Chapter 5

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.