she came to, who the doctor and nurses were (with whom she became acquainted later), in fact she claimed that for about a year she did not know where she was. But she remembered having been tube-fed (this took place over a long period). Mary D.'s (Case 4) stupor also commenced at home, and under observation lasted for three months. She had no recollection of going to the Observation Pavilion, of the transfer to Manhattan State Hospital, and of a considerable part of her stay here, including such obtrusive facts as a presentation before a staff meeting, an extensive physical and a blood examination, and she claimed not to have known for a long time where she was. Annie K.'s (Case 5) stupor commenced at home. Although she recalled the last days there and some ideas and events at the Observation Pavilion, the memory of the journey to Ward's Island was vague, as was that of entrance to the ward, and she claimed not to have known where she was for quite a while. Specific occurrences, such as the taking of her picture (with open eyes two months after admission), an examination in a special room, her own mixed-up writing (end of second week) were not remembered. But it is quite interesting that an angry outburst of another patient within this same period, which was evidently not recorded, is clearly remembered.

We shall later show that when the patient comes out of a stupor the condition may be such that, for a time at least, retrospective accounts are difficult to obtain. It must also be remembered that not infrequently the more marked stupors may be followed by milder states, and it is important, if we wish to determine how much is remembered, not to confuse the two states or not to let the patient confuse them. For example, Mary D. (Case 4), who showed two separate phases, while she claimed not to know of many external facts, also added that she could not understand the questions which were asked. From observation in other cases it seems that in marked stupor any such recollection about the patient's own mental processes would be quite inconsistent. We have to assume, therefore, that this remark referred in reality to the second milder phase, for which, as we shall see, it is indeed quite characteristic. It is not necessary to burden the reader with other cases, all of which consistently gave such accounts.

We see, then, that in the marked stupor the intellectual processes are regularly interfered with, as evidenced by almost complete amnesia for external events and internal thoughts. In other words, this would indicate that the minds of these patients were blank. Inasmuch as direct observation during the stupor adduces little proof of mentation, we may assume that such mental processes as may exist in deepest stupor are of a primitive, larval order.

Before we examine more carefully the milder grades of stupor, it will be necessary to say a few words about the retrospective account which the patient gives of intellectual difficulties during the incubation period of the psychosis. As a matter of fact, we find that these accounts are remarkably uniform. While some patients, to be sure, speak of a more or less sudden lack of interest or ambition which came over them, others of them speak plainly of a sudden mental loss. Mary. C. (Case 7) claimed she suddenly got mixed up and lost her memory. Laura A. spoke at any rate of suddenly having felt dazed and stunned. Mary D. (Case 4) said she felt she was losing her mind and that she could not understand what she was reading. Maggie H. (Case 14) began to say that her head was getting queer. We see from this that the interferences with the intellectual processes may in the beginning be quite sudden.

In some instances a more detailed retrospective account was taken, which may throw some light upon the interferences with the intellectual processes with which we are now concerned. Emma K., whose case need not be taken up in detail, had a typical marked stupor which lasted for nine months, preceded by a bewildered, restless, resistive state for five days. She was in the Institute ward for the first four months, including the five days above mentioned; later in another ward. When asked what was the first ward which she remembered, she mentioned the one after the Institute ward, and when asked who the first physician was, she mentioned the one in charge of the second ward. However, when taken to the Institute ward, she said it looked familiar, and was able to point to the bed in which she lay, though somewhat tentatively. The same rousing of memory occurred when the first physician, who saw her daily, was pointed out to her. She remembered having seen him, and then even recalled the fact that he had thrown a light into her eyes, but remembered nothing else. This observation would seem to show that with some often repeated or very marked mental stimuli (throwing electric light into her eyes) a vague impression may be left, so that it may at least be possible to bring about a recollection with assistance, whereas spontaneous memory is impossible. In another instance, the patient was confronted with a physician who had seen a good deal of her. She said that he looked familiar to her, but she was unable to say where she had seen him. Here then again evidence that a certain vague impression was made by a repeated stimulus.

