Case 17.—Celia C. Age: 18. Admitted to the Psychiatric Institute May 2, 1914.

F. H. Four years after this attack her mother was a patient in the hospital with an atypical manic-depressive psychosis from which she apparently recovered.

P. H. The patient herself was described by superficial observers as being bright, sociable, well-informed and very ambitious.

When 18 years of age she was working very hard preparing for some examinations, and worried lest she should fail in them. Some years later the patient accounted for her psychosis by saying she had a quarrel with her sister, immediately after which she began to feel depressed. The anamnesis states that she was slow, complained of not being able to think and feeling as if she had no brain. She was sent to a general hospital, where she was apprehensive, wanted her mother to stay with her and one night called out "Mother."

The case being recognized after a few days as a psychosis, she was sent to the Observation Pavilion, where she was described as jumping about in bed in a jerky, purposeless manner, resistive when anything was done for her, and mute. Her sister reported that when she visited her the patient said "Go away, I am dead."

On admission she looked dazed, stared vacantly and had a tendency to draw the sheet over her. When put on her feet she let herself fall limply. At times she became agitated, sobbed and cried loudly, especially when attempts were made to examine her physically, or, when she was asked questions, she scarcely spoke.

Her psychosis lasted but a little more than three months under observation and was characterized by the following symptoms: She was usually in bed, staring blankly or appearing otherwise quite indifferent and apathetic, but not infrequently, especially during the first few weeks, she was quite restless, resistive, whined and suddenly appeared startled or distressed with no occasion for this reaction in the environment. Rarely she was suddenly assaultive. When attempts were made to examine her, she was frequently mute or would repeat the question with a rising inflection, not getting anywhere, or would say, "What shall I say," or "I, I——" never finishing her sentence. After orientation questions she might say "This is—this is—this is——" all this, together with a rather perplexed appearance, gave the impression of considerable bewilderment, but at no time did she complain of autopsychic perplexity. It was difficult to judge of her orientation on account of her failure to answer questions, but it soon appeared that she knew the names of the nurses, for she sometimes called them spontaneously by name. She always ate reluctantly.

During these examinations, however, other symptoms often appeared. When she was talked to, she was apt to indulge in depressive statements and show considerable distress. Such remarks were: "I must confess my guilt," "I am a bad girl and I have to face my guilt," or "I have sinned," or, standing up with a dramatic air, "I must stand up and tell the truth." Once she said, "It is too late to live now." She spoke of having lied and usually would not say what about, but once on questioning replied "I said I would not tell what happened here." She was asked, What do you mean? and answered "I took my oath not to tell anything." Pressed further she said that the nurses poisoned her. Another time she said she was in prison. To her aunt who visited her she said, "I am a prostitute," and once she remarked to the doctor, "I have killed my honor," and on another occasion in the middle of the night she called out, "Chinatown Charlie, come here." She thought the doctor was her brother.

Most of these statements were associated with painful emotion, but there were a few occasions when an element of elation cropped out. Thus on one occasion she laughed, another time gripped the doctor's pad and tried to read it. When the nurse laughed, she made a funny grimace at her and said "Why do you laugh?" Again she once sang two songs, but after the first verse got stuck and kept repeating one word.

At the end of three months she improved rather rapidly and was in a condition for discharge as "recovered" a month later. Retrospectively she said that she recalled feeling guilty, thinking that her mother was dead, having been killed by the patient as a result of worrying over the latter's failure in her examinations and refusal to eat. She remembered, too, that at times she thought the building was burning. Some things like "Chinatown Charlie" she denied remembering, although she had a good recollection for the external facts throughout the psychosis. Her insight was superficially good, but she was reluctant to discuss her psychosis, in fact claimed that she had been made more of a lunatic by coming to the hospital than she was on admission.

Some five years later she had another somewhat similar attack, again following a quarrel, this time with a fellow employee. In this second psychosis, however, manic elements were much more prominent.

Case 18.—Catherine M. Age: 24. Admitted to the Psychiatric Institute November 10, 1913.

F. H. Information as to the family is confined to the two parents. The mother, who was frequently seen, seemed to be a natural, sensible woman. The father, on the other hand, had been alcoholic all his life, had had two convulsions while drinking, and had little respect from any member of the family, including the patient.

