Chapter 13

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.