Chapter XI: Malignant Stupors

As we have seen, the benign stupors are characterized by apathy, inactivity, mutism, a thinking disorder, catalepsy and negativism. All these symptoms are also found in the stupors occurring in dementia præcox. In fact this symptom complex has usually been regarded as occurring only in a malignant setting. There can be no question about the resemblance of benign to dementia præcox stupors. Even such symptoms as poverty and dissociation of affect, usually regarded as pathognomonic of dementia præcox, have been described in the foregoing chapters. Either recovery in our cases was accidental or there is a distinct clinical group with a good prognosis. If the latter be true, the symptoms must follow definite laws; if they did not, we would have to abandon our principles of psychiatric classification. Naturally, then, we seek to find the differences between the cases that recover and those that do not. There is never any difficulty in diagnosis where a stupor appears as an incident in the course of a recognized case of catatonic dementia præcox. We shall therefore consider only such clinical pictures as resemble those described in this book, in that the symptoms on admission to a hospital or shortly after are those of stupor. It should be our ambition to make a positive diagnosis before failure to recover in a reasonable time leads to a conclusion of chronicity.

It is probably safe to assume, on the basis of as large a series as ours, that the symptoms of stupor _per se_ imply no bad prognosis. Further, it has been noted that a relatively pure type of reaction is seen, the symptoms appearing with tolerable consistency. In analyzing the histories of dementia præcox patients, therefore, one looks for inconsistencies among, or additions to, the stupor symptoms. We may say at the outset that we have been able to find no case of malignant stupor that showed what we regard as a typical benign stupor reaction, and it is questionable whether partial stupor as we have described it, ever occurs with a bad prognosis. Usually the discrepant symptoms in the dementia præcox cases are sufficiently marked to enable one to make a positive diagnosis quite soon after the case comes under observation.

The law of benign stupor is a limitation of energy, emotion and ideational content. In dementia præcox we have a re-direction of attention and interest to primitive fantastic thoughts and a consequent perversion of energy and emotion. In many malignant stupors one can detect evidence of this second type of reaction in symptoms that are anomalous for stupor. For instance, one meets with frequent silly and inexplicable giggling. Then, too, smiling, tears or outbursts of rage, the occasions for which are not manifest, are much more frequent than in typical stupor. Similarly, delusional ideas (not concerned with death at all) may appear or the patient may indulge in speech that is quite scattered, not merely fragmentary. Two cases may be cited briefly to illustrate these dementia præcox symptoms superadded to those of stupor.

CASE 20.--_Winifred O’M._ Age: 19. Single. Admitted to the
Psychiatric Institute May 6, 1911.

_F. H._ The occurrence of other nervous or mental disease
in the family was denied.

_P. H._ The patient seems to have been rather shy and
goody-goody in disposition. According to her mother this
seclusiveness did not begin to be markedly noticeable until
the winter before her psychosis, when there was some
trouble about getting work. She had previously been to a
business school. Then she held a position as stenographer
temporarily. When this job was over she had a number of
positions that did not last long and was once idle for two
months. In February (three months before admission) her
father was out of work, which added to her worry.

_Onset of Psychosis:_ Nine days before admission a young
man died in the house where they lived. The next day her
mother insisted on the patient and her sister going to the
funeral. On coming home the patient complained of being
afraid and having a funny feeling. She woke up at 2:30 that
night and lit all the gas, for which she could give no
explanation. The day following, or a week before admission,
she was slow, confused, could not get her clothes together.
The next day she was restless and worried, giving a
superficial explanation for the latter. She played the
piano a great deal. The following day she was fidgety and
cried. At 4 p.m. she was put to bed and appeared to fall
asleep. At midnight when a priest called she said to him
privately that she was all over the world, that she went to
the 12th floor of the Metropolitan Building, that she sat
down and took the man’s money, $7, and came right away. She
recognized the priest. Three days before admission she
wanted to stay in bed, kept her eyes closed. When spoken to
she would smile but did not open her eyes. She did not pass
her urine all day. Her mother then gave her some medicine
which the doctor had left. The patient immediately had a
peculiar attack in which she heaved her breast, drew her
head back, clenched her fists and worked her feet. Saliva
escaped from the side of her mouth. This attack lasted some
three to five minutes.

Her mother then called an ambulance and she was taken to
the _Observation Pavilion_. She thought that the ambulance
doctor was an uncle, a soldier in the Philippines, of whom
she was very fond. There she remained in bed, with all her
muscles relaxed, her mouth constantly open, saying nothing
and indeed resisting efforts which were made to get her to
open her eyes.

_Under Observation:_ She sat or lay down with her eyes
closed and usually limp, although occasionally resistive.
There was practically no reaction to pin pricks. Sometimes
she opened her mouth as if to speak but rarely did so
except in a very low tone and after repeated questioning.
Her answers were rarely relevant. To the usual orientation
questions she gave no answers that would indicate that she
knew where she was. Sometimes she said “Jimmy” when asked
her name, and replied to another question, “Jimmy big smile
on.” Once she said, “I don’t know myself--what I am talking
for--what I am doing.” In general her speech seemed to
indicate that her thought was directed entirely inward and
that she paid no attention whatever to the questions. In
most benign cases such a condition is accompanied by
perplexity or a dreamy, dazed expression. This the patient
had not. On the other hand, she was sometimes definitely
scattered. For example, when asked, How do you feel? she
replied, “Large all name.” Again to the command, Tell me
your trouble, her answer was, “I couldn’t tell my mother
last night and I can’t tell her this night and I can’t tell
my _proud_.” She referred in a fragmentary way to being
crazy and to having been dead. She admitted hearing voices
but may not have understood the question.

A week after admission, when visited by her mother, the
latter asked her to kiss her. The patient opened her mouth
widely and put out her tongue. This is a type of response
which we have never seen in our benign cases.

Two days later repeated questioning made it evident that
the patient knew more about her environment than would be
expected, judging from her other symptoms. She gave the
month correctly knew that she was in a hospital and told of
having recently been visited by her father. At the same
interview she spoke of masturbation, of wanting to marry
her uncle, and of having been in bed with her father. The
last she referred to as a “fall.” Such frank incest ideas
are never found in benign psychosis in our experience.
Other dementia præcox ideas appeared quite soon, for within
three days, when she was talking slightly more freely, she
spoke of having often imagined she was having sexual
experiences as a result of the influence of a man who lived
upstairs, and that even when sitting with her family at the
table she felt sexual sensations.

Her condition then remained essentially the same for some
time. Then about six weeks after admission she became
somewhat less resistive, was frequently seen sitting up in
bed, moving her lips considerably (without speech) and
regarding the surroundings with a bright interested
expression and occasionally smiles. About this time she
began exposing herself and chewing her finger nails.

Four months after admission she was noted as being very
resistive and negativistic, allowing saliva to accumulate
in her mouth and making no attempt to keep the flies off
her. At the same time she would keep in her mouth food that
had been put there without chewing it.

Two months later she seemed to laugh occasionally when
other patients did so, but at the same time she showed a
cataleptic tendency and was quite mute.

Six months after admission she began to feed herself but
rather sloppily. When one would speak to her, she would
occasionally smile, but if shaken she would weep silently.
About this time she began to do a little work in the ward,
pushing a floor polisher.

For the next couple of months her condition was about the
same. She would stand around the ward, doing a little work
if urged, might even dance if forced to. She was
consistently mute. She was dirty but often decorated
herself. Rarely she was assaultive.

Then ten months after admission she one day suddenly
became talkative, distractible and emotional, laughing and
crying. There was with this, however, no open elation. Her
talk was obscene, at times flighty, at times definitely
scattered. All her habits were filthy.

This pseudomanic episode lasted for a couple of months, and
then she settled down to a fairly consistent deterioration
with indifference, silly laughter, occasional
assaultiveness, destructiveness and untidiness.

Nearly two years after admission she had another period of
excitement lasting about a couple of months. Shortly after
this she began to fail physically, and in November, 1913,
two years and five months after her admission, she died of
pulmonary tuberculosis.

In summary, then, we see that this patient exhibited symptoms of dementia præcox from the outset of her stupor, with scattering, genital sensations and incest ideas. The stupor symptoms gradually gave way to the typical indifference, negativism, obscenity, filthiness and inexplicable conduct of dementia præcox. At the beginning, however, the condition was superficially similar to that of a benign stupor, it being only on careful observation that other symptoms were noted.

CASE 21.--_Rose S._ Age: 23. Admitted to the Psychiatric
Institute April 5, 1905.

_F. H._ The mother was living, the father dead. Otherwise
no pertinent information was secured.

_P. H._ The patient was said always to have been somewhat
seclusive, mingling little with other people; this tendency
was so strong that she would leave the room when visitors
came. She always slept a great deal. It was stated that she
was able to do heavy housework quite well, but never
learned cooking.

At 16 she hired out as a servant for a year and a half, and
then did laundry work. When 18 she had an illegitimate
child by a co-worker.

_History of Psychosis:_ About a year before admission the
patient’s sister was burned to death. When the patient
heard of this she said that something had come up in her
throat. Henceforth she often complained of a lump in her
throat, and often bit her nails. Two months before
admission she suddenly left the laundry, again spoke of the
lump in her throat, and claimed to have seen the dead
sister. Two weeks later when the family had an anniversary
mass for the sister the patient appeared sad, but the
following day laughed, said she had seen her “sister
beckoning her to come.” She also thought she saw her
picture “and Heaven was behind it.” She also talked of
“dead relatives and friends.” A reaction of levity in
connection with a sister’s death is highly suggestive of a
malignant psychosis.

Two weeks before admission her mother found her in a
stupor, immovable, with her eyes closed. In 24 hours she
woke up, began to sing “Rest for the Weary,” prayed, then
was stuporous again for six hours. When she came out of
this, she said she was “going to die,” God had told her so
and talked of her own funeral arrangements. She again went
into a stupor, in which she was sent to the Observation
Pavilion.

At the _Observation Pavilion_ she was described as happy,
laughing, singing, saying she felt happy, but adding, “I
like to be sad too, I am going to Heaven Easter Sunday.”
She claimed that her sister frequently stood in front of
her, and that she knew she wanted her to go with her.

_Under Observation:_ For about three weeks the patient
showed a variable stupor. She would lie with a mask-like
face inaccessible, cataleptic, drooling saliva, often with
her mouth open. When taken up, she was usually perfectly
flaccid, but once she let herself slide on the floor after
she had stood immobile at the window. Sometimes there was
marked resistance to passive motions, especially when
attempts were made to open her mouth or eyes, or on one
occasion when the examiner tried to open her hand in which
she held her handkerchief. Yet when one persisted in urging
her to respond there frequently could be elicited more or
less marked reactions. Thus repeatedly she could be made to
obey some commands, as showing the tongue, etc., even when
she would not answer. Once when her eyes were opened, tears
rolled down her cheeks--again, she usually reacted to pin
pricks by slight flushing, once she said, “Stop! it
hurts.” Again, she said, “Leave me alone, I want to sleep.”

So far the description of this reaction is that of a benign
stupor. There were, however, other symptoms. In the first
place, she could sometimes be made to open her eyes and
write, although she would not speak. In spite of the
penmanship being careless, there were no mistakes. This
exhibition of an unhabitual and more difficult intellectual
effort when the patient was mute is suggestive of an
inconsistency. So was her habit of sometimes singing a
hymn, “Rest for the Weary,” when no other sign of mental
life was given. But, more important than these, she could
not infrequently be induced to answer questions and at such
times she spoke promptly and with natural affective
response.

A number of her replies were of the type to be expected in
a benign stupor. In the first place, she spoke of her
condition as “going off to sleep” and also as “death,” “I
was dead all day.” “I died three times yesterday,” or she
merely described it by saying “I go off into states when I
lie with my mouth open and eyes closed, and cannot speak or
open my eyes.” When asked how she got into this condition,
she said “My sister died and I think it was on my mind.”
Again she said she became sad at the anniversary mass of
the sister and had been sad ever since. On the other hand,
she also stated that when she came home from the mass she
first was silly and danced. Spontaneously she spoke of
having frequently had visions of her dead sister; once she
saw her with wings. In explanation of her singing “Rest for
the Weary,” she said it was the hymn sung at her father’s
funeral. An anomalous feature had to do with her
description of her feelings. She claimed to have no memory
of her stupor periods and yet said of them: “I feel
peaceful-like,” or “I feel awfully happy and sad together,”
or “I am sad and contented--I like it that way.”

A striking symptom was that, when a sensory examination was
made during the first few days during one of the periods
when she responded well, she showed glove and stocking
anesthesia, also anesthesia of neck and left breast.

But in addition to the above statements the patient also
began to make others of a definite dementia præcox type.
About ten days after admission she said, “What any one says
goes right through my brain,” or she talked of being
hypnotized. “The typewriting machine turned my eyes--three
or four girls turned my eyes--they look at me and get their
chance, their left eye--turning me into images. I want to
be the way I was born--turn my body! look how their bodies
are turned before they die,” or “Take it if you get it--he
got the name out--I was over there to death--himself to
death--of, you know--you played out--she is played out.”
... This while she snickered between the sentences. As
early as four weeks after admission she had begun to giggle
or laugh, often in an empty fashion, and a transition from
the more constrained stuporous state, with interruptions of
laughter, to an indifferent silly, muttering to herself was
gradual.

In 1909 she was described as not talking, standing around,
showing no interest in anything, muttering. The only
response obtained was “I don’t know.” In December, 1911,
she was transferred to another hospital as a case of
deteriorated dementia præcox.

_To Recapitulate:_ We have here a young woman who for a year had indefinite mental symptoms and suddenly developed a stupor. This was atypical in that she sang and wrote when otherwise apparently deeply stuporous. When persuaded to talk, her utterances, even as early as ten days after admission, were of a malignant type and with such statements she giggled. This last is apparently a highly important sign. Quite frequently in our cases the first signal of a dementia præcox reaction has been giggling in a setting of what was apparently a typical benign stupor.

As has frequently been stated, symptoms of benign stupor are closely interrelated. Consequently the reaction is, when benign, a consistent one. We do not find free speech with profound apathy and inactivity, nor do we expect to meet with unimpaired intellectual functions when other evidences of deep stupor are present. The inconsistency of mental operations which characterize dementia præcox, however--the “splitting” tendency which Bleuler has emphasized in his term “schizophrenia”--is just that added factor which may produce disproportionate developments of the various stupor symptoms in the dementia præcox type of that reaction. Examples of this have been given in the two cases just quoted. The history of the following patient shows this tendency more prominently.

CASE 22.--_Nellie H._ Age: 20. Admitted to the Psychiatric
Institute June 11, 1907.

_F. H._ The father had repeated depressions; he died of
typhus fever. The mother was living.

_P. H._ The brother of the patient stated that she was like
other girls, and very good at school. At 16 she became
quieter, less energetic. She came to America at 17. After
arriving here she has seemed low spirited, cranky and
faultfinding. She often complained of indefinite stomach
trouble and headaches; when at home she often had a cloth
around her head. The informant recalled that she said, “I
wish I could get sick for a long time and get either cured
or die.” However, she worked. For one and a half years
prior to admission her “crankiness” is said to have become
much worse. She complained continually of being tired;
quarreled much with her mother; said she did not have
enough to eat. It is also stated that she was constantly
afraid of losing her job.

_History of Psychosis:_ For six months before admission she
said frequently that her boss was giving her hints that he
liked her. (She did not know him socially at all.) Six days
before admission she came home, saying the boss had told
her he had no more work for her. Nevertheless, she went
back next day and was again sent home. At home she sat
gazing. Next day again wanted to go and see the boss, but
was prevented. At times she tried to get out of the window;
again sat gazing, repeating to herself “Always be true.”
She said she was in love with the boss. When the doctor
gave her medicine she thought it was poison. Finally she
began to be talkative and elated. At the _Observation
Pavilion_ she became very quiet.

_Under Observation:_ She lay in bed indifferent, not
eating, unless spoon-fed, when she would swallow. She
soiled herself. She answered no questions as a rule, and
only on one occasion, when urged considerably, said in
answer to questions that this was a hospital, so that she
evidently had more grasp on the nature of her environment
than her behavior indicated. To her brother who called on
her during the first ten days she said she could not find
her lover here (an idea inconsistent with the benign stupor
picture).

Then she became more markedly stuporous, drooling saliva,
very stiff, often lying with head half raised, gazing
stolidly, never answering, soiling. Later, after a month,
this was less consistent. She now and then went to the
closet, sometimes she smiled, ate some fruit brought to
her, spoke a little. Repeatedly when people came she clung
to them, wanted to go home, again was seen to weep
silently. On another occasion she suddenly threw the dishes
on the floor with an angry mood, without there being any
obvious provocation. Again she got quite angry when urged
to eat her breakfast, and on that occasion pulled out some
of her own hair. Usually she had to be fed, was stiff,
sitting with closed fists, not reacting as a rule in any
other way, wholly inaccessible and has been that way for
years. The stupor merged into a catatonic state merely by
the development of the inconsistency in her affective
reactions.

We see then that inconsistencies among the stupor symptoms themselves and the intrusion of definitely dementia præcox symptoms differentiate the malignant from the benign reactions. As a matter of fact, we find, as a rule, that careful examination of the onset reveals further atypical features, suggestions or definite evidences of a dementia præcox reaction before the stupor itself appears. One common occurrence is a slow deterioration of character and energy that proceeds for months or years before flagrantly psychotic symptoms appear.

Then when delusions or hallucinations are eventually spoken of by the patient, an appropriate or adequate reaction is lacking. In a benign psychosis false ideas do not appear with an equable mood unless the stupor reaction has already begun.

More important than this, although in benign stupors there may be a reduction or an insufficient affect, it is never inappropriate. This pathognomonic symptom of dementia præcox frequently occurs in the onset to malignant stupors. In fact we often find in reviewing such cases that a plain dementia præcox reaction has been in evidence, that a diagnosis has not been made simply because the stupor picture blotted out this earlier psychosis before an opinion was formed. Frequently these early symptoms are reported in the anamnesis and not actually observed by the physician.

Three cases may be cited as examples of dementia præcox onsets. It will be noted that the ensuing stupors were, like those already quoted, atypical.

CASE 23.--_Catherine H._ Age: 21. Admitted to the
Psychiatric Institute October 10, 1904.

_F. H._ The mother’s brother had two attacks of delirium
tremens. The mother died when the patient was eleven years
old; she is said to have been normal. The father was
living.

_P. H._ The patient was always a nervous child, had very
bad dreams, but she was smart at school up to ten or
eleven, and played with other girls. Then she began to work
less well, got thin, more nervous, complained of headaches.
It was about that time that her mother died. (The reaction
to the death was said not to have been different from that
of her sister.) She was kept at home and was quiet.... “You
could see something was working on her.” She began to
menstruate at 14, and it was claimed that she then wakened
up a little. It was further stated that she was always
“stuck up” about her clothes.

At 16 she went to work in a factory, but her sister thought
the work was too much for her, so she was taken home.
Thereafter she lived alone with her father, doing his
housework, her sister having married about that time. At 17
her hair began to come out excessively, so that she had to
cut it, and when it grew again it was gray. She became very
sensitive about this, even refused to take positions
because she thought people would remark about it.

For two years before admission she evidently was different.
Although she did her father’s housework well enough, she
turned against her sister and refused to speak to her
because, she alleged, the sister had not come to help her
in her housework. Another pronounced manifestation during
that time was her frequent talk about her bowels. She
complained of constipation, creepy, crawling sensations in
the stomach which she thought was a “tapeworm.” She got
pamphlets and took patent medicines. She was taken to a
physician nine months before admission, who operated on her
for piles. While still in the hospital she asked her father
to take her home to die (although there was no reason for
such a request). Again she said the gauze had been left in
the rectum too long and that the rectum was full of wind.
Later she said the rectum was closing up. After this, the
sister stated, she was extremely nervous if she passed a
day without a movement of the bowels. She was quiet
henceforth, went out less and said little, claiming it was
better for her head if she said little. She often sat, head
in hand, in the hall. All through the summer she frequently
remarked, “I am a good girl.” Four months before admission
during a period of five weeks she would let her bowels move
when standing up. This was relieved by enemas. The father
states that she was cranky to him, that sometimes when he
merely asked a question she would say, “You hurt my
feelings,” and once, “You break my heart.” Occasionally she
seemed to worry about the money spent for her on doctors
and medicine.

About two months before admission she said everybody was
looking at her. Ten days before admission she said, “I have
been sick all this time and thought I was going to die. Now
I think Tom (her brother) is going to die.” She became
fearful of being left alone. Finally she went to the
priest, who told her to go home. Then she prayed, leaving
the candles burning in the room. That night she was found
kneeling before a church in her nightgown. Again she threw
a lot of articles into the yard, saying a curse had been
put on her by her father, and she did not wish to give him
anything. When she was taken to the Observation Pavilion
she said, “I am a good girl--my mother is dead--it is all
my father’s fault.”

At the _Observation Pavilion_ she put her arm under a hot
water faucet “to save the world,” prayed and laughed--again
sank back and appeared as if asleep. She said, “I hear
angels telling me how to pray when I lose my
thoughts--sisters and nuns are all around me here, to save
and purify the world now and forever, and at the hour of
our death.”

_Under Observation:_ On admission the patient kept her eyes
closed, sang hymns in measured tones, or prayed, or showed
a certain ecstasy in her face while her lips quivered and
tears ran down her cheeks. On the whole, she answered few
questions. When asked how she felt, she said she was happy.
(Why do you cry?) “I was crying when I asked God to save
souls.” (Are you afraid?) “Not now, I have been afraid of
everything on Earth ever since my mother died.” (What do
you mean?) “No one would look at me or talk to me--they
said I was a bad girl, but I was pure.” Again she said,
“They laughed about me, talked about me--and they drew up a
play about me--Devil’s Island.” Or she spoke about having
had stomach trouble, bowel trouble, teeth trouble, eye
trouble, compound, complicated trouble. (What do you mean?)
“Father scolding all the time, he sent me to get bug
medicine (true). God gives that medicine to the one that
started all the trouble--Devil’s Island.”

She soiled her bed and was asked why she did it. She said
“I have been transformed into a baby, the Lord said I was
too pure to be a woman--I had to become a baby to save the
world.” Or when asked her name she called herself “Baby
Chadwick of the whole world--divine Irish Catholic
World--Amen,” or again “I am the Roman Catholic Irish
Divine Baby.”

Although she was not essentially disoriented she called the
place “mid-heaven,” or “a holy house, sort of a hospital.”
She also said, “In two years more there will be a new world
and it will be more happy and holy.”

The day after entrance the patient, though in part as
described, had a spell when she kept her eyes closed and
was rigid. Spells like these returned. (About a month after
admission she became completely stuporous.) She prayed at
times, at other times was constrained, or kept her eyes
closed. Her orientation throughout was good. The content of
her psychosis, in addition to the praying attitude, had a
more or less vague religious coloring. Thus she called the
hospital the “House of God.” Again, when on one occasion
she had jumped at the window guard and was asked “why?” she
said “holy communion.” Again she said she was “Mary, Virgin
Mother.” But this religious trend was intermingled with
remarkable elements of another sort. Thus when in order to
study her knowledge of the events after admission, she was
asked what she had done when she was brought into the ward,
she said, “I went into the sanctuary where my bowels moved
and water passed from me.” (Why do you call it sanctuary?)
“Because Jesus did the same thing I did.”

Possibly vague sexual allusions are also contained in the
following: She said one day to the doctor, “Everything went
wrong last night, good, pure, true and holy doctor, I led
you astray and you were dying last night, may the Almighty
God forgive me, I ought to have died, but I fought it out,
for, if I had died, my mother’s soul would not have been
saved in Heaven and from the flames of Hell.” Again, “I
will not look at you again, good, pure, holy doctor of the
world.” (Why?) “I am afraid I will lead you astray.” And
also: “I led James. Peter astray too.” It should be added
that she sometimes masturbated rather shamelessly.

She said she heard her mother’s voice. (What did she say?)
“Something in the sky for me, angels call for me.” (What do
the angels say?) “The name of my good mother in Heaven.”
Again she said she had heard her mother the night she came
here. (What did she say?) “It was like a voice--feed the
calf--that means me, I suppose.”

Then after a month the stupor became more continuous. She
lay totally inactive for the most part, had to be fed,
soiled herself, drooled saliva, was at times cataleptic,
often rigid. Her limbs became cyanotic. A few times tears
were seen. On other occasions she whispered “peace,” or
“peace for hazing,” or “pray--peace,” or “I like to be
good.” Usually no responses could be obtained.

After some months she was at times seen laughing. This
gradually passed into a state of total disinterestedness
and inaccessibility. She could finally be made to polish
the floor in an automatic fashion, but never spoke, and
five years after admission she was transferred to another
hospital, where she died (eleven years after admission to
the ward of the Institute) without any change in her mental
condition having taken place.

CASE 24.--_Adele M._ Age: 22. Admitted to the Psychiatric
Institute November 11, 1904.

_P. H._ The father stated that the patient was always
“cranky,” had outbursts of temper, even when a small child
and was quarrelsome; also said that she was “seclusive,”
had few friends, was averse to meeting people, never had a
beau. She was taken out of school at 14 because she was not
promoted on two successive occasions from the same class.
Then she was put to work, but she was usually discharged
for incompetency.

_Onset of Psychosis:_ Three years before admission it was
noted that she laughed occasionally without cause. She was
idle. This laughing, and also crying, was sometimes more
frequent, again less noticeable.

Six months before admission she began to say she wanted to
leave home, but made no move to do so. Then she began to
speak of bad odors, made some remarks about the neighbors
talking about her--saying she should kill herself; again
she said the family would be brought to death, or the
mother was falling to pieces, the father looked sick. She
also said her head was swelling and was getting thick.
Finally she wanted to hire a furnished room and kill
herself and asked if 75 cents which she had was enough to
do it with.

Two weeks before admission she left home, wandered about
all night, was picked up by the Salvation Army, and
returned to her home. She said she wanted to die.

At the _Observation Pavilion_ she stated that her mother
was falling to pieces and her father sick. She also said
she wanted to die.

_Under Observation:_ The patient was at first petulant,
saying “I don’t want to stay here,” turning her face away
from the doctor, generally uninterested. Though it could be
established that she was quite oriented, often her answers
were “I don’t know,” or she did not answer. But she was
also seen crying at times, and she was apt to bite her
finger nails. She had to be tube-fed. Gradually these
tendencies increased so that she lay in her bed with head
covered, saying in a peevish tone, when spoken to, “Oh, let
me alone.” And for years she was mute, lying with her head
covered, tube-fed. When reëxamined in 1914 (ten years
later), she was found lying in bed with an empty smile.
There was paper stuffed in her ears. When approached, she
turned her head away and would not talk.

CASE 25.--_Catherine W._ Age: 42. Admitted to the
Psychiatric Institute November 11, 1904.

_F. H._ The father died at 75, the mother at 44. Two
sisters died of tuberculosis. A brother wanted to marry but
was opposed by the father; he set fire to the house of the
girl and then drowned himself.

_P. H._ The patient came to this country when 20, and
worked for some years as a servant. Then she married after
a short acquaintance. The husband, according to his own
statement, drank, and there was friction from the first.
She left him a few weeks after marriage, and a few months
later he went to Ireland; she also went some time later but
did not go to see him. Then they lived together again. They
had four children, but had had no intercourse for nine
years.

_Development of Psychosis:_ Eight years before admission
the patient became nervous, slept badly, but got better. It
was claimed that for six years she had been quieter and
more sullen than before. Three years before admission the
patient had to take a place as janitress, since she needed
the money. From the first she had trouble with the tenants
and accused everybody of being in league against her. Some
six or eight weeks after she had taken the position, she
developed what was called typhoid fever, and some time
later the daughter came down with the same disease. After
the typhoid she was more antagonistic towards her husband,
accused him of infidelity, repeatedly locked him out of the
house, but continued to do her housework. About six months
after this illness she left her home, but returned in a
week. She had vague ideas thereafter that the priests were
saying things against the family, and she often quarreled
with the tenants. For a year she had done no work but sat
about. Ten days before admission she stopped eating.

_Under Observation:_ The patient was mute, stolid, gazing
straight ahead, sometimes cataleptic. She had to be
tube-fed, was usually very resistive to any passive
motions; quite often she retained her urine, but she did
not hold her saliva. Yet there was some quick responses at
least in the beginning. At such times it was found that she
was oriented, but nothing could ever be obtained about her
feelings, etc., except that she once said, when asked
whether she was worried, that she “felt weak,” had “nothing
to worry about.” Occasionally she was seen to cry silently;
at times she would breathe faster when questioned, or
flush; once she took hold of the doctor’s hand when he
questioned her, and cried, but made no reply. On another
occasion she was affectionate to her son, kissed him,
although she paid no attention to her daughter who
accompanied the son. Later she said to the nurses, “He is
the best son that ever lived.” But more and more she became
disinterested, totally inaccessible, resistive, had to be
tube-fed. In this condition she remained for five and a
half years. At the end of that time she died of tubercular
pneumonia.