P. H. The patient was said always to have been healthy, from a physical standpoint, although never robust. She got on well at school, and then worked first as a stock girl and later as clerk in a department store, where her work was efficient and she advanced steadily. As a child she played freely with other girls but little with boys. As she grew older she moved about socially a little more, made the acquaintance of men as well as of girls, but never cared much for the former and had no love affairs until she met her husband. She was never demonstrative but always rather quiet and modest. Occasionally she spoke of thinking that people talked about her, but the informant doubted if she brooded over this, because she was not of a worrying disposition. Considering the ideas which appeared in her psychosis, it is striking that in her normal life she was rather antagonistic towards her father on account of his alcoholism and the crudity of his speech and manners.

When she met her husband she liked him from the first, although she at no time became really demonstrative. They were engaged for a year, during which time she agreed to a postponement of three months for the marriage, which was suggested by her mother. For some time before this event she was working harder than usual and seemed a bit worn out. She ceased working a month before marriage and improved physically, although she became rather nervous, that is, she was more easily startled, an accentuation of what had been a characteristic for some years. Her husband stated that at this time she became fearful of the approaching marriage relations and asked him to be kind to her in this respect. She was married a year before admission. For two and a half months she refused intercourse and visited her mother's home a great deal. She finally submitted. She was quite frigid but became pregnant at once. Her abnormality then became apparent. She kept the fact of her pregnancy to herself for several months and then when she told her mother wanted to have an abortion performed. Neurotic symptoms appeared. She became sensitive with her husband, correcting his grammar, and cried easily. She also began to be anxious about the approaching childbirth, and with this became more religious.

For the first few days after the delivery, she was fussy with the nurse so that two in succession had to be discharged. On the fifth day she woke up and seeing a nurse lying on the couch beside her bed thought the latter was colored. On the seventh day she had a dream in which she thought she "nearly died in childbirth." Then she began to talk of dying for her baby or of having two babies, of dying herself and rising again after Easter Sunday. She became antagonistic to her husband and with this excited and confused so that she was taken to the Observation Pavilion.

On admission she looked pale and exhausted, had a slight temporary fever and a coated tongue. Her orientation was usually vague but sometimes she gave fair answers. Her verbal productions were rather fragmentary and with the exception of some repetitions there did not seem to be any special topics which dominated her train of thought.

For some days the great weakness and the slight fever continued, and then, as it gradually cleared up, there came a change in her mental condition that settled into the state which characterized the rest of her psychosis. She talked less and was often quite inactive, frequently lying with her eyes closed for long periods, or sat or stood about. Such movements as she made were slow and languid. Her expression was either blank, absorbed, or gave the appearance of peculiar appealing perplexity. This last was not infrequently associated with a rather sheepish smile. She was never resistive and always ate and slept well. With the exception of a few times she did not soil herself. The most interesting feature of her mood reaction was that in a general setting of a slight perplexity there appeared at times and evidently associated with definite ideas, changes in her emotional state. Sometimes this was a matter of distress or of mild ecstasy, sometimes she became markedly blocked. There was at no time any frank elation, but often an appropriate smile, that is, appropriate to the situation and to the thought to which she was giving expression at the time. Then, rarely, there were sudden bursts of peculiar conduct, such as throwing herself on the floor or running down the hall. When questioned as to her motive for these acts, she would flush, look perplexed and apparently be unable to explain them.

Her verbal productions dealt with a rather limited range of topics which can be briefly summarized. As in the other cases, the reader will notice that the bulk of these ideas are of a kind not usually prominent in the typical stupor cases. Many of her thoughts seemed centered around her husband. She always knew him when he visited her, but in her thoughts there was a constant change as to his personality. She persistently confused him with the physicians, with her father, and with God, and one remark is typical, "I thought he was God, priest, doctor, lawyer—well, I wanted to go to Heaven; I thought he would still be my husband; I always hoped that I would be home in Heaven." Not unnaturally with this confusion there were doubts about her marriage. People said her marriage was wrong and her husband bad. Frequently she thought he was dead, or voices informed her that she was not married to him, or that he was the devil in Hell. In this connection she also said that people called her a whore, or it seemed as if she were accused of not being married.

As prominently as appeared the ideas of the invalidity or impossibility of her marriage, to the same extent did her father assume an important rôle for her. As a rule he appeared in religious guise as God, but often he was the doctor—"I knew my father at home and my father in Heaven; which God do you mean? did you say God or father?" At times she spoke of being in Heaven and that God seemed to be God, doctor or priest. In this connection there were ideas of being under the power of some one, God, devil or father.

As is usually the case where strong interest is expressed in the father, ideas of the mother being dead occurred, although in the frankest form she reported them as dreams; for instance, one night she woke up screaming, said that she had dreamed that her mother was dead and her sister dying. That, in the psychoanalytic sense, this represented a removal of a rival, making union with her father easy, appeared in the statement that her father was dead but that she had dreamed he had come to life again for some one else. When asked what she meant, the question had to be repeated several times, then she said "My mother died, my father and mother had a quarrel." There is more than a suggestion here of a difference in the significance of death, in so far as it concerned the two parents. The mother dies and remains dead, that is, she is gotten rid of. The father dies but takes on a spiritual existence and comes to life again, a frequent method in psychoses for legitimizing the idea of union with the parent by elimination of the grossly physical.

There were strikingly few allusions to the plainly sexual. She spoke of being married to the doctor, and even went so far as to say that they belonged together in bed. On another occasion she called him "darling." Once she reported that it was said that she was going to have babies and babies and babies. These references were, however, quite isolated, so that the erotic formed a very small part of her productions.

Delusions of death, we have seen, are the most constant content of true stupors. In this case they were present but distinctly in the background. She spoke quite frequently of being in Heaven. She also talked of being crucified. Once she said "I died but I came back again." This last utterance was rather significant in that frankly accepted ideas of death were unusual; for instance, she would say sometimes, "I think I am in Heaven, again not. It confuses me, but I know I am in Heaven."

In general, then, her ideas were, on the whole, not at all typical of stupor but much more like those met with in other manic-depressive conditions. Correlated with this was an unusual mood picture. Quietness and apparent apathy of the patient were interrupted by little bursts of emotion, and throughout the psychosis there was a coloring of perplexity. Not only was this last objectively noticeable, but she spoke very frequently of it and always in connection with the inconsistency of the ideas in her mind which puzzled her. For instance, in speaking to the doctor she said "I think of you as Bill (her husband's name) sometimes—I get confused thinking of Bill as God, doctor, lawyer, priest." Again, referring to her husband, she made these curious statements: "They seemed to speak of him as being in the wrong—the right—it seems that the right devil is the wrong one for me—they say he is not the right one for me; they say he went wrong from the time we were married." Again, she said that she did not know who her father was, and went on: "It puzzles me, this father business, I knew my father at home and my father in Heaven." Again, "Which God do you mean? Did you say God or father?" A hint as to how this subjective confusion made the environment seem uncertain comes from the statement, "You looked like the devil and yet you were God."

Distress and anxiety appeared not infrequently and always appropriately. The distress was usually occasioned by an idea of injury to others, as when she cried over the fancied accusation of drowning her husband and mother; or in connection with accusations of herself, such as when she reported "They called me a whore." As has been stated, there was never any frank elation, but an element of pleasurable expansive emotion was frequently present in connection with her religious utterances. This came particularly when she spoke of union with her father as God. She seemed to swell with ecstatic emotion. It was especially well marked once when she threw herself on the floor and when asked what she was trying to do replied, "I want to do what God wants me to do, drop dead or anything at all." Perhaps the most unusual affective reaction was a blocking which occurred when certain topics appeared. This is a phenomenon quite unusual for stupor, where speech seems to stimulate and arouse the patient as a rule. One got the impression that ideas tended to come into this patient's mind which were painful enough to disturb her capacity for connected thought. A good example of this reaction was when she was speaking of her father having died and coming to life again. On being asked what she meant, she became quite blocked and the question had to be repeated several times, when finally the apparently unrelated statements appeared: "I dreamed my mother died—they had a quarrel." Who had a quarrel? she was asked, and replied "My mother and father." Apparently her thinking about her father coming to life for some one not her mother stimulated deeply unconscious ideas concerning the separation of her mother and father, and her taking the mother's place, and these ideas were sufficiently revolutionary to upset her capacity of speech for the time being.

She recovered completely about six and a half months after her admission.

Case 19.—Celia H. Age: 19. Admitted to the Psychiatric Institute October 22, 1913.

F. H. The father was living; he always drank, and especially in later years contributed little to the support of the family. The mother was living and said to be normal, while a brother was coincidentally insane, with a recoverable psychosis.

P. H. The mother stated that the patient was bright at school, enjoyed company and going out, had a droll wit, was not at all seclusive, no dreamer, helped to support the family and was efficient. She was very much attached to her brother and once said that if anything should ever happen to him she thought she would die. She also cared much for her older sister, with whom she worked, and for her mother.

Three months before the patient's admission her brother became depressed, mute, seemed worried, cried at times. He was sent to the country. Two months before admission, when the mother and the patient went to bring the brother to town, and while they were at the station, he suddenly tried to throw himself under a train but was restrained just in time. The patient appeared intensely frightened, but did not talk. In fact, she seemed somewhat bewildered and at once became dull. "Her movement and manner were much as at present."

When the patient was able later to give a retrospective account of the onset, she claimed that for some months before this incident she saw that her brother was losing his mind. She worried about this as well as about her work, and felt worn out. She said that when the brother tried to throw himself under the train she was terrified and could not speak or move, and that her mind got upset at once, "I lost my memory." The others forgot her and left her alone on the platform. Strangers put her on another train and she knew nothing until she arrived at home.

The mother added that at the time when the incident with the brother happened, the patient was menstruating and that this ceased at once.

At home she sat about inactive and did not seem even to worry. Whenever any one asked her about her brother she replied that he was dead. For two weeks before admission she said she was rich, that she owned all the property around. She also said she was married to Mattie S. In this connection the mother says that a foolish neighborwoman, the mother of Mattie S., told the patient since her sickness, by way of encouragement, that she should marry her son (the man mentioned). Finally, the patient also expressed the idea that her mother was a stranger, that her real mother was dead.

At the Observation Pavilion she was described as wandering about in a perplexed manner, restless, resistive, answering few questions and in a low tone. She said things were "changed," also that she was married to S.

Under Observation: 1. For about ten days the patient's condition may be described as follows: The most striking feature was a certain restlessness with insistence on going out, with complaints that this and that had been done to her and with senseless struggling when interfered with. But all the motions were slow, the whole restlessness aimless and impulsive. Although the facial expression was somewhat perplexed, it changed remarkably little, and whenever asked whether she felt worried or anxious she denied it, and, indeed, there was only a suggestion of perplexity in her face.

The ideas which she expressed during this time referred to a few topics only, namely, marriage, wealth, and State prison. The remarkable fact was that all the ideas about marriage and wealth were spoken of, often immediately, again after some interval, now in the positive and again in the negative sense. Thus she said she was "Mrs. S.," again "You kept me from marrying Mattie S.," or "I am not supposed to be here—I am a married person," but also "You kept me from getting married." Or, "Take off that black dress, I am a bride," again "You have taken my bridal crown off my head," "The steamboats (seen from the window) are mine—I own the ships, the oceans, the land and everything," or again, she said she owned a kingdom, was Sh.'s wife, a wealthy woman, had millions. Sometimes she connected the millions with Sh. "Sh. has millions." On the other hand, she said: "I owned all this before I came. I have nothing now," or "You have taken the regal crown from me," "You have made a pauper of me," "They did it again, they took my millions away," or "Let me out, they are taking my millions."

Other ideas throughout this period were that this was a State prison, that "bums" were around. On one occasion she said "You can't put down all these things and make me out a lunatic." At another time she pulled a patient's hair and then said without fun: "I fixed the leading lady of the dump—she knows a lot, but she does not know enough to keep her soup cool." When questioned about this woman (who at the time while cleaning had moved the furniture), she said: "I don't know where I am at."

The orientation during these days was not markedly disordered, when one got down to it. Although she spoke of State prison, it was always found she knew the name and the location of the hospital, the names of people around her, even the date approximately, though she was apt to say it was February 19, 1492, or October 19, 1492, or when the year was not given as 1492 she said it was "1900 or 1901, or 1911 or 1912." Frequently, however, it was hard to hold her attention.

Finally, it should be mentioned that she very often wet herself in bed or when standing, even when standing in the examining room.

2. The period following and lasting for two months may be given in the form of abstracts of each note.

November 7: Yesterday quiet, though struggling. Says without change of expression, "I saw four people killed—my mother, my brother, a priest, and my dear sister—we were all killed." Again, "I don't know where I am," "I am an orphan, my people died" (without affect).

November 20: More quiet recently, says little, but tries to get out when brought to the examining room, but when not prevented walks slowly about as before, says she wants to go home. Looks peculiarly blank.

November 23: Has remained quiet, says she is Dr. M.'s wife. But when told she is not married, she agrees. Her attitude towards the doctor is not changed, but when the nurses talk to him, she has tried to prevent it.

December 6: Has remained quietly in bed, gazing about. Slow in motion. She has spoken of being Dr. M.'s wife, again President Wilson's wife, again "Vincent (brother) is the ruler of the world."

At interview says little, seems abstracted, answers briefly in low tone. (Does anything bother you?) "No." (Are you natural?) "Yes." (Who are you?) "C. H." (correct). (You said you were the President's wife?) "No." (Are you married?) "No." (You talked about the kingdom?) "I own the kingdom" (affectlessly). (Where is Vincent?) "Here." (Have you heard him?) "Yes." (What did he say?) "Nothing." (Is he all right?) "Yes." (Where is your mother?) "Home." (Why don't you go home?) "I can't." (Why not?) "I can't." (Why not?) "The family tree is broken, the Cardinal." (What about him?) "Nothing." (Retrospectively she said later she thought her brother was a cardinal.)

December 8: When her mother visited her she said "It is about time you come—I thought you were dead." Has walked down the hall "looking" for her dead cousin. When asked if she wanted to see her brother, said, "Ain't he dead?"

December 12: Cries out in an affectless tone like a huckster, "Father MacN., take me to Heaven," repeating this over and over.

December 15: Quiet as a rule, then for a time at the door, pulling at it and with whining voice but affectlessly saying "Give me the key—I want to go to the river—you can't keep me from Heaven—it is either Heaven or the river, give me the keys, give me the keys, open the door," "The niggers are taking possession." To the physician to whom she had claimed to be married, often repeats "You don't belong to me, I don't belong to you." (What about the niggers?) "A band of niggers, that is all they are." (Are the nurses niggers?) "That is all they are." Asked about her people, she says "They are in Heaven." (Where are you?) "I am in Heaven" (without change of expression). Again, when asked where her people are, says "At home." Then she went willingly back to bed and was quiet. In the afternoon she again went to the door and tried to get out. When questioned, she said "I don't want to be an animal," "Everybody is making an animal of me" (pointing to an animal picture). Then again, while trying the door, repeats in the same affectless manner that she wants to go "to the river," "to the bottom of the river," "to Heaven to see my mother." This last was said in a whining tone, with some tears. She kept turning the knob, tried to get the keys, and struggled impulsively when prevented.

December 23: Though quiet on the whole, when a visitor came yesterday, she ran after this woman saying "I want my generations," and clung to her, and to-day at intervals keeps talking about wanting to see her generations but is often quiet. (Retrospectively she said she wanted to see all her ancestors from the beginning of time.)

December 27: Of late often talks affectlessly about wanting to die or wanting to go to Heaven, struggling impulsively to get medicine away from the nurses, asking for poison, trying to drink her own urine, or even the fluid in the bed pan after she had been given an enema, all evidently with suicidal intent.

December 28: Still constant, impulsive and apparently affectless attempts at suicide, tries to get medicine away from nurses, to get the fire extinguisher bottles, a bottle of ink, etc., struggling when prevented.

But when examined quiet, even smiles at a joke. When questioned, denies feeling either worried or depressed. She said she wanted to go home. She gave poor attention to the questions. Later she threw a wet sheet over a patient and laughed (this is rare). Later she slapped another patient. Again she began to talk about wishing to go to the grave. Calls Dr. M. "Uncle John."

December 30: Talks either about wanting to die, or wanting to go to Heaven, or wanting to go to Ireland, all this as usual in an affectless way. Calls Dr. M. "Uncle John." Keeps shouting "Take me to Ireland."

January 9, 1914: Often quiet in bed, again goes to door, talks about wanting to go "to Heaven" or "to Ireland." On the whole, says little.

It seems, then, that the transition was not abrupt, that many traits of the first period remained, but that she was on the whole much quieter, with the exception of some spells when she insisted on going out or killing herself. At such times she showed an affectless, impulsive excitement. Whether there was an element of perplexity then is not clear from the notes. The topics of which she spoke also changed. The idea of wealth was rarely expressed, also the idea of marriage was much in the background, but prominent ideas were those of death, Heaven, killing herself, going to Ireland—all of which she produced in an affectless way. It should be added that she persistently wet and soiled during this, as well as in the first period.

3. Then followed three months of greater inactivity. She lay in bed gazing, moving very little, not even when her meals were brought. She answered but little and consistently wet and soiled. This state lasted from about the middle of February until the beginning of April.

4. From this stuporous state she emerged during the next four weeks, the awakening being associated with persistent efforts to arouse her. She then was, for six or seven weeks, nearly normal, so far as her mood went, but had a tendency to cling to some of her ideas and was overtalkative. Her memory for the earlier phases of the psychosis was good, as she recalled not only many external events but most of her false ideas. She said, however, that her mind had been a blank for the third stage and she remembered nothing of it. At the end of this time she cleared up entirely and was discharged as "recovered." She continued well for some months, during which she was occasionally examined.