Another feature should here be mentioned, namely, that isolated facts may be remembered when the rest is blank. We have seen above that Annie K. (Case 5), while very vague about most occurrences, recalled a sudden angry outburst in detail. Another patient, though the period of the stupor was a blank, recalled some visits of her mother. At these times, as she claimed, she thought she was to be electrocuted and told her mother so, "Then it would drop out of my mind again." These facts are very interesting. We can scarcely account for such phenomena in any other way than by assuming that certain influences may temporarily lift the patient out of the deepest stupor. In spite of the fact that stupors often last for one or two years almost without change, a fact which would argue that the stupor reaction is a remarkably set, stable state, we see in sudden episodes of elation that this is not the case, and other experiences point in the same direction. A similar observation was made on a case of typical stupor with marked reduction of activity and dullness. A rather cumbersome electrical apparatus (for the purpose of getting a good light for pupil examination) was brought to her bedside. Whereas before, she had been totally unresponsive, she suddenly wakened up, asked whether "those things" would blow up the place, and whether she was to be electrocuted. During this anxious state she responded promptly to commands, but after a short time relapsed into her totally inactive condition. We have, of course, similar experiences when we try to get stuporous patients to eat, who, after much coaxing may, for a short time, be made to feed themselves, only to relapse into the state of inactivity.

Such variations are paralleled, as we shall later show, by a suddenly pronounced deepening of the thinking disorder. We have already seen that the onset may be quite sudden. All this indicates that, in spite of a certain stability, sudden changes are not uncommon. Finally, we know that, in spite of the fact that stupor is an essentially affectless reaction, certain influences may produce smiles or tears, or, above all, angry outbursts, which again can hardly be interpreted otherwise than by assuming that those influences have temporarily produced a change in the clinical picture, in the sense of lifting the patient out of the depth of the stupor. All these facts suggest that inconsistencies in recollection are correlated with changes in the clinical picture.

As is to be expected, the cases with partial stupors remember much more of what externally and internally happened during their psychoses. Rose Sch. (Case 6), who had a partial stupor during which she answered questions but showed a great difficulty in thinking, said retrospectively that she felt mixed up and could not remember. Although she recalled with details the Observation Pavilion and her transfer, she was not clear about their time relations (how long in the Observation Pavilion, how long in the first ward). Mary C. (Case 7), whose activity was not entirely interfered with and who showed some thinking disorder, said retrospectively that she could not take in things. Henrietta H. (Case 8), who had a partial stupor, claimed to have known all along where she was, but that she felt mixed up, that her thoughts wandered and that she felt confused about people. In the cases where a partial stupor was preceded by a marked one, such as in phase 2 of Anna G. (Case 1) and phase 2 of Mary D. (Case 4), we have no retrospective account regarding the partial stupor, because emphasis in the analysis was naturally laid on the period comprising the most marked disorder. However, we can gather from the few cases at our disposal that the patients retrospectively lay stress chiefly on their inability to understand the situation.

We finally have to consider the group of suicidal cases. We have information only in regard to two cases, namely, Margaret C. (Case 10) and Pearl F. (Case 9). In both of these, we find that a good many things that happened during the period under consideration were remembered, as were also the patients' own actions. In Rosie K. (Case 11) we have at least the evidence that she remembered her own impulses, namely, that she refused food because she wanted to die. In other words, in these partial stupors with impulsive suicidal tendencies the interference with the intellectual processes seems to be moderate, and memory for external events not markedly affected.

2. Information Derived from Direct Observation

The evidence can best be presented by considering the details of some cases.

Rose Sch. (Case 6) was remarkable, in connection with the present problem, in her unusually poor answers. She either merely repeated the questions, or made irrelevant superficial replies, or said she did not know, this even with very simple questions. When better, too, though not quite well, she showed striking discrepancies in time relations and incapacity to correct them. It would seem that in this case there was something more than an acute interference with the intellectual processes, such as we are here discussing. As a matter of fact, we have the statement in the history that the patient herself said she was slow at learning in school and had not much of an education. A congenital intellectual defect and the attitude which it creates may, however, as my experience has repeatedly shown me, very greatly exaggerate an acute thinking disorder. The case, therefore, while it shows us an unquestionably acute interference with the intellectual processes, does not give us useful information about its nature. More information can be gathered from Mary D. (Case 4). Even toward the end of her marked stupor some replies were obtained chiefly by making her write. When asked to write Manhattan State Hospital, she wrote Manhatt Hhospshosh, and for Ward's Island, Ww. Iland. Again, instead of writing 90th Street, she wrote 90theath Street. These are plainly reactions of the path of least resistance or, in these instances, of perseveration. Of the same nature are some of her other replies in writing or speaking. After she had been asked to write her name, she was requested to add her address, or the name of the hospital; she merely repeated the name. Similarly, when asked whether she knew the examiner, she said "Yes," but when urged to give his name, she gave her own. In the partial stupor at a time when she knew where she was, knew the names of some people about her, the year and approximately the date, she made mistakes in calculation and could not get the point of a test story. Moreover, she failed in retention tests without there being any evidence of anything like a marked fundamental retention disorder, such as we find in Korsakoff psychosis. It seems that these results are best termed defects in attention, which chiefly interfere with the apprehension of more difficult tasks. As we shall see later, this seems to be rather characteristic of these cases. Another point which should be mentioned is the fact that her reaction to questions which she was unable to answer (such as matters which referred to her amnesic periods) was peculiar, inasmuch as she did not only not try to think them out, but seemed indifferent to her incapacity, simply leaving the question unanswered. This too, as we shall see later, is characteristic. Laura A., at a time when she could be made to reply, merely repeated the question, again a reaction of least resistance. The same patient sometimes asked, "Where am I?" Mary C. (Case 7) made similar queries. Although she was at times approximately oriented, she would say, "I don't know where I am," or "I can't realize where I am," or more pointedly, "I can't take in my surroundings." She often did not answer and sometimes seemed bewildered by the questions. Henrietta H. (Case 8) again showed some defect of orientation and mistakes in calculation, and above all, marked mistakes in writing (for Manhattan State Hospital—Manhaton Hotspal). A special feature here is that this occurred immediately after she had been quite talkative, but suddenly had relapsed into a dull state. Anna G. (Case 1), during the third phase of her psychosis, showed the following: Although she was approximately oriented and answered promptly simple questions; e.g., about orientation or simple calculation, she, like these other patients, simply remained silent when more difficult intellectual tasks were required of her (more difficult calculations); or when she was asked how long she had been here (which involved data that could not be available to her, owing to her amnesia); or when questions were put to her regarding her feelings or the condition she had passed through. On the other hand, she sometimes gave appropriate replies in the words "yes" or "no," but it was difficult to say whether these answers did not also represent the path of least resistance.

We will finally take up the last phase of Margaret C. (Case 10). Although she was entirely oriented, there was a certain vagueness about her answers which is difficult to formulate. She was telling about the onset of her sickness and said that at that time her mind was taken up with prayers about the salvation of her relatives. She was asked exactly when it was that she thought of this and she answered "Now?" (What period are we talking about?) "The present." (What did I ask you?) "About this period of my sickness." (Which one?) "What sickness?" She said herself at this point, "I am rather stupid." Again when asked how her mind worked, she said, "Pretty quickly sometimes—I don't know." (As good as it used to?) "No, I don't think so." (What is the difference?) "There is no difference." (What did I ask you?) "The difference." (The difference between what?) "You did not say." In this the shallowness of her comprehension and thinking is well shown, and it seems here again perhaps justifiable to formulate the main defect as one of attention, which prevents completion of a complicated process of comprehension. A feature of further interest in this case is that automatic intellectual processes, such as those necessary for the writing of a long poem from memory, were not interfered with.

Summary

In the most pronounced stupor we have evidently a more or less complete standstill in thinking processes. Practically no impressions are registered and consequently nothing is remembered except events that occurred in some short periods when some affective stimulus, or a brief burst of elation, lifts the patient temporarily out of the deep stupor. It is impossible to say whether the statement of a complete standstill has to be qualified. In some stupors repeated environmental stimuli sometimes make at least a vague impression, so that while spontaneous recollection is impossible a feeling of familiarity is present when the patient is again confronted with this environment. This might be an exception to the dictum of complete mental vacuity, or it may be that there are somewhat less pronounced stupor reactions. When more is perceived, there is often a retrospective statement of having felt mixed up, being unable to take in things, or, directly under observation, the patient may say, "I cannot realize where I am," "I cannot take in my surroundings." In harmony with this is the fact that questions often produce a certain bewilderment. In quite pronounced states in which some replies can still be obtained, we find that the intellectual processes may be interfered with to the extent of a paragraphia, i.e., a remarkably mixed-up writing in which perseveration (one form of following the path of least resistance) plays a prominent part. This same principle is also seen in such reactions as the repetition of the question or the senseless repetition of a former answer. These phenomena remind us of what we see in epileptic confusions, in epileptic deterioration and in arteriosclerotic dementia.

In milder cases difficulties in orientation may be more or less marked; or there may be incapacity to think out problems, although the orientation is perfect. The more automatic mental processes may run smoothly (memory and calculation may be excellent) and there may yet be a certain shallowness in thinking, a defect of attention (a purely descriptive term) which is most obvious in the patient's inability to grasp clearly the drift of what is going on or the meaning of complicated questions. I am inclined to think that poor results in retention tests are entirely due to this attention disorder, for we have no evidence of any fundamental retention defect such as we find in the totally different organic stupors. From a practical point of view it is important at this place to call attention to the fact that such mild changes are particularly seen in end stages. Even when pronounced negativistic tendencies do not play a prominent role, the patient is then apt to be silent chiefly as a result of the residual disorder in the intellectual processes. Still more striking are the conditions which are on a somewhat higher level and in which the shallowness of the responses, due to the residual disorder of attention, together with the last traces of the affectlessness, are apt to create the impression of a dementia. In such cases the opinion is often held that the patient has reached a defect stage from which recovery is impossible, whereas a thorough knowledge of these end stages teaches us that they are not only recoverable but quite typical for the terminal phases of stupor.

Considering these data, especially those gathered in the end stages, it would appear that there is no tendency in this intellectual disorder associated with the stupor reaction for any special side of mental activity to be most prominently affected. It looks rather as if it were a question of a general diminution of the capacity to make a mental effort which in its different intensities accounts for the symptoms.

FOOTNOTES:

[5] See Chapter XV.



CHAPTER V

THE IDEATIONAL CONTENT OF THE STUPOR

Brief survey of the ideas associated with stupor: Having thus described the formal manifestations of the various stupor reactions, it will now be interesting to see what ideas seem to be associated with these reactions. It is, of course, impossible to obtain during a considerable part of the stupor any statement of the patients' thoughts. We therefore have to depend on their utterances during periods when the inactivity temporarily ceases, or on the retrospective account which the patient gives after the stupor has completely disappeared; and as we shall see, we also may obtain considerable information by studying the ideas which occur in the period preceding the stupor. These last may be autogenous delusions or thoughts about actual events which precipitated the psychosis.

It is not likely that many observers have a very clear conception about what sort of ideas to expect. We have, as a rule, not been in the habit of paying much attention to the content of delusions, hallucinations, and the like. So far as we could judge, therefore, the ideas expressed might be expected to be fairly multiform, and it was distinctly interesting to us when we found a marked tendency for the trends of ideas to remain within a certain small compass.[6] It was possible, to state this at once, to show that in by far the majority of cases the same set of ideas returned, and that these ideas had among themselves a definite inner relationship, being concerned with thoughts of "death." In isolated instances other ideas were found as well, and they will have to be discussed later. For the present we shall take up more habitual content.

In addition to the eleven cases already described, it may be well to cite four others which present material now of interest to us.

CASE 12.—Charlotte W. Age: 30. Admitted to the Psychiatric Institute October 21, 1905.

F. H. The father was alcoholic and quick-tempered; he died when the patient was a child. The mother was alcoholic and was insane at 40 (a state of excitement from which she recovered). A brother had an attack of insanity in 1915. A maternal uncle died insane.

P. H. The patient was described as jolly, having many friends. She got on well in school and was efficient at her work.

She was married at 23 and got on well with her husband. The latter stated, however, that she masturbated during the first year of her married life. The first child was born without trouble.

First Attack at 25: Two or three days after giving birth to a second child, her mother burst into the room intoxicated. The patient immediately became much frightened, nervous, and developed a depressive condition with crying, slowness and inability to do things. During this state she spoke of being bad and told her husband that a man had tried to have intercourse with her before marriage. This attack lasted six months and ended with recovery.

When 29, a year before her admission, she had an abortion performed, and four months later another. Her husband was against this, but she persisted in her intention. Seven months before admission she went to the priest, confessed and was reproved. It is not clear how she took this reproof, but at any rate no symptoms appeared until three weeks later, after burglars had broken into a nearby church. Then she became unduly frightened, would not stay at home, said she was afraid the burglars would come again and kill "some one in the house." The patient herself stated later, during a faultfinding period, that at that time she was afraid somebody would take her honor away, and that she thought burglars had taken her "wedding dress." "Then," she added, "I thought I would run away and lead a bad life, but I did not want to bring disgrace to the family."

The general condition which she presented at this time is described as one of apprehensiveness when at home. For this reason she was for five weeks (it is not clear exactly at what period) sent to her sister, where she was better. About a month before the patient was admitted, the husband moved, whereupon she got depressed, complained of inability to apply herself to work, became slow and inactive, and blamed herself for having had the abortion performed. She began to speak of suicide and was committed because she bought carbolic acid. She later said that while in the Observation Pavilion she imagined her children were cut up.

Under Observation the condition was as follows:

1. For the first three days the patient, though for the most part not showing any marked mood reaction, was inclined at times to cry, and at such times complained essentially that this was a terrible place for a person who was not insane.

2. On the fourth day the condition changed, and it will be advisable to describe her state in the form of abstracts of each day.

On October 24 the patient began to be preoccupied and to answer slowly. A few days later she became distinctly dull, walked about in an indifferent way or lay in bed immobile. Twice on October 27 she said in a low tone and with slight distress, "Give me one more chance, let me go to him." But she would not answer questions. At times she lapsed into complete immobility, lying on her back and staring at the ceiling. When the husband came in the afternoon, she clung to him and said: "Say good-by forever, O my God, save me." Again, very slowly with long pauses and with moaning, she said: "You are going to put me in a big hole where I will stay for the rest of my life." On October 28 she was found with depressed expression and spoke in a rather low tone, but not with decided slowness as had been the case on the day before. She pleaded about having her soul saved; "Don't kill me"; "Make me true to my husband"; once, "I have confessed to the wrong man the shame of my life." Later she said she did not tell the truth about her life before marriage. Again she wanted to be saved from the electric chair. At times she showed a tendency to stare into space and to leave questions unanswered.

3. From now on a more definite stupor occurred, which is also best described in summaries of the individual notes.

Oct. 29. Lies in bed with fixed gaze, pointing upward with her finger and is very resistive towards any interference. She has to be catheterized.

Oct. 30. Can be spoon-fed but is still catheterized. During the morning she knelt by the bed and would not answer. At the visit she was found in a rather natural position, smiling as the physician approached, saying "I don't know how long I have been here." Then she looked out of the window fixedly. At first she did not answer, but, when the physician asked whether she knew his name, she laughed and said, "I know your name—I know my name." Then she would not answer any more questions but remained immobile, with fixed gaze. When her going home was mentioned, however, she flushed and tears ran down her cheek, though no change in the fixedness of her attitude or in her facial expression was seen.

Nov. 1. Lies flat on her back with her hands elevated. She is markedly resistive.

Nov. 2. Free from muscular tension and more responsive. When asked whether she felt like talking, she said in a whining tone, "No, go away—I have to go through enough." Then she spoke of not knowing how long the nights and days were, of not having known which way she was going. When asked who the physician was she whimpered and said, "You came to tell me what was right." She called him "Christ" and another physician "Jim" (husband's name), though, later in the interview, she gave their correct names. When asked about the name of another physician, she said: "He looks like my cousin, he was here, they all came the first night. I did not take notice who it was till I went through these spirits, then I knew it was right."—She paused and added: "My God—mother it was; she is here on Earth, somewhere in a convent—Sister C. (who actually is in a convent) she was here, too, I could hear her." She said they all came to try to save her. When asked whether she had been asleep, she said: "No, I wasn't asleep, I was mesmerized, but I am awake now—sometimes I thought I was dead." (When?) "The time I was going to Heaven." Again: "I went to Heaven in spirit, I came back again—the wedding ring kept me on Earth—I will have to be crucified now." (Tell me about it.) "Jim will have to pick my eyes out—I think it is him. Oh, it is my little girl." (Who told you?) "The spirits told me." Again: "Little birds my children—I can't see them any more—I must stay here till I die." (Why?) "The spirits told me—till I pick every one of my eyes out and my brains too." When asked what day it was, she said, "It must be Good Friday." (Why?) "Because God told me I must die on the cross as he did." When asked why she had not spoken the day before, she said that "Jesus Christ in Heaven" had told her she should not tell anything, "till all of you had gone, then I could go home with him, because that is the way we came in and it was Jim too all the time." Finally she said crossly, "Go away now, you are all trying to keep me from Jim" (crying).

Nov. 3. Knelt by bed during the night. This morning lies in bed staring, resistive, again she is markedly cataleptic. She has to be spoon-fed, and is totally unresponsive. In the afternoon she was found staring and resistive. Presently she said with tears: "I am waiting to be put on the cross."

Nov. 4. Still has to be catheterized. She sits up, staring, with expressionless face, but when asked how she felt she responded and said feebly: "I don't know how I feel or how I look or how long I have been here or anything." (What is wrong?) "Oh, I only want to go to a convent the rest of my days." (Why?) "Oh, I have only said wrong things, I thought I would be better dead, I could not do anything right." Later she again began to stare.

Nov. 5. During the night she is said to have been restless and wanted to go to church. To-day she is found staring, but not resistive. When questioned she sometimes does not answer. She said to the physician, "I should have gone up to Heaven to you and not brought me down here." She called the physician "Uncle James." Again she said, "I want to go up to see Jim." Sometimes she looks indifferent, again somewhat bewildered.

Nov. 6. She eats better, catheterizing is no longer necessary. She is found lying in bed, rigid, staring, resistive, does not answer at first, later appears somewhat distressed, says "I want to go and see Jim." (Where?) "In Heaven." She gave the name of the place and of the physician, also the date.

Nov. 8. In the forenoon, after she had presented a rather immobile expression and had answered a few orientation questions correctly, she suddenly beckoned into space, then shook her fist in a threatening manner. When later asked about this, she said: "Jim was down there and I wanted to get him in." (And?) "You was up here first." (And?) "I thought we was going down down, up up—the boat— —you came in here for—to lock Jim out so we wouldn't let him in." Later she said, when asked whether anything worried her, "Yes, you are taking Jim's place."

Nov. 9. During the night she is reported to have varied between stiffness with mutism and a more relaxed state. Once, the nurse found her with tears, saying "I want to go down the hall to my sister—to the river," and a short time later with fright: "Is that my mother?" Again she said: "Oh dear, I wish this boat would stop—stop it—where are we going?" In the forenoon she was quiet and unresponsive. In the afternoon she said in a somewhat perplexed way, "We were in a ship and we were 'most drowned." (When was that?) "Day before yesterday it must have been"—Again she said in the same manner: "It was like water. I was going down. I could hear a lot of things." She claimed this happened "to-day." "I saw all the people in here, it was all full of water," "I have been lying here a long time—do you remember the time I was under the ground and it seemed full of water and every one got drowned and a sharp thing struck me?" "I was out in a ship and I went down there in a coffin." When asked whether she had been frightened at such times, she said: "No, I didn't seem to be, I just lay there." She also said: "the water rushed in," and when asked why she put up her arms, she said, "I did it to save the ship."

Nov. 10. She is still fairly free. She said that when she was on the ship things looked changed, "the picture over there looked like a saint, the beds looked queer." (How do things look now?) "All right." (The picture too?) "The same as when I was going down into a dark hole." When asked later in the day where she was, she said, "In the Pope's house, Uncle Edward is it?" but after a short time she added, "It is Ward's Island, isn't it?"

Nov. 11. Inactive, inaccessible, but for the most part not rigid.

Nov. 14. Varies between mutism with resistance and more relaxed inactivity. To-day lies in a position repeatedly assumed by her, namely, on her stomach with head raised, resistive towards any interference, immobile face, totally inaccessible.

Nov. 15. Freer. She said: "One day I was in a coffin, that's the day I went to Heaven." She also said she used to see "the crucifix hanging there" (on the ceiling)—"not now but when I was going to Heaven." (When was that?) "Over in that bed" (her former bed). Later she added, "The place changed so ... things used to be coming up and down (dreamily)—that was the day I was coming up on the ship or going down." She is quite oriented.

Nov. 17. Usually stands about with immobile face, preoccupied, but she eats voluntarily.

Nov. 24. When the husband and sister came a few days ago she said she was glad to see them, embraced them, cried and is said to have spoken quite freely. To-day she speaks more freely than usually. When asked why she had answered so little, she said she could not bring herself to say anything, though she added spontaneously, "I knew what was said to me." When shown a picture of her cataleptic attitude with hands raised, she said dreamily, "I guess that must have been the day I went to Heaven, everything seemed strange, things seemed to be going up and down." (Did you know where you were?) "I guess that was the day I thought I was on the ship." When the sister spoke to her, she seemed depressed and said, "If only I had not done those things I might be saved, if I had only gone to church more."

Dec. 3. Seems depressed. She weeps some, says she is sad, "There seems to be something over my heart, so I can't see my little girls." Again: "I should have told you about it first—I should not have bought it"—(refers to buying carbolic acid). She wrote a natural letter but very slowly.

4. There followed then a state lasting for six months, during which the patient was rather inactive, preoccupied, even a little tense at times. Sometimes she did not answer, again at the same interview spoke quite promptly. For the most part the affect was reduced, at other times she appeared a little uneasy, bewildered, or again depressed. She said that sometimes a mist seemed to be over her. Now and then spoke of things looking queer and she asked, when the room was cleaned, "Why do they move things about?" and she added irrelevantly: "I thought the robbers broke into my house and stole my wedding dress and my children's dresses" (refers to the condition during the onset of her psychosis). In the beginning of this state, when asked about the stupor, she spoke again of the "ship" and about going "down, down," but also said that on one occasion she heard beautiful music, was waiting for the last trumpet and was afraid to move. Moreover, she had some ideas referring to the actual situation which were akin to those in the more marked stupor period. Although she admitted she was better, she said on December 8 that she still had queer ideas at times, "I sometimes think the doctor is Uncle Jim" (long dead). She also spoke of other patients looking like dead relatives, and added, "Are all the spirits that are dead over here?" "We never die here, the spirits are here." But after that date no such ideas recurred, in fact this whole period seems to have been remarkably barren of delusions. Exceptionally isolated ones were noted. Thus, on January 28 it is mentioned that she stated she sometimes felt so lonely, and as though people were against her; and on February 13 she said she felt as though the chair knew what she was talking about. It is also mentioned in January that she wept at times, but this seems not to have been a leading feature at all. In March, when asked why she was not more active and cheerful, her lips began to quiver and she said, "Oh, I thought my children would be cut up in Bellevue." "I don't know why I feel that way about them." She sometimes cried when her friends left her.

5. Then followed a week of a rather faultfinding, self-assertive state, during which she demanded to be allowed to go home, saying indignantly that she was not a wicked woman, had done nothing to be kept a prisoner here; she wanted justice because another patient had called her crazy. But in this period also she said that after the robbery (at home) she felt afraid that her honor would be taken away. When told that her husband had been with her, she said "Yes, but I was afraid they would get into a fight." (You mean you were afraid the other man would kill him?) "No, he is not dead." She further talked of a disagreement she had at that time with her husband, and that she felt then like running away and leading a bad life, but thought of the children. With tears she added: "I would not do anything that is wrong. I have my children to live for." Quite remarkable was the fact that she then told of various erotic experiences in her life, though with a distinctly moral attitude and minimizing them.

6. On June 16 another state was initiated with peculiar ideas, the setting of which is not known, as she told them only to the nurses. She said that she was not Mrs. W. but the Queen of England, again that she was an actress, or again the wife of a wealthy Mr. B., and that she was going to have a baby. But at night she is said to have been agitated and afraid she was to be executed. She asked to be allowed to go to bed again, then stopped talking, and remained in this mute condition for about a week. She often left her bed and went back again, remained much with a perplexed expression. On one occasion she put tinsel in her hair saying it was a golden crown.

7. At the end of that time she became freer and more natural, and remained so for three weeks. She occupied herself somewhat. When asked what had happened in the condition preceding, said she thought she was a queen or was to be a queen.

8. Towards the end of this period she had again three more absorbed days, but when examined on the third of these days got rather talkative and somewhat drifting in her talk on superficial topics.

9. Two days later she began to sing at night, kissed everybody, said it was the anniversary of her meeting her husband, again cried a little, and on the following morning began to sing love songs, with a rather ecstatic mood, and at times stood in an attitude of adoration with her hands raised. This passed over to a more elated state, during which she smiled a good deal, often quite coquettishly; she sang love songs softly; on one occasion put a mosquito netting over her head like a bridal veil; or she held her fingers in the shape of a ring over a flower pinned to her breast. But even during this state she said little, only once spoke of waiting for her wedding ring, and again, when asked why she had been singing, said "I was singing to the man I love." (Why are you so happy?) "Because I am with you" (coquettishly).