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 2½ 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 præcox (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° 